Novel approach to management of a posterior tracheal tear complicating percutaneous tracheostomy

B. P. Madden*, A. Sheth, T. B. L. Ho and G. McAnulty

Department of Cardiothoracic Surgery, St George’s Hospital, Blackshaw Road, London SW17 0QT, UK

*Corresponding author. E-mail: adassa.savizon@stgeorges.nhs.uk

Accepted for publication: October 6, 2003


    Abstract
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
We treated a patient who developed a posterior tracheal wall perforation and severe respiratory compromise following percutaneous tracheostomy, using a covered expandable metallic stent. The stent was deployed under direct vision using rigid and fibreoptic bronchoscopy. The defect was sealed and the right lung, which had been collapsed, was re-expanded. The patient was subsequently weaned from mechanical ventilation. Late complications included halitosis, which was treated with nebulized colistin sulphate, and the development of intratracheal granulation tissue, which was cleared using low power (10 W) Nd:YAG laser.

Br J Anaesth 2004; 92: 437–9

Keywords: equipment, tracheal stent; complications, tracheal tear; surgery, percutaneous tracheostomy


    Introduction
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
The introduction of a new generation of expandable metallic stents has led to significant improvement in the management of patients with large airway compromise, for whom formal surgical repair may be inappropriate or contraindicated.1 We describe the use of a covered expandable metallic tracheal stent in a patient who developed a large posterior tracheal tear complicating percutaneous tracheostomy.


    Case report
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
A 58-yr-old male who had a history of hypertension and hyperthyroidism was admitted to the intensive care unit of his local hospital with respiratory failure, secondary to severe pneumonia. He was treated with i.v. antibiotics and mechanical ventilation. His chest X-ray showed bilateral pulmonary infiltrates and a heavy growth of Pseudomonas aeruginosa was cultured from the sputum. Fourteen days after tracheal intubation, percutaneous tracheostomy was performed using a serial dilatation technique (Cook Cialgia). Fibreoptic bronchoscopy was not used. Immediately after the tracheostomy, the patient developed surgical emphysema and a right-sided pneumothorax was diagnosed. A right intercostal chest drain was inserted and he continued to be mechanically ventilated through the tracheostomy tube. However, the right lung failed to re-expand. The patient was hypoxaemic despite ventilation with an inspired oxygen fraction of 1.0 (PaO2 6.8 kPa). Sedation with midazolam (6 mg h–1) was continued and intermittent boluses of atracurium were given to achieve neuromuscular block. Within 6 h he was transferred to our intensive care unit with a diagnosis of tracheal perforation. Mechanical ventilation was continued via the tracheostomy tube. A nasogastric tube was inserted.

Following a brief period of stabilization after transfer, and approximately 12 h after the tracheostomy, the patient was taken to the operating theatre where he was placed on a trolley in the supine position with a sandbag beneath the shoulders and the neck extended. Anaesthesia was maintained with a propofol infusion and bolus doses of alfentanil. Neuromuscular block was achieved with boluses of atracurium. The tracheostomy tube was removed and a rigid bronchoscope introduced. Ventilation was established using a Sanders jet ventilator. A fibreoptic bronchoscope was then introduced through the lumen of the rigid instrument and a 3.5 cm long tear of the middle third of the membraneous trachea was identified, extending to 2.5 cm above the carina. There was haemorrhage throughout the endobronchial tree.

An 8 cm (6.5 cm covered portion) expandable metallic stent (Fig. 1) was inserted under direct vision. This fully sealed the defect and did not obstruct either main bronchus. A 7 mm inside diameter armoured translaryngeal tracheal tube was introduced through the stent and the patient was effectively ventilated without a significant air leak. A post-procedure chest X-ray showed expansion of the right lung. The chest drain was removed 2 weeks following stent insertion by which time the right lung was expanded fully and there was no further air leak into the pleural cavity. Bronchoscopy at this time showed a satisfactory position of the stent with complete seal of the tracheal defect. The patient was weaned from mechanical ventilatory support over the following week.



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Fig 1 UltraflexTM covered stent. (Courtesy of Boston Scientific, MA, USA.)

 
After discharge to the ward, a gastrograffin swallow suggested a degree of tracheal aspiration but no evidence of tracheoesophageal fistula. The patient continued to receive nasogastric feeding and speech therapy for a further 3 weeks before discharge home.

