Introduction: Tracheal rupture is a very rare but potentially devastating complication of oesophagectomy.
Conservative nonoperative treatment is planned for tracheal rupture in patients breathing spontaneously or with a planned extubation within the first 24 h. However, the management of patients with severe respiratory failure requiring mechanical ventilation remains a difficult problem.
Case: A 74 year old woman was admitted to our Intensive Care Unit post oesophagectomy resulting in a tear of the posterior trachea. The tear involved the lower 4 cm of the trachea, and the carina, and was repaired immediately. She was extubated post-operatively, and initially managed conservatively with high flow oxygen. On the second post-operative day she developed respiratory failure, with hypoxia, hypercarbia and respiratory distress, requiring positive pressure ventilation.Initially she was intubated orally, with a 5.0 endotracheal tube inserted into the right mainstem bronchus via fibreoptic bronchoscope. A tracheotomy was then performed, and a size 5.0 endotracheal tube was inserted into the left mainstem bronchus, via the tracheotomy, with the cuff inflated below the level of the tracheal tear. Once the left side was secure the oral tube was removed. Subsequently, a right sided 5.0 endotracheal tube was passed, via the tracheotomy, into the right mainstem bronchus with the cuff inflated below the level of the tear.Two separate ventilators were used, with pressure regulated volume control.Her arterial blood gases and chest x-ray improved over the following 24 hours.
Conclusion: For patients who require positive pressure ventilation post tracheal rupture, the presence of an endotracheal tube with an inflated cuff, and positive airway pressure impairs healing. For patients with disruption of the lower one third of the trachea, selective bilateral mainstem bronchus intubations to allow positive pressure ventilation are ideal. This a llows patients to be ventilated according to a protective ventilatory protocol while the tracheal rupture is allowed to heal.
1. Management of Low Tracheal Rupture in Patients Requiring Mechanical Ventilation for Acute Respiratory Distress Syndrome. Wallet, F et al. Anesthesiology: January 2008 - Volume 108 - Issue 1 - pp 159-162