Tracheal lacerations after endotracheal intubation: a proposed morphological classification to guide non-surgical treatment.
OBJECTIVE
Postintubation tracheobronchial lacerations (PITLs) are traditionally managed surgically. We sought to evaluate the rationale for non-surgical management of PITL.


METHODS
From January 2003 to November 2008, 30 patients with PITL were observed in our institution. PITL were graded as follows: Level I - mucosal or submucosal tracheal involvement without mediastinal emphysema and without oesophageal injury; Level II - tracheal lesion up to the muscular wall with subcutaneous or mediastinal emphysema without oesophageal injury or mediastinitis; Level IIIA - complete laceration of the tracheal wall with oesophageal or mediastinal soft-tissue hernia without oesophageal injury or mediastinitis; Level IIIB - any laceration of the tracheal wall with oesophageal injury or mediastinitis. All patients with Level I, II and IIIA PITL were treated conservatively with endoscopic instillation of fibrin glue (Tissucol, Baxter Healthcare, Deerfield, MA, USA).


RESULTS
All patients with Level I (n=3), II (n=24) and IIIA (n=2) PITL were successfully treated conservatively. The patient with a Level IIIB injury underwent posterolateral thoracotomy repair of the trachea. No mortality was reported. Mean hospital stay was 12.9 days. Flexible bronchoscopy at 7, 28, 90 and 180 days showed no abnormalities. Complete healing was attained in all patients by day 28.


CONCLUSIONS
Level I or II PITL should be managed non-surgically. When adequate respiratory status is present, Level IIIA PITL can be managed conservatively in selected institutions only, because these injuries are high-risk injuries. Any PITL associated with injury involving the oesophagus or with mediastinitis (Level IIIB) must be treated as soon as possible by surgery.
Cardillo
Giuseppe
G
Department of Thoracic Surgery, Azienda Ospedaliera San Camillo-Forlanini, Carlo Forlanini Hospital, Rome, Italy. gcardillo@scamilloforlanini.rm.it
Carbone
Luigi
L
Carleo
Francesco
F
Batzella
Sandro
S
Jacono
Raffaelle Dello
RD
Lucantoni
Gabriele
G
Galluccio
Giovanni
G
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001999:Bronchoscopy; D002648:Child; D005260:Female; D015718:Fibrin Tissue Adhesive / Q000627:therapeutic use; D006801:Humans; D007442:Intubation, Intratracheal / Q000009:adverse effects*; D022125:Lacerations / Q000145:classification* / Q000209:etiology / Q000473:pathology / Q000628:therapy; D008297:Male; D008875:Middle Aged; D014014:Tissue Adhesives / Q000627:therapeutic use; D014132:Trachea / Q000293:injuries* / Q000473:pathology; D015599:Trauma Severity Indices; D016896:Treatment Outcome; D055815:Young Adult
D015718:Fibrin Tissue Adhesive; D014014:Tissue Adhesives