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      Left mainstem bronchial rupture during one-lung ventilation with Robertshaw double lumen endobronchial tube -A case report-

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          Abstract

          Lung separation using a double-lumen endobronchial tube is necessary for video assisted thoracoscopy (VATs). Bronchial rupture after intubation with a double-lumen endobronchial tube has been rarely reported. We report a case of a 70-year-old man who had solitary pulmonary nodule in his right upper lobe. He was intubated with a left-sided Robertshaw double-lumen endobronchial tube. He underwent a VATs right upper lobectomy with the one-lung ventilation of left lung. During the operation, the rupture of the left mainstem bronchus was detected. Immediately, the thoracotomy was performed and the ruptured left mainstem bronchus was repaired with absorbable sutures (vicryl). Seven days later he had a bronchoscopy to examine the left mainstem bronchus. There was no evidence of the bleeding, leakage and inflammation. Subsequent course was uneventful. Tracheobronchial injuries related to the double-lumen endobronchial tube are discussed.

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          Management of postintubation tracheobronchial ruptures.

          P Ramon, G. A. Wurtz, Marie Pougeoise … (2006)
          To determine whether nonoperative management can be applied to iatrogenic postintubation tracheobronchial rupture (TBR). Prospective cohort study. Thirty consecutive patients with TBR complicating intubation between June 1993 and December 2005 entered the study. Patients not receiving mechanical ventilation at time of diagnosis were treated nonsurgically. Patients receiving mechanical ventilation who were judged operable underwent surgical repair, while nonoperable candidates had their TBR bridged by endotracheal tubes. Fifteen patients not requiring mechanical ventilation underwent simple conservative management. TBR length measured 3.85 +/- 1.46 cm (mean +/- SD). Eight TBRs showed full-thickness rupture with frank anterior intraluminal protrusion of the esophagus. In three patients, transient noninvasive positive pressure ventilatory support (NIV) was necessary. All lesions healed without sequelae. Two patients receiving mechanical ventilation underwent surgical repair and died. Thirteen patients receiving mechanical ventilation were considered at high surgical risk, and TBR bridging was attempted as salvage therapy. Complete bridging was achieved in five patients by simply advancing the endotracheal tube distal to the injury. Separate bilateral mainstem endobronchial intubation was necessary in six patients whose TBRs were too close to the carina. Nine of 13 patients (69%) treated with nonoperative therapy completely recovered. We conclude that conservative nonoperative therapy should be considered in patients with postintubation TBR who are breathing spontaneously, or when extubation is scheduled within 24 h from the time of diagnosis, or when continued ventilation is required to treat an underlying respiratory status. Surgical repair should be reserved for cases in which NIV or bridging the lesion is technically not feasible.
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            Iatrogenic ruptures of the tracheobronchial tree.

            John R Silber, G Rettig, H. Hofmann … (2002)
            Iatrogenic tracheobronchial ruptures are seldom but severe complications after intubation or bronchoscopy. Therefore, we evaluated the reasons, the subsequent therapy and the outcome of patients with tracheal rupture, who were admitted to our hospital. In a retrospective study we examined 19 patients (15 women, four men; 43-87 years) treated for acute tracheobronchial lesions. Eleven (58%) patients had a tracheobronchial rupture by single-lumen tube, four (21%) by double-lumen tube and two patients (10%) by tracheal cannula. A total of 47% of whom were carried out under emergency conditions. Two patients had a rupture due to a stiff bronchoscopy. Mean symptoms were mediastinal and subcutaneous emphysema. Two emergency collar incisions had been done. The localization of ruptures was in all cases in the paries membranaceus, length: 1-7 cm (mean: 4.8 cm). The interval between the onset of symptoms and the diagnose differed widely (up to 72 h), nine (47%) diagnoses were made during intubation/bronchoscopy. One patient, with a small tear (1 cm) was treated conservatively with fibrin-glue. The other 18 patients had surgical repair through a thoracotomy. The postoperative mortality was determined with 42%, which was not dependent on the rupture but basically by the underlying diseases requiring intubation. Iatrogenic tracheal rupture is a dangerous complication with potentially high postoperative mortality, mostly influenced by the underlying disease. Early surgical repair must be the preferred treatment.
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              Tracheobronchial injuries. Conservative treatment.

              Michelle L. Lampl (2004)
              Tracheal lacerations are iatrogenic, localized, low impact injuries with longitudinal tears (in about 1:20,000 intubations). In contrast traumatic tracheobronchial ruptures are high velocity injuries with horizontal transections. Between 1986 and 2002, we treated 27 tracheobronchial injuries (8 bronchial 3 of them iatrogenic, 19 tracheal 17 of them iatrogenic (+1 horizontal rupture+1 tracheoesophageal stabbing)). Extension of the tears 5-12 cm. All bronchial ruptures, the tracheal rupture as well as six iatrogenic tracheal tears have been managed operatively. All the other underwent conservative treatment. (1) critically ill patients, (2) delay in diagnosis >72 h, and (3) refusal of operation. It consists in endotracheal intubation for 5-9 days. This way we prevent pressure peaks as well as retention achieving a continuous control. Conservative group: 12/13 patients survived, neither stenosis nor megatrachea. Operative group: 1 patient died (MOF), 1 postoperative stenosis (Montgomery tube for 2 months). Tracheobronchial ruptures have to be operated. Lacerations show frequently discrete clinical signs, but typical X-rays. They can be dealt with conservatively in the majority of cases as well as operatively. According to our experience, conservative treatment is safe and shows a mortality as low or lower than operative procedures.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Korean J Anesthesiol
                Journal ID (publisher-id): KJAE
                Title: Korean Journal of Anesthesiology
                Publisher: The Korean Society of Anesthesiologists
                ISSN (Print): 2005-6419
                ISSN (Electronic): 2005-7563
                Publication date (Print): December 2010
                Publication date (Electronic): 31 December 2010
                Volume: 59
                Issue: Suppl
                Pages: S21-S25
                Affiliations
                [1 ]Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea.
                [2 ]Department of Thoracic and Cardiovascular Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea.
                Author notes
                Corresponding author: Mi Hwa Chung, M.D., Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 948-1, Daerim 1-dong, Yeongdeungpo-gu, Seoul 150-071, Korea. Tel: 82-2-829-5226, Fax: 82-2-845-1571, mhchung20@ 123456hallym.or.kr
                Article
                DOI: 10.4097/kjae.2010.59.S.S21
                PMC ID: 3030039
                PubMed ID: 21286443
                SO-VID: 5e900e27-15be-468d-9c9b-632793610cb4
                Copyright © Copyright © The Korean Society of Anesthesiologists, 2010
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 10 March 2010
                Date revision received : 02 April 2010
                Date accepted : 13 April 2010
                Categories
                Subject: Case Report

                ScienceOpen disciplines: Anesthesiology & Pain management
                Keywords: bronchial rupture,intubation,double lumen endobronchial tube,complication
                Data availability:
                ScienceOpen disciplines: Anesthesiology & Pain management
                Keywords: bronchial rupture, intubation, double lumen endobronchial tube, complication

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