Indications for surgery in tracheobronchial ruptures

Objective: Ruptures of the tracheobronchial tree present a life-threatening situation. Nevertheless, therapy is still controversial. Though conservati ve treatment by antibiotics and intubation with the cuff inflated distal to the tear is favored by some authors, surgical repair is unavoidable in man y cases. Methods: We present a series of 31 patients (mean age 43.6 years, range 8-72 years) with iatrogenous or posttraumatic tracheobronchial ruptur es treated since 1975. Fifteen ruptures were longitudinal tears of the trac hea, not extending lower than a distance of 3 cm from the bifurcation, 11 i nvolved the bifurcation and/or the main bronchi. The total length of the lo ngitudinal tears ranged from 2 to 12 cm, five were transverse near complete abruptions of the trachea or main bronchi. Involvement of the full thickne ss of the wall with free view into the pleural space or to the esophageal w all was present in 29 cases. Twenty-nine out of the 31 patients underwent s urgical repair and two were treated conservatively. The length and depth of the lesion, the degree of subcutaneous emphysema, pneumothorax and/or pneu momediastinum as well as clinical signs suggesting incipient mediastinitis were considered when making the decision for surgery. Results: Twenty-five out of the 29 patients experienced an uneventful recovery. Four patients di ed of sepsis unrelated to the tracheobronchial trauma. One of the two patie nts who underwent conservative therapy also recovered uneventfully. The oth er one died because of multi-organ failure due to underlying myocardial inf arction. Conclusions: Conveniently localized short lacerations, especially if they do not involve the whole thickness of the tracheal wall, can be tre ated with antibiotics and intubation with the cuff inflated distal to the t ear, avoiding high intrabronchial pressures also after eventual extubation. In all other cases surgical repair is to be preferred. (C) 2001 Elsevier S cience B.V. All rights reserved.