Pedicled pericardial patch in tracheal reconstruction in children - Novel technique to provide vascularized tissue for salvaging difficult airways.

BACKGROUND: Management of large central airway defects are often complex. Children who present with these defects have multiple co-morbidities or have had previous surgeries. Surgical options include various tissue cover for these defects without longer term benefits. Vascularized autologous pericardial patch offers a better solution to these defects by providing vascularity and potential for remodelling in future. METHODS: 41 children (M:F of 24:17) were operated for large trachea-bronchial defects between January 2015 and August 2022. The median age of was 12 months with median weight of 8.9 kg (IQR 3.3 kg-17.7 kg) Causes leading to the central tracheal defect include failed repair of previous trachea-oesophageal fistula (TOF) (n = 21) and acquired fistula due to button battery injury (n = 11). Surgical repair consisted of autologous pedicled pericardial patch repair for the airway defect under cardiopulmonary bypass. RESULTS: There were two operative deaths related to extensive sepsis and necrosis of reconstructed trachea. Four children had further reoperation with additional patch. Bronchoscopy was used as surveillance in all these children, with use of airway stents (biodegradable stent) in 9 children. The median ventilation time was 8 days, with tracheostomy being needed in 5 for long term support. CONCLUSIONS: Autologous pericardial patch is a versatile technique and can be used to salvage large tracheal defects when other method have failed or not feasible. Tracheomalacia at the site of repair could be managed with biodegradable stents. Vascularity and ciliary function of the patch still needs to be evaluated.

Management of membranous tracheal rupture due to the endotracheal tube cuff during thyroid surgery.

Tracheobronchial ruptures can be extremely dramatic and life threatening and are encountered in approximately 5 out of 100,000 cases after orotracheal intubation. They can occur as a result of intubation, tracheostomy, and bronchoscopy. In this case report, we presented a 56-year-old female patient with a history of thyroid surgery 27 years prior who presented to our clinic with recurrent multinodular goiter. The patient underwent a complementary complication-free thyroidectomy assisted by intermittent intraoperative nerve monitoring. After hemostasis, final controls involving digital palpation of the possible remnants of the thyroid gland and a search for pathological lymph nodes in the central compartments, a mass structure with a rubbery consistency suspicious for residue thyroid tissue was palpated in both posterolateral aspects of the trachea, but more prominently in the left. The anesthesia team was asked to decrease the cuff pressure, assuming that the palpated mass could be the cuff of the endotracheal tube, and the mass was noted to shrink. The membranous tracheal rupture due to the endotracheal tube cuff was closed with sutures running superiorly, and a superiorly based strap muscle flap was placed over during thyroid surgery. The patient was discharged on day 7. A simple routine digital examination by the attending surgeon dealing with the thyroid surgery would contribute favorably to prognosis, as such a precaution would allow early repair in cases where such injuries occur.

Comparison of Mechanical Forces used in Open Tracheotomy versus Percutaneous Tracheotomy Techniques.

OBJECTIVE: To understand the etiology of tracheotomy-induced tracheal stenosis by comparing the differences in techniques and mechanical force applied with open tracheotomy (OT) versus percutaneous tracheotomy (PCT) placement. METHODS: This study is an unblinded, experimental, randomized controlled study in an ex-vivo animal model. Simulated tracheostomies were performed on 10 porcine tracheas, 5 via a tracheal window technique (OT) and 5 using the Ciaglia technique (PCT). The applied weight during the simulated tracheostomy and the compression of the trachea were recorded at set times during the procedure. The applied weight during tracheostomy was used to calculate the tissue force in Newtons. Tracheal compression was measured by anterior-posterior distance compression and as percent change. RESULTS: Average forces for scalpel (OT) versus trocar (PCT) were 2.6 N and 12.5 N (p < 0.01), with the dilator (PCT) it was 22.02 N (p < 0.01). The tracheostomy placement with OT required an average force of 10.7 N versus 23.2 N (p < 0.01) with PCT. The average change in AP distance when using the scalpel versus trocar was 21%, and 44% (p < 0.01), with the dilator it was 75% (p < 0.01). The trach placement with OT versus PCT had an average AP distance change of 51% and 83% respectively (p < 0.01). CONCLUSION: This study demonstrated that PCT required more force and caused more tracheal lumen compression when compared to the OT technique. Based on the increased force required for PCT, we suspect there could also be an increased risk for tracheal cartilage trauma. LEVEL OF EVIDENCE: NA Laryngoscope, 134:103-107, 2024.

