SESSION TITLE: Bronchology/Interventional Procedures Cases I
SESSION TYPE: Affiliate Case Report Slide
PRESENTED ON: Sunday, October 26, 2014 at 10:45 AM - 12:00 PM
INTRODUCTION: Tracheal laceration is a known complication of emergent endotracheal intubation. Patients with tracheal laceration present a management challenge. There is no established standard for treatment of this patient population. Interventions reported include conservative management, stent placement, or surgery.
CASE PRESENTATION: A 59 year-old female with status asthmaticus presented to an outside hospital after cardiac arrest. The patient underwent difficult intubation in the field. On arrival she was noted to have diffuse subcutaneous emphysema. CT scan of the chest showed subcutaneous emphysema, pneumomediastinum, and a right lateral posterior tracheal membrane tear. Patient was transferred to our institution for further management. Inspection bronchoscopy revealed a 7 cm full thickness longitudinal tear of the posterior membranous trachea extending from upper trachea to 2 cm above the main carina. Clinical course was complicated by status asthmaticus, aspiration pneumonia, and profound hypoxemia. Due to severe respiratory compromise surgical repair was not an option. Because of concerns that positive pressure ventilation and endotracheal tube position could both worsen tracheal injury, a tracheal stent was considered. In order for the patient to tolerate the procedure, especially in setting of severe respiratory compromise, the procedure was done with circulatory support from venovenous extracorporeal membrane oxygenation (VV-ECMO). While supported by VV-ECMO the patient underwent rigid bronchoscopy with placement of a polyurethane covered nitinol tracheal stent 16mm x 80 mm (Aero®). Patient remained on ECMO support for 48 hours after stent placement. Patient was weaned from mechanical ventilation and 4 weeks after stent placement the stent was removed demonstrating complete healing of the laceration.
DISCUSSION: Full thickness tracheal posterior membrane laceration can be managed with covered nitinol tracheal stent placement. EMCO can be utilized in patients with severe respiratory failure that otherwise would not tolerate rigid bronchoscopy for stent placement. There are no clear guidelines on timing for stent removal. Ideally stents should remain in place long enough to allow healing, but not long enough to make removal difficult.
CONCLUSIONS: Tracheal posterior membrane laceration can be managed with tracheal stent placement.
Reference #1: Yamamoto S, Endo S, Endo T, Mitsuda S. Successful silicon stent for life-threatening tracheal wall laceration. Ann Thorac Cardiovasc Surg. 2013 Feb 20;19(1):49-51.
DISCLOSURE: The following authors have nothing to disclose: Ehab Hussein, Ray Shepherd, Orlando Debesa, Samira Shojaee
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