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J.M. Wihlm

Conservative vs. surgical approach in tracheo-bronchial traumas. Les Hôpitaux Universitaires de STRASBOURG. J.M. Wihlm. Department of Thoracic Surgery, Strasbourg, France. Classification of tracheo-bronchial traumas Controversy about conservative management

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J.M. Wihlm

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  1. Conservative vs. surgical approach in tracheo-bronchial traumas Les Hôpitaux Universitaires de STRASBOURG J.M. Wihlm Department of Thoracic Surgery, Strasbourg, France

  2. Classification of tracheo-bronchial traumas Controversy about conservative management Tracheal laceration after intubation Criteria for conservative or surgical treatment Conclusion Tracheo-bronchial traumas

  3. blunt injury 1-2% penetrating injury 2-9% gunshot stab iatrogenic endoscopic intubation combined : larynx, esophagus Classification of tracheo-bronchial traumas Incidence Location

  4. Surgical treatment Grillo, Mathisen, Symbas ... Couraud, Marty-Ane, Massard ... Conservative management surgical series D'Odemont, Amauchi, Jones ... individual publications Molins ... discussions ... Controversy about conservative management

  5. Total cicumferential disruptions 24 Laryngo-tracheal junction 14 Trachea 1 Main bronchi 7 (1+) Lobar bronchi 2 Non- cicumferential disruptions23 Laryngo-tracheal junction 6 Trachea 9 Main bronchi 4 (3+) Lobar bronchi 4 Post-traumatic tracheobronchial lesions 47 cases Velly, Couraud : Eur J Cardio-thoracic Surg (1991) 5 : 352-355

  6. Associated lesions Musculoskeletal 27 Brain 19 Pulmonary artery 4 (2+) Esophagus 2 (1+) Spine 4 Heart 1 Aorta 1 Post-traumatic tracheobronchial lesions 47 cases Velly, Couraud : Eur J Cardio-thoracic Surg (1991) 5 : 352-355

  7. Treatment (1) Death before treatment 2 Medical and endoscopic management 7 Surgical procedure 38 End-to-end anastomosis 20 with stenting 13 Suture of laceration 14 (1+) Pulmonary resection 4 (1+) Post-traumatic tracheobronchial lesions 47 cases Velly, Couraud : Eur J Cardio-thoracic Surg (1991) 5 : 352-355

  8. Treatment (2) Medical and endoscopic management : 7 Laryngotracheal intubation + laser 2 partial laryngotracheal disruption associated injuries of the larynx Medical + endoscopic follow-up 5 short tracheal laceration partial bronchial disruption Post-traumatic tracheobronchial lesions 47 cases Velly, Couraud : Eur J Cardio-thoracic Surg (1991) 5 : 352-355

  9. 1980 - 1995 14 patients ¨1 male : 13 females ¨ median age : 54 years (15 - 80) ¨ mechanism : - single lumen tube : 9 - tracheostomy : 4 - double lumen tube : 1 Tracheobronchial lacerations after intubation and tracheostomy Massard, Wihlm : Ann Thorac Surg (1996) 61: 1483-87

  10. 1- circumstances ¨females : 9 ¨surgery : 7 intensive care : 2 ¨2 : difficult intubation (stylet) ¨4 : selective right main-stem intubation Tracheobronchial lacerations after intubation experienced physician in all events Massard, Wihlm : Ann Thorac Surg (1996) 61: 1483-87

  11. 2- signs and diagnosis ¨constant signs : pneumomediastinum / cervical emphysema ¨accessory signs : pneumothorax : 2 ¨ moment of diagnosis : induction : 1 recovery room : 2 Tracheobronchial lacerations after intubation Massard, Wihlm : Ann Thorac Surg (1996) 61: 1483-87

  12. 3- Location of tracheal tears (n=9) Massard, Wihlm : Ann Thorac Surg (1996) 61: 1483-87

  13. Endoscopic view

  14. Tracheobronchial lacerations after intubation 4- Interval between injury & repair

  15. 5- treatment ¨armed expectancy : 3 ¨ emergency repair : 6 - cervical approach : 1 - right side thoracotomy : 5 suture-repair of membranosa + pleural flap Tracheobronchial lacerations after intubation Massard, Wihlm : Ann Thorac Surg (1996) 61: 1483-87

  16. 6- modalities of anaesthesia ¨ proximal tear : selective right or left sided single lumen intubation (endoscopic control) ¨ distal tear : - proximal single lumen intubation - as the tear is exposed : - 4 x selective intubation of left bronchus - 1 x Jet Tracheobronchial lacerations after intubation Massard, Wihlm : Ann Thorac Surg (1996) 61: 1483-87

  17. 7- results ¨weaning and extubation : - early < 12 hours : 4 - intermediate = 24 hours : 1 - delayed POD+5 : 1 ¨ tracheal and bronchial healing - per primam : 8 - covered dehiscence : 1 Tracheobronchial lacerations after intubation Massard, Wihlm : Ann Thorac Surg (1996) 61: 1483-87

  18. ¨inexperience or technical difficulties are not the primum movens ¨cuff inflation +++ selective right side intubation ! Tracheobronchial lacerations after intubation Discussion : Mechanisms

  19. Mechanism of intubation-related tracheal tears

  20. Prognosis depends mainly on ¨precociousness of diagnosis and treatment ¨underlying health state Conservative treatment is an option Tracheobronchial lacerations after intubation Conclusion Massard, Wihlm : Ann Thorac Surg (1996) 61: 1483-87

  21. Elective circumstances cause delay in diagnosis clinical and radiological symptoms location laryngo-tracheal disruption + assoc. lesions membraneous trachea distal bronchus endoscopic presentation : covering, gap length of tear : < 3cm, partial Criteria for conservative or surgical treatment A.

  22. Imposed general condition age delay in diagnosis sepsis and inflammation ventilator dependency associated lesions brain injury polytrauma failure of initial treatment Criteria for conservative or surgical treatment B.

  23. Surgical approach = gold standard Multiple anatomo-clinical presentations Conservative treatment in selected cases Controversy necessary for improving both selection and care of a still severe condition Conclusion

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