The patient was re-admitted 3 months later for planned fibreoptic bronchoscopy under general anaesthesia. This demonstrated a satisfactory stent position but some granula tion tissue lying proximally. This tissue was removed with forceps. Scheduled bronchoscopy under general anaesthesia at 6 months again revealed a small ridge of granulation tissue proximal to the stent. This was removed with low power (10 W) Nd:YAG laser therapy.

The patient has returned to work and remains asymptomatic apart from some halitosis, which is controlled with nebulized colistin sulphate.


    Discussion
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 Abstract
 Introduction
 Case report
 Discussion
 References
 
Posterior tracheal wall rupture is an uncommon, although well recognized, potentially fatal injury, which may complicate percutaneous tracheostomy.2 It is still uncertain whether a single or serial dilatation technique carries a higher risk of this complication. Minor, posterior, incomplete tears are more common and usually heal without intervention. Larger, complete tears may present with airway bleeding, air leak around the tracheostomy tube or into the mediastinum, inability to achieve adequate ventilation, or pneumothorax. Urgent surgical intervention may be indicated and the approach may necessitate cardiopulmonary bypass.3 However, patients who require tracheostomy in the intensive care unit frequently have other significant co-morbidity, which can render the risk of surgical intervention high or prohibitive.

Covered stents, in which a single layer of translucent polyvinyl chloride envelops the metallic frame (UltraflexTM, Boston Scientific, Watertown, MA, USA) (Fig. 1), have been developed recently.4 5 Their fine titanium mesh construction and mid-section covering leads to a uniform radial tension on the airway wall and prevents penetrating growth of granulation tissue. Furthermore, they can effectively seal defects. Tracheal or bronchial ischaemia, wall perforation, and migration of the stent are uncommon.1 5 These stents are usually deployed under direct vision using a rigid bronchoscope.

The development of these stents represents a significant step forward in the management of patients with large airway compromise because of intrinsic or extrinsic obstruction, or fistula formation. They offer an effective, direct and less invasive means of sealing tracheal tears.6 The procedure is straightforward and can be performed in the intensive care unit. Stent deployment commits the patient to prospective outpatient surveillance to monitor for complications. Although uncommon these include granulation tissue formation, stent migration, halitosis, and recurrent respiratory tract infection.5

Fibreoptic bronchoscopic inspection during percutaneous tracheostomy to confirm correct positioning of the guidewire within the tracheal lumen is likely to reduce the risk of inadvertent posterior tracheal damage and perforation. But it may not eliminate the incidence of this complication entirely.7

The employment of a covered expandable metallic stent should be considered for the treatment of a tear complicating percutaneous tracheostomy, particularly for those patients in whom the risk of surgery is unacceptably high.


    References
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 Abstract
 Introduction
 Case report
 Discussion
 References
 
1 Rafanan AL, Mehta AC. Stenting of the tracheobronchial tree. Radiol Clin North Am 2000; 38: 395–408[ISI][Medline]

2 Walz MK, Schmidt U. Tracheal lesion caused by percutaneous dilatational tracheostomy—a clinico-pathological study. Intensive Care Med 1999; 25: 102–5[CrossRef][ISI][Medline]

3 Sadony V, Schramm G, Doetsch N. Management of extensive lesions of the lower trachea using emergency cardiopulmonary bypass. Thorac Cardiovasc Surg 1979; 27: 195–8[ISI][Medline]

4 Madden BP, Stamenkovic SA, Mitchell P. Covered expandable tracheal stents in the management of benign tracheal granulation tissue formation. Ann Thorac Surg 2000; 70: 1191–3[Abstract/Free Full Text]

5 Madden BP, Datta S, Charokopos N. Experience with Ultraflex expandable metallic stents in the management of endobronchial pathology. Ann Thorac Surg 2002; 73: 938–44[Abstract/Free Full Text]

6 Madden B, Datta S, Hussain I, McAnulty G. Tracheal stenting for rupture of the posterior wall of the trachea following percutaneous tracheostomy. Monaldi Arch Chest Dis 2001; 56: 320–1[Medline]

7 Hinerman R, Alvarez F, Keller CA. Outcome of bedside percutaneous tracheostomy with bronchoscopic guidance. Intensive Care Med 2000; 26: 1850–6[CrossRef][ISI][Medline]