INTRODUCTION: Tracheal laceration is a rare and potentially deadly complication of endotracheal intubation. Primary surgical repair is considered the preferred treatment, however patient co-morbidities may preclude surgical intervention.
CASE PRESENTATION: A 77-year-old female was intubated by Emergency Medical technicians for respiratory arrest at a skilled nursing facility. By the time she was brought to the Emergency Department subcutaneous emphysema was noted and a CT scan of her chest showed a 4cm full-thickness tear in the mid trachea involving the membranous layer. Emergency thoracotomy with posterior tracheal repair was performed and a chest tube left in place. Air-leak persisted and then increased and the tracheal repair was found to have dehisced along the suture lines. A second surgery was performed for revision along with a tracheostomy. A long tracheostomy tube was used with the intent of bridging the tracheal repair site. She remained stable for a few days but when her air-leak increased again a repeat CT scan was obtained. It showed tracheal repair dehiscence again with the tracheostomy tube extending into the right pleural space through the defect in the right posterolateral tracheal wall. The patient developed sepsis and additional surgical interventions were deemed to be prohibitively risky. A decision was made to attempt tracheal stenting in an effort to reduce her air leak, but the tracheal tear was noted to extend down to the main carina and it was felt that a tracheal self expandable metal stent could not be used because of the extent of the tracheal defect. A customized silicone Y stent was then placed via rigid bronchoscopy, completely covering the tracheal laceration. Almost immediately, the air-leak decreased and her oxygenation improved. She continued to improve clinically over the following days, with resolution of her sepsis and pneumonia. She was eventually discharged to a long-term acute care facility.
DISCUSSIONS: Early surgical repair has traditionally been considered as the cornerstone of therapy; however non-operative management of tracheal laceration has been described. Surgical repair is particularly advocated for full thickness lacerations greater than two cm and those involving the carina. With the significant morbidity and mortality associated with surgical repair, non operative techniques may be necessary in some patients. Massimo et al reported successfully bridging tracheal tears with endotracheal tubes in 13 non operable patients. There are few case reports of self-expandable metal stents used to manage tracheal tears, but these cannot be used when the tear extends to the carina. Metal stents are also more difficult to remove. Silicone Y stents cover the carinal region and are easily removed even following long emplacement times. They are also less prone to migration compared with straight silicone stents. We believe this is the first report of the successful use of a silicone Y stent to manage a tracheal tear after failure of surgical attempts.
CONCLUSION: Surgical repair remains the primary management for tracheal tears. Silicone Y stent placement may be a helpful option in patients with large tracheal tears, who are not surgical candidates, or have failed surgery.
DISCLOSURE: Somnath Ghosh, No Financial Disclosure Information; No Product/Research Disclosure Information