Ulcération du tronc brachio-céphalique par une canule de trachéotomie

We report the case of a 27-year-old severe head trauma patient who developed an erosion of the brachiocephalic artery, 19 days after the insertion of a tracheal cannula. Emergency treatment included overinflation of the tracheostomy cuff and surgery via sternotomy, with occlusion of the tracheostomy and the tracheo-arterial fistula and reimplantation of the brachiocephalic artery via a vascular prosthesis. This life-threatening complication is due to close anatomic relationships between the trachea and the brachiocephalic artery. In our case, the tip of the cannula eroded the anterior trachea wall resulting in a tracheo-arterial fistula with massive haemorrhage. Warning symptoms such as pulsations of the cannula and aspiration of blood must be recognised without delay and followed by an adequate pre-established management.     

Aortopexy with tracheal reconstruction for postoperative tracheomalacia in congenital tracheal stenosis

PurposeCongenital tracheal stenosis is a rare condition and can be difficult to manage. One source of difficulty is postoperative tracheomalacia requiring long-term tracheal stenting. To prevent symptomatic postoperative tracheomalacia, we have been adding aortopexy to tracheal reconstruction since 2008. The aim of this study was to evaluate efficacy of aortopexy for preventing postoperative tracheomalacia after reconstruction of congenital tracheal stenosis.MethodsRetrospective chart review was conducted. From October 2003 to March 2011, 24 had tracheal reconstruction without aortopexy (group A) and 8 with aortopexy (group B). Statistical analysis was performed using Fisher's Exact test.ResultsOne had anastomotic leakage in group A, and 1, in group B (P = .44). Eleven patients required tracheostomy because of postoperative tracheomalacia confirmed by postoperative bronchoscopy in group A vs none in group B (P = .029).ConclusionsWe found that aortopexy with tracheal reconstruction reduced the need for postoperative tracheostomy in this patient group. Although there is a potential risk of anastomotic leakage because of the suspension suture on the anterior tracheal wall to aorta, we did not detect an increased incidence after aortopexy. Thus, aortic suspension may be a useful adjunct to prevent symptoms of tracheomalacia in these patients.     

A case of subglottic tracheal stenosis following tracheostomy successfully treated with laryngo-tracheal anastomosis]

A 77-year-old male patient underwent laryngo-tracheal anastomosis for subglottic tracheal stenosis. He developed exertional dyspnea 10 month after tracheostomy. Anterior and lateral wall of the cricoid cartilage and the first two tracheal cartilages were resected, preserving the recurrent laryngeal nerves. The distal trachea was anastomosed to the thyroid cartilage primarily and tracheostomy was made at 6th tracheal ring. Postoperatively, anterior flexion of the neck was maintained for a week. Oral intake was started on the 2nd postoperative day. The patient showed smooth recovery. The important points of this operation are: 1) preoperative evaluation of the residual subglottic space, 2) intraoperative care for preservation of the recurrent nerves, especially at the lateral sides of the crycoid cartilage, and 3) postoperative maintenance of the cervical anterior flexion.     

Suprastomal tracheal stenosis after dilational and surgical tracheostomy in critically ill patients

We have previously reported cases of severe suprastomal stenosis after tracheostomy. In this observational study we investigated the occurrence of suprastomal stenosis as a late complication. Patients with persistent tracheostomy after intensive care underwent an endoscopic examination of tracheostoma, larynx and trachea. A percutaneous dilational tracheostomy was employed in 105 (71.9%) and surgical tracheostomy in 41 (28.1%) of the cases (n = 146). The incidence of severe suprastomal stenosis (grade II > 50% of the lumen) was 23.8% (25 of 105) after dilational tracheostomy and 7.3% (3 of 41) after surgical tracheostomy (p = 0.033). Age, gender, underlying disease, ventilation time, and swallowing ability were not significantly associated with the tracheal pathology. This study suggests that dilational tracheostomy is associated with an increased risk of severe suprastomal tracheal stenosis compared to the surgical technique.     

Upper airway compromise after inhalation injury. Complex strictures of the larynx and trachea and their management.

OBJECTIVE: Strictures of the upper airway caused by burns have features distinct from other benign stenoses. The authors reviewed their experience with burn-related stenoses to define the principles of treatment. SUMMARY BACKGROUND DATA: The combined effects of inhaled gases and heat in burn victims produce an intense, often transmural, inflammation of the airway, further complicated by intubation. The incidence of laryngotracheal strictures in survivors of inhalation injury is high, but the reported experience with their treatment is limited and often unduly separated into injuries of larynx and trachea. METHODS: Presentation, treatment, and long-term follow-up are reviewed in 9 women and 9 men age 9 to 63 years, who were evaluated over a 22 year period for chronic airway compromise after inhalation injury. There were 18 tracheal stenoses, 14 subglottic strictures, and 2 main bronchial stenoses. Laryngotracheal strictures stenosis. T-tubes were placed in 15 patients, in low subglottic or tracheal stenosis below the vocal cords, in high subglottic stenosis through the vocal cords, and as a stent after resection of subglottic stenosis. RESULTS: There were two deaths during follow-up, one from respiratory failure and one from an unrelated cause. Two patients underwent evaluation only. Early in this series, one tracheal and one laryngotracheal resection resulted in prompt restenosis. Of the remaining 14 patients, 9 are without airway support from 2 to 20 years later. Four have permanent tracheal tubes. One patient required tracheostomy 8 years after successful subglottic reconstruction. CONCLUSIONS: Strictures of the upper airway related to inhalation injury are associated with prolonged inflammation and involve larynx and trachea in a majority of patients. These complex injuries respond to prolonged tracheal stenting (mean, 28 months) and resection or stenting of subglottic stenoses with recovery of a functional airway and voice in most patients. Early tracheal resection should be avoided.     

