Indications for surgery in tracheobronchial ruptures

Ruptures of the tracheobronchial tree present a life-threatening situation. Nevertheless, therapy is still controversial. Though conservative treatment by antibiotics and intubation with the cuff inflated distal to the tear is favored by some authors, surgical repair is unavoidable in many cases.

We present a series of 31 patients (mean age 43.6 years, range 8--72 years) with iatrogenous or post-traumatic tracheobronchial ruptures treated since 1975. Fifteen ruptures were longitudinal tears of the trachea, not extending lower than a distance of 3 cm from the bifurcation, 11 involved the bifurcation and/or the main bronchi. The total length of the longitudinal tears ranged from 2 to 12 cm, five were transverse near complete abruptions of the trachea or main bronchi. Involvement of the full thickness of the wall with free view into the pleural space or to the esophageal wall was present in 29 cases. Twenty-nine out of the 31 patients underwent surgical repair and two were treated conservatively. The length and depth of the lesion, the degree of subcutaneous emphysema, pneumothorax and/or pneumomediastinum as well as clinical signs suggesting incipient mediastinitis were considered when making the decision for surgery.

Twenty-five out of the 29 patients experienced an uneventful recovery. Four patients died of sepsis unrelated to the tracheobronchial trauma. One of the two patients who underwent conservative therapy also recovered uneventfully. The other one died because of multi-organ failure due to underlying myocardial infarction.

Conveniently localized short lacerations, especially if they do not involve the whole thickness of the tracheal wall, can be treated with antibiotics and intubation with the cuff inflated distal to the tear, avoiding high intra-bronchial pressures also after eventual extubation. In all other cases surgical repair is to be preferred.