To the Editor,

We report a case of tracheobronchial rupture (TBR) that occurred during mediastinoscopy and was further complicated by severe respiratory distress syndrome. The patient was conservatively treated by selective bilateral main stem bronchial intubation without tracheostomy. The patient gave written consent for publication of this article.

A 38-yr-old female was referred for enlarged mediastinal nodes without systemic symptoms. Bronchial biopsies were negative for malignant cells and mycobacterium tuberculosis (MTB) stain. The patient underwent mediastinoscopy; however, during the procedure, severe bleeding developed from the biopsied right lower paratracheal nodes and did not stop with tamponade. An attempt at hemostasis with electric coagulation resulted in a tear, 1 cm wide, involving the anterior lower tracheal and right main stem bronchial wall. The patient was hemodynamically stable without any respiratory impairment and her trachea was extubated and managed conservatively. On the fifth postoperative day, severe respiratory distress syndrome developed. A computed tomography (CT) scan showed bilateral interstitial/alveolar infiltrates, pleural effusion, pneumomediastinum, and subcutaneous emphysema. Hypoxemia and ensuing septic shock required mechanical ventilation, invasive hemodynamic monitoring, fluids, and norepinephrine infusion. Virtual CT (Figure) and bronchoscopy confirmed a carinal tear not susceptible to be bridged by an orotracheal tube. To ensure emergency respiratory support, the TBR was crossed over by selective bilateral main stem bronchial intubation using Ruschelit® Super Safety Clear™ microlaryngeal tubes, 38 cm long (Rusch; Teleflex Medical, NC, USA). The internal diameter (5 mm) of the tube facilitated daily bronchoscopy to verify correct bronchial tube positioning as well as to clear secretions. A protective ventilation strategy was adopted with 6 mL·kg−1 tidal volume and < 35 cm H2O transalveolar pressure. Nodal biopsy examination showed tubercular granulomas with a positive acid-fast stain. Specific antimicrobial treatment was started. A CT scan on the sixth day of mechanical ventilation showed resolution of both the alveolar infiltrate and the pneumomediastinum. Ventilatory weaning began on the tenth day postoperatively, and the patient was discharged from the intensive care unit on the 15th day. One year following injury, the patient had no clinical complaints, and bronchoscopy revealed complete healing of the mucosal tracheal defect without any signs of stenosis.

Figure
figure 1

Tracheal anterior wall lesion on the computerized tomography virtual bronchoscopy

Full size image

There is evidence supporting the conservative management of TBR, even in mechanically ventilated patients.1,2 Most published reports of conservatively managed iatrogenic TBR describe longitudinal lacerations of the posterior membranous tracheal wall, usually in association with intubation or tracheostomy. These defects are generally regularly shaped with well-vascularized edges. The current report presents a necrotic irregularly-shaped disruption of the anterior cartilaginous tracheal wall. Our experience substantiates that conservative management can be an effective course even in such unfavourable cases.

Whether or not immediate surgical repair might have prevented the occurrence of mediastinitis and respiratory distress syndrome is not within the scope of this article. Once acute respiratory failure had developed, several therapeutic options were considered: 1) surgical repair, which was excluded because of a reported high mortality rate in ventilator-dependent patients and the fear of suture disruption due to MTB infection; 2) stent placement, which was considered as the last resort due to positioning considerations, hypergranulation and removal; 3) bilateral selective main stem bronchial intubation with the two cuffs inflated distal to the carinal tear was successful in this case despite mechanical ventilation, septic shock, and respiratory distress syndrome. Conti et al. 3 reported a series of 30 patients with iatrogenic TBR. Six of those patients were treated by bridging the tracheal defect with two tubes inserted through a large tracheostomy. The present report supports the feasibility of bilateral orotracheal bronchial intubation without tracheostomy, owing to the use of small extra-long endobronchial tubes. Potential risks of this technique are tear enlargement during cannulation and tube dislodgment with atelectasis/pneumonia of the right upper lobe. Deep sedation and daily bronchoscopy are therefore recommended.