Tracheal injuries and fistulas

Abstract

Tracheal and tracheobronchial injuries due to trauma or iatrogenic etiology are rare but potentially lethal events. Traumatic injuries result from penetrating trauma (in 75–80 % of cervical tracheal injuries), but most are associated with blunt thoracic trauma: High-energy impact or rapid hyperextension. About 80 % of blunt tracheal ruptures occur within 2.5 cm of the carina, resulting in a circular disruption. The most common reasons for iatrogenic tracheal lacerations are single-lumen intubations under emergency conditions and dilational tracheostomies. The risk of tracheal lacerations seems to increase with difficult or emergency intubations, multiple vigorous attempts by an inexperienced anesthesiologist, or the inappropriate use of a stylet. Overweight patients are susceptible to an overestimation of the size of their endobronchial anatomy and hence the selection of oversized endotracheal tubes. Iatrogenic lacerations typically result in a longitudinal tear in the membranous part of the trachea that may reach down into the main bronchus. Typical symptoms are dyspnea, hemoptysis, (massive) soft tissue or mediastinal emphysema, and pneumothorax. However, the diagnosis may be delayed because superficial tracheobronchial injuries are not always readily apparent. Tracheobronchoscopy will reveal the location and extent of the laceration. Radiographic findings may include pneumothorax, pneumomediastinum, and fractures of the bony thorax.