[Tracheal rupture treated with robotic surgery: the importance of evidence-based practice in nursing management. A case report]. / Rottura tracheale trattata con chirurgia robotica: l'importanza dell'evidence-based practice nella gestione infermieristica. Un caso clinico.

. Tracheal rupture treated with robotic surgery: the importance of evidence-based practice in nursing management. A case report. Tracheal rupture is a very rare condition with high morbidity and mortality. While it has a multifactorial etiology, however it occurs most frequently after orotracheal intubation. The case of a 76-year-old woman who underwent out-of-hospital orotracheal intubation for severe respiratory failure due to a state of coma is described. The patient suddenly developed a subcutaneous emphysema extending from the chest to the skull due to tracheal laceration. The management of the case is described with special focus on nursing goals to prevent ventilator associated pneumonia and mediastinitis, avoid the endotracheal tube dislocation and further tracheal injuries. The case presented underlines the importance of a systematic recourse to evidence-based practice (EBP), which allowed to effectively manage a complex situation.

GATA6 promotes fibrotic repair of tracheal injury through NLRP3 inflammasome-mediated epithelial pyroptosis.

Tracheal injury is a challenging emergency condition that is characterized by the abnormal repair of the trachea. GATA6, a well-established transcription factor, plays a crucial role in tissue injury and epithelial regenerative repair. This study aims to evaluate the role of GATA6 in NF-κB-mediated NLRP3 inflammasome activation and pyroptosis after tracheal injury. Tracheal tissues and serum samples were collected from clinical patients and a rat model of tracheal injury. Upon GATA6 knockdown or overexpression, BEAS-2B and rat tracheal epithelial (RTE) cells were treated with lipopolysaccharides and nigericin before being co-cultured with primary tracheal fibroblasts. The changes of NLRP3 inflammasome activation and pyroptosis and their underlying mechanisms were detected. Additionally, the role of GATA6 downregulation in tracheal injury was verified in rats. GATA6 expression and NLRP3 inflammasome activation were upregulated following tracheal injury in the epithelium of granulation tissues. GATA6 silencing inhibited NLRP3 priming, NLRP3 inflammasome activation, and pyroptosis in BEAS-2B and RTE cells. Mechanistically, GATA6 was determined to have bound to the promoter region of NLRP3 and synergistically upregulated NLRP3 promoter activity with NF-κB. Furthermore, GATA6 overexpression promoted epithelial-mesenchymal transition via modulating the NF-κB/NLRP3 pathway. Epithelial NLRP3 inflammasome activation triggered ECM production in fibroblasts, which was suppressed by GATA6 knockdown and induced by GATA6 overexpression. Finally, the downregulation of GATA6 alleviated NLRP3 inflammasome-mediated pyroptosis induced by tracheal injury in rats, thereby reducing tracheal stenosis, inflammation, and fibrosis. GATA6 promotes fibrotic repair in tracheal injury through NLRP3 inflammasome-mediated epithelial pyroptosis, making it a potential biological therapeutic target for tracheal injury.

[Cervical Trachea Injury Caused by Suicide Attempt:Report of a Case].