Formation of a tracheoesophageal common channel after alkaline injury

We describe tracheoesophageal common channel formation in a 40-year-old woman who swallowed alkaline detergent. Necrosis and fistula formation between the posterior tracheal wall and the anterior esophageal wall were visualized by panendoscopy 15 days after the injury. Urgent tracheostomy, tube hypopharyngostomy, gastrostomy, and feeding jejunostomy were performed. Tracheoesophageal common channel formed by anterior tracheal wall and posterior esophageal wall was visualized by bronchoscopy at 48 days after the injury. Progression was observed by a panendoscopy, bronchoscopy, and chest computed tomography. Sequelae included trismus, obliteration of laryngopharynx, proximal cervical esophagus, and thoracic esophagus below the carina, stomach stricture, and scarring of the scalp, neck, back, and thighs.     

Tracheal ring fracture during a PercuTwist tracheostomy procedure

Because of difficult weaning from mechanical ventilation, a 59-yr-old man admitted for emergency cardiac surgery underwent a bedside PercuTwist tracheostomy on day 14 of his intensive care unit stay. We observed a double fracture of the second tracheal ring during the initial dilation process with the PercuTwist dilator, associated with distal migration of a cartilage fragment, which was avulsed from the anterior portion of the second cartilaginous ring. IMPLICATIONS: Like other antegrade single-step techniques, the PercuTwist tracheostomy presents the risk of anterior tracheal wall damage during the initial stage of the dilation process. Antegrade forces applied to the trachea should be minimized by sufficiently deep skin incision and both slow and smooth initial rotation of the dilator.     

Laryngotracheal resection and reconstruction for subglottic stenosis.

Eighty patients with inflammatory stenoses of the subglottic larynx and upper trachea were treated by single-stage laryngotracheal resection and reconstruction. Fifty stenoses originated from postintubation lesions (endotracheal tubes, tracheostomy, cricothyroidostomy), 7 originated from trauma, 19 were idiopathic, and 4 were miscellaneous. Repair consisted of resection of the anterolateral cricoid arch in all patients, plus resection of posterior laryngeal stenosis where present, with salvage of the posterior cricoid plate, appropriate resection and tailoring of the trachea, and primary anastomosis using a posterior membranous tracheal wall flap to resurface the bared cricoid cartilage in 31 patients. One postoperative death resulted from acute myocardial infarction. Long-term results were excellent in 18 patients, good in 48, satisfactory in 8, and failure in 2. Three additional patients had good results at discharge but were followed up for less than 6 months.     

Tracheo-innominate fistula after initial percutaneous tracheostomy

We report a tracheo-innominate fistula formation after tracheostomy in a 68-year-old man with Guillain-Barré syndrome. The initial percutaneous tracheostomy had to be revised surgically after the tube dislodged from its insertion site in the trachea. Three days later, massive bleeding occurred and emergency surgery revealed a fistula. This was surgically repaired but subsequently re-bled with a fatal outcome. The post mortem report found an aneurysmal ectatic innominate artery with a fistula involving the anterior tracheal wall. The aetiology, diagnosis and management of tracheo-innominate fistula are discussed.     

The protective effect of cuff lubrication in critically ill patients with tracheostomies

