Acute major airway injuries: clinical features and management

Patients with an acute major airway injury are coming at our attention with increasing frequency. Despite of its nature, post-traumatic or iatrogenic, these lesions may be life-threatening. An early diagnosis and a prompt treatment reduce morbidity and mortality.

In the last 10 years, on a total of 55 patients treated in our institution for benign lesions of the major airway, 20 were with an acute injury; eleven females and nine males with a mean age of 58 years (range of 24--92). Twelve lesions were iatrogenic (orotracheal intubation) and eight were post-traumatic (three blunt traumas, five penetrating traumas). The cervical trachea was involved in 13 cases (one associated to an incomplete esophageal transection and two associated to laryngeal injuries), the thoracic trachea in six cases (four extended to the right mainstem one and to the left). Sixteen patients underwent immediate surgical repair (13 direct sutures of the tear and three complex restorations of the airway): 11 by cervicotomy and five by thoracotomy. In six cases the suture of a posterior tracheal wall tear was achieved through a new approach which provides for a small collar incision and a longitudinal tracheotomy.

All the patients were discharged healed with a normal patency of the airway. At a mean follow up of 49 months (range of 9--122) endoscopy showed a perfect healing process of the lesions. One patient, treated in a conservative fashion, required endoscopic laser Nd-YAG removal of a granuloma.

Early diagnosis and surgical repair are the goals to persecute to achieve the best outcomes in this potentially lethal lesions. The surgical approach should be the thoracotomy if the trauma involves the 1/3 inferior trachea and/or a mainstem, the cervicotomy in the case it was injured the 2/3 superior trachea and the larynx. Posterior tracheal wall tears may be repaired via the new transcervical/transtracheal technique. The conservative treatment should be reserved to those patients with minimal signs and symptoms, and with an adequate patency of the airways.