Traumatic tracheal injuries are rare, but life-threatening. A 20-year-old man who became recluse stabbed in his neck by a kitchin knife for the purpose of suicide and was transferred to our hospital. He had stabbed wound about 8 cm in length in his anterior neck. No injury of lung, esophagus, cervical vessels was seen by cervical and chest enhanced computed tomography (CT). Emergency surgery was performed. Exploration of his neck revealed almost all of cartilage of trachea was cut in the hight just caudal to cricoid cartilage. The membranous portion of trachea was not injured. The cartilage of trachea was sutured. He was extubated on the 6th postoperative day and discharged on the 35th postoperative day. No injuries to his cervical vessels or esophagus must have contributed to his good postoperative course.j.

Operative Management of Aerodigestive Injuries: Improved Survival Over two Decades.

INTRODUCTION: Non-iatrogenic aerodigestive injuries are infrequent but potentially fatal. We hypothesize that advances in management and adoption of innovative therapies resulted in improved survival. METHODS: Trauma registry review at a university Level 1 center from 2000 to 2020 that identified adults with aerodigestive injuries requiring operative or endoluminal intervention. Demographics, injuries, operations, and outcomes were abstracted. Univariate analysis was performed, P < .05 was statistically significant. RESULTS: 95 patients had 105 injuries: 68 tracheal and 37 esophageal (including 10 combined). Mean age 30.9 (± 14), 87.4% male, 82.1% penetrating, and 28.4% with vascular injuries. Median ISS, chest AIS, admission BP, Shock Index, and lactate were 26 (16-34), 4 (3-4), 132 (113-149) mmHg, .8 (.7-1.1), and 3.1 (2.4-5.6) mmol/L, respectively. There were 46 cervical and 22 thoracic airway injuries; 5 patients in extremis required preoperative ECMO. 66 airway injuries were surgically repaired and 2 definitively managed with endobronchial stents. There were 24 cervical, 11 thoracic, 2 abdominal esophageal injuries-all repaired surgically. Combined tracheoesophageal injuries were individually managed and buttressed. 4 airway complications were successfully managed, and 11 esophageal complications managed conservatively, stented, or resected. Mortality was 9.6%, half from intraoperative hemorrhage. Specific mortality: tracheobronchial 8.8%, esophageal 10.8%, and combined 20%. Mortality was significantly associated with higher ISS (P = .01), vascular injury (P = .007), blunt mechanism (P = .01), bronchial injury (P = .01), and years 2000-2010 (P = .03), but not combined tracheobronchial injury. CONCLUSION: Mortality is associated with several variables, including vascular trauma and years 2000-2010. The use of ECMO and endoluminal stents in highly selected patients and institutional experience may account for 97.8% survival over the past decade.

[INTUBATION RELATED TRACHEAL RUPTURE: EXPECTING THE UNEXPECTED].

INTRODUCTION: This case involved a 67-year-old female who was admitted for general anesthesia for a mitral clip procedure. Following anesthesia induction, the patient underwent an uneventful orotracheal intubation. Shortly afterwards she developed an ongoing respiratory failure, accompanied by neck and chest subcutaneous emphysema. Upon workup, she was found to have a 6 cm long tracheal laceration on the posterior side. Emergency repair surgery was performed using an extracorporeal membrane oxygenator (ECMO). The patient passed away 11 days later from sepsis. The aim of this case report is to increase awareness of this rare intubation complication, and explore the best approach to prevent, diagnose and treat tracheal injuries during endotracheal intubation.

A Rare Self-Inflicted Stabbing to the Neck Injuring the Distal Trachea and Proximal Esophagus.

Penetrating neck trauma poses a significant risk to multiple vital structures, which if not treated immediately may lead to devastating consequences. Our patient presented after sustaining self-inflicted stab wounds to the neck. He was taken to the operating room for a left neck exploration and median sternotomy, revealing a distal tracheal injury. Following repair of the tracheal injury, an intraoperative esophagogastroduodenoscopy demonstrated a full-thickness esophageal injury 15 cm proximal to the tracheal injury. Both injuries were the result of separate stab entries originating from the same external midline wound. To our knowledge, this case report is unique in bringing this circumstance to the literature, demonstrating the importance of full intraoperative examination to assess for concomitant wounds in stab injuries after the initial pathology has been found and the initial stab trajectory understood.

