C Perry, B Phillips
endoluminal stent, medicine, percutaneous tracheostomy, surgery
C Perry, B Phillips. Managing Tracheal Perforations Following Percutaneous Dilation Tracheostomy. The Internet Journal of Surgery. 2000 Volume 2 Number 1.
In the overall management of patients requiring
prolonged mechanical ventilatory support, Percutaneous Dilation Tracheostomy
(PDT) has replaced open tracheostomy in many centers. While infrequent, one
of the most devastating morbidities associated with PDT is tacheal wall
injury. We have successfully managed two such injuries with endotracheal
tube advancement beyond the anatomical site of laceration thereby cresting a
temporary, but functional, endoluminal stent.
Ciaglia first described the technique of Percutaneous Dilation Tracheostomy (PDT) in 1985.1 Subsequent reports revealed a complication rate from two to thirty-nine percent.2,3 In our review of the literature, the most common complications included hemorrhage, loss of airway, hypoxia, pneumothorax, peristomal leak, and tracheal wall injuries.3,4 Prior reports have documented successful repair of posterior tracheal lacerations occurring during PDT with either local exploration or thoracotomy (primary closure and drainage).5 However, managing this injury with a thoracotomy adds considerable morbidity. An alternative to traditional management, endoluminal stenting (i.e., endotracheal tube advancement beyond the tracheal laceration), has been described for injuries associated with open tracheostomy.6,7 To our knowledge this theory has not been applied for injuries occurring during PDT. Presented are two cases of tracheal wall injury occurring during PDT, which were both managed with endoluminal stenting.
A twenty-year-old male, ejected during a high-speed motor vehicle crash, was admitted to the intensive care unit for a closed head injury (GCS 3T). The patient had been orally intubated prior to his arrival. He was extubated on the fourth hospital day, subsequently aspirated and required re-intubation. He developed ARDS requiring pressure controlled inverse ratio ventilation. On his tenth intensive care day, a percutaneous bedside dilation tracheostomy was performed. The patient developed subcutaneous emphysema and a tension pneumothorax with a continuous air leak after tube thoracostomy. Subsequent bronchoscopy revealed a small linear posterior tracheal wall laceration just distal to the insertion site. An oral endotracheal tube was placed under bronchoscopic guidance with the cuff inflated beyond the site of perforation and the tracheostomy tube was removed. Esophagoscopy was unremarkable. Repeat endoscopy two weeks later revealed mucosal healing. The mechanical ventilatory support was subsequently weaned and the patient extubated. He continues to do well at six months follow-up.
A twenty year old male was admitted to the intensive care unit after sustaining a severe closed head injury (GCS 3T) and femur fracture in a motor vehicle collision. He had been orotracheally intubated in the field for unresponsiveness. He received PDT on hospital day three. The patient developed massive subcutaneous emphysema and a pneumothorax requiring chest tube thoracostomy. Bronchoscopy demonstrated a linear disruption of the posterior trachea, distal to the tracheostomy site. Esophogoscopy did not reveal an esophageal injury. An endotracheal tube was advanced under bronchosopy to a point beyond the tracheal laceration, and the tracheostomy tube was removed. Repeat bronchoscopy one week later revealed healing of the tracheal perforation and a percutaneous tracheostomy was placed. The patient eventually was weaned from mechanical support.
Bedside PDT has several advantages when compared to oral endotracheal intubation: improved pulmonary hygiene and patient comfort, as well as facilitating mechanical weaning.8 In addition, PDT is less expensive than open tracheostomy and avoids the risks associated with transportation to the operative suite.9,10 At our institution, an open tracheostomy performed in the operating room will cost $2,463
Oral endotracheal tube advancement beyond the site of tracheal perforation is an option for the management of small iatrogenic tracheal lacerations occurring in clinically stable patients after PDT. However, further experience with this technique of tracheal stenting is necessary to evaluate its overall efficacy and long-term results.
Charles Perry M.D.
The University of Arizona
Department of General Surgery
1501 North Campbell Ave.
P.O. Box 245058
Tucson, AZ 85724-5058
Fax: (520) 626-2247
Phone: (520) 626-7747