[Traumatic Tracheobronchial Injuries - Recommendation of the Interdisciplinary Working Group of the DGT and DGU to Establish a Uniform Classification for Diagnostics and Therapy]. / Traumatische tracheobronchiale Verletzungen ­ Empfehlung der interdisziplinären Arbeitsgruppe der DGT und DGU zur Etablierung einer einheitlichen Klassifikation für Diagnostik und Therapie.

Traumatic tracheobronchial injuries are extremely rare. In comparison, iatrogenic injuries are somewhat more common. A literature search revealed that there is a large number of case reports and small case series for this clinical entity. There are hardly any reviews and they usually have a low level of evidence. One reason for this is the lack of a classification to allow comparison of the individual cases with each other. There is only one classification for iatrogenic injuries of the posterior tracheal wall, which the authors modified and expanded with regard to traumatic tracheobronchial injuries. This classification was extended by the authors to also include traumatic injuries. A three-digit classification is presented here. The grading of the injury covers the entire spectrum of injury patterns, from peribronchial emphysema to wall injuries of different depths to subtotal and complete rupture of the bronchus. In addition, the anatomical location and the cause of the injury were added to the classification. The levels of injury in the tracheobronchial tree are distinguished anatomically. The third digit distinguishes traumatic, iatrogenic and spontaneous injuries. On the basis of the three-digit classification resulting from these parameters, it is possible to group individual cases together and to develop recommendations for diagnostics and therapy.

Human Tracheal Transplantation.

Long-segment tracheal airway defects may be congenital or result from burns, trauma, iatrogenic intubation damage, or tumor invasion. Although airway defects <6 cm in length may be reconstructed using existing end-to-end reconstructive techniques, defects >6 cm continue to challenge surgeons worldwide. The reconstruction of long-segment tracheal defects has long been a reconstructive dilemma, and these defects are associated with significant morbidity and mortality. Many of these defects are not compatible with life or require a permanent extended-length tracheostomy that is fraught with complications including mucus plugging and tracheoesophageal fistula. Extensive circumferential tracheal defects require a reconstructive technique that provides a rigid structure able to withstand the inspiratory pressures, a structure that will biologically integrate, and contain functional ciliated epithelium to allow for normal mucociliary clearance. Tracheal transplantation has been considered the reconstructive "Holy Grail;" however, there has been a long-held scientific dogma that revascularization of the trachea was not possible. This dogma stifled research to achieve single-staged vascularized tracheal transplantation and prompted the introduction of many creative and inventive alternatives. Throughout history, alloplastic material, nonvascularized allografts, and homografts have been used to address this dilemma. However, these techniques have largely been unsuccessful. The recent introduction of a technique for single-staged vascularized tracheal transplantation may offer a solution to this dilemma and potentially a solution to management of the fatal tracheoesophageal fistula.

Conservative Management of Large Tracheal Perforation due to Traumatic Intubation.

Tracheal perforation is a rare complication of intubation and is associated with high mortality. Here we describe a case of large, full-thickness tracheal perforation from traumatic intubation after an elective procedure. The injury was managed with prolonged intubation that bypassed the site of injury, and the patient was successfully extubated after 11 days. Conservative management of tracheal perforation after traumatic intubation is an option in select patients that avoids need for surgery.

[Post-intubation rupture of thoracic trachea in a patient with iatrogenic esophageal perforation and mediastinitis]. / Postintubatsionnyi razryv grudnogo otdela trakhei u bol'noi s perforatsiei pishchevoda pri fibroendoskopii i mediastinitom.

Iatrogenic injuries of the esophagus and trachea are rare. However, these are life-threatening events due to severe complications. The authors report iatrogenic perforation of cervical esophagus with a long false passage in posterior mediastinum in an 83-year-old patient undergoing endoscopic retrograde cholangiopancreatography for choledocholithiasis. Post-intubation rupture of thoracic trachea was diagnosed early after suturing the defect of esophagus and drainage of mediastinum. Treatment strategy was analyzed and conservative management of tracheal injury was substantiated.

Tracheobronchial rupture in children due to chest compression.

A tracheobronchial rupture can be lethal. Its etiology in children varies and includes blunt trauma and iatrogenic injury. Most of the latter are associated with tracheal intubation, with other, iatrogenic causes scarcely being reported. We herein reported the first case of tracheobronchial rupture caused by chest compression during cardiopulmonary resuscitation. The present case highlights the importance of close follow-up after cardiopulmonary resuscitation, even if the patients are not intubated.

A Novel Case Report of Iatrogenic Tracheal Rupture Caused by a Laser-Resistant Endotracheal Tube Under Transoral Laser Laryngeal and Nasopharyngeal Surgery.

BACKGROUND Intraoperative tracheal rupture due to endotracheal intubation is a rare but serious complication that requires prompt responses. Transoral laser microsurgery is effective for dissection of laryngeal and nasopharyngeal lesions, and a laser-resistant endotracheal tube is therefore commonly used under general anesthesia. CASE REPORT We present the case of a 69-year-old man in whom a rare complication involving endotracheal tube tip dislodgement during transoral laser surgery led to iatrogenic tracheal rupture. We used a Laser-Flex cuffed endotracheal tube, which is a non-inflammable, armored stainless-steel tube with a Murphy eye. Repeated mobilization of the laryngoscope blade and excessive neck extension for adequate laryngeal exposure during surgery may have led to significant soft tissue swelling and tube tip displacement, inducing tracheal rupture with the keen edge of the Murphy eye. At the end of the surgical procedure, subcutaneous emphysema was observed in the right anterior neck. Computed tomography revealed subcutaneous emphysema and pneumomediastinum without esophageal injury or mediastinitis. The injury was 1 cm in length, with wall involvement to a depth to the muscular wall in the membranous trachea at a point 2 cm proximal to the carina, in which we could position the alternative endotracheal tube distal to the tracheal rupture. After conservative treatment, the patient was extubated and mechanical ventilation was ceased. CONCLUSIONS During transoral laser laryngeal and nasopharyngeal surgery, dislodgement of the laser-resistant endotracheal tube tip can lead to iatrogenic tracheal rupture. In this case, injury during application of a Laser-Flex cuffed endotracheal tube with a Murphy eye, was followed by conservative treatment. This treatment achieved a successful outcome.

What we have learned from a patient with partial tracheal rupture caused by penetrating neck injuries: a case report.

BACKGROUND: Airway management of patients with direct airway trauma caused by penetrating neck injuries is always challenging. When a failed airway occurs and surgery access is difficult, it is crucial to find the optimal approach to save the life. We propose the concept "Cannot intubate, Cannot oxygenate, Difficult surgery access" to describe this emergency scenario. CASE PRESENTATION: We report a case of a 24-year-old woman who presented with partial tracheal rupture and pneumothorax caused by a knife stab injury to the neck. A "double setup" strategy, simultaneous preparation for orotracheal intubation and tracheotomy, was carried out before rapid sequence induction. A tracheotomy under local anesthesia or an awake intubation was not preferred in consideration that the patient had a high risk of being uncooperative owing to existing mental disease and potential smothering sensation during operation. During rapid sequence intubation, distal part of the tube penetrates the tear and creates a false lumen outside the trachea then a failed airway subsequently occurred. Rescue tracheotomy was successfully performed by an otolaryngology surgeon, with the help of limited ventilation using sequential bag-mask and laryngeal mask airway ventilation provided by an anesthesiologist, without severe sequelae. CONCLUSIONS: The endotracheal tube have a risk of penetrating the tear outside the trachea in patient with partial tracheal rupture during orotracheal intubation, and once it occurs, proceeding directly to an emergency invasive airway access with optimizing oxygenation throughout procedure might increase the chance of success in rescuing the airway.