Aspiration of infected secretions past the tracheal tube cuffcauses ventilator associated pneumonia (VAP).¹ This aspirationoccurs despite an adequate intracuff pressure, because the fluidleaks along longitudinal folds within the wall of a high volumelow pressure (HVLP) cuff.² Previous in vitro work has suggestedthat KY jelly cuff lubrication might prevent this leakage byphysically blocking the folds.³ The objective of this studyis to quantify the effect of cuff lubrication on subglotticto tracheal dye aspiration in critically ill patients with tracheostomies. Methods: This is a prospective open observational study. Seventeencritically ill patients who required a tracheostomy were recruited.All the study patients initially received a size 8 mm ID PortexProfile cuffed tracheostomy tube at percutaneous tracheostomyby the Grigg’s technique. Lubrication was determined bythe preference of the clinician performing the percutaneoustracheostomy. All the tracheostomy tubes had been modified bythe addition of a fine bore catheter that was glued above thecuff to enable dye instillation into the subglottic space. Thecuff was inflated to 30 cm H₂O (2.9 kPa) and maintained at thispressure by intermittent checks prior to dye instillation and8 hourly using a cuff inflator (Portex, UK). Blue food dye (E122)0.5 ml followed by saline 3 ml was instilled daily through thecatheter into the subglottic space. The nurse responsible forthe patient was instructed to report dye obtained from trachealaspirates (performed post instillation and at least 4 hourlythereafter). Tracheobronchial aspiration was deemed to haveoccurred if dye was retrieved from the trachea. The Wilcoxonrank sum test was used for the data analysis. Results: Sixteen of the 17 cuffs leaked after a median of 1day. One cuff did not leak despite 10 days of testing. Of thecuffs that leaked, nine cuffs were lubricated and leaked aftera median of 2 days (range 1–5) and seven cuffs were notlubricated and leaked after a median of 1 day (0–1). Lubricationthus appeared to protect against leakage for longer than non-lubrication(P<0.05, Wilcoxon rank sum test for unpaired samples). Conclusion: This study suggests that cuff lubrication affordsprotection against aspiration for 1–5 days. Cliniciansshould be aware that a HVLP cuff cannot reliably prevent thetransit of fluid from the upper airway to the lungs after amedian of 2 days even with lubrication. Occasionally a HVLPcuff will be an exact fit for the trachea in which it is inflatedand folds will not form in the cuff wall. In this circumstanceleakage is prevented. It is likely that the one cuff that didnot leak despite 10 days of testing was an exact fit for thatpatient’s trachea. Until a cuff is available that preventsaspiration at acceptable tracheal wall pressures we would recommendthat all tracheal and tracheostomy cuffs are lubricated withKY jelly prior to insertion.     

Characteristics and surgical management of respiratory complications accompanying pathologic lesions of the brain stem.

Three life-threatening respiratory complications are regularly encountered in patients who survive the initial insult from a diffuse brain stem lesion--central alveolar hypoventilation, upper airway obstruction, and aspiration pneumonitis. From treating 13 patients who did survive, a surgical plan for managing the respiratory sequelae of such injuries has evolved and consists of: 1)Diaphragm pacing to correct hypoventilation; 2) tracheostomy for bypass of the upper airway obstruction; 3) gastrostomy for bypass of the impaired structures of swallowing; 4) surgical closure of the larynx to prevent aspiration. All 13 patients manifested central apnea, which was controlled in five by bilateral phrenic nerve stimulation and in eight by unilateral stimulation. All patients required tracheostomy to provide an airway for artificial ventilation and for secretion removal. In ten patients aspiration necessitated gastrostomy. The spontaneous recovery of the ability to swallow allowed closure of the gastrostoma in three but in others aspiration remained a serious complication. One patient died of massive aspiration after discharge from the hospital. Three patients had surgical closure of the larynx to prevent aspiration. Seven patients are alive; six of them are leading productive lives, though several have severe disability due to paresis or ataxia. Six died after discharge from the hospital. Three deaths were not related to the basic problem but the three others may have been.     

An unusual complication of tracheal intubation

We report a previously undescribed complication of tracheal intubation. The complication arose as a result of tracheal intubation performed as an emergency procedure in a patient with an abnormal anteriorly placed larynx. Subsequent corrective laryngeal surgery was required after a temporary tracheostomy had been performed.     

Vascular-pedicled costal cartilage graft for the treatment of subglottic and upper tracheal stenosis

Background/purpose

Free costal cartilage graft for the treatment of subglottic and tracheal stenosis is widely used, but postoperative granulation formation is a problem. To reduce the risk of granulation formation after free costal graft, a new operation of costal cartilage graft with vascular pedicle was introduced.

Methods

A vascular pedicled fifth costal cartilage graft is prepared using internal thoracic artery and vein and intercostal artery and vein as a vascular pedicle. The prepared graft is brought to the upper trachea. The anterior wall of cricoid is split, and the costal cartilage graft is implanted to the split part and tracheostomy. Extubation on the next day is possible if the general condition of the patient permits.

Results

In 3 cases of subglottic or upper tracheal stenosis, this operation was performed. All the patients had tracheostomy made during early infancy. The postoperative course was uneventful, and all the patients were extubated soon after the operation. No granulation tissue was obserbed by postoperative bronchoscopic examinations.

Conclusions

Costal cartilage graft with vascular pedicle is a safe and useful new operation for the treatment of subglottic and upper tracheal stenosis. There also is a possibility of using this procedure for the treatment of long segment tracheal stenosis.     

Upper esophagectomy with pharyngolaryngectomy for esophageal carcinoma at the cervicothoracic junction.

The choice remains controversial as to which surgical procedure should be selected for carcinomas situated in the esophagus at the cervicothoracic junction involving the trachea. After mediastinal tracheostomy associated with pharyngolaryngoesophagectomy and thoracic esophagectomy, numerous reports have previously described severe postoperative complications, such as tracheal necrosis and rupture of the great vessels in the neck. To prevent such complications, we have developed the procedure called "upper esophagectomy" followed by a free jejunal graft and mediastinal tracheostomy through either manuburectomy or upper median sternotomy. We have established that this procedure maintains the vascular networks between the trachea and the esophagus, avoids an occurrence of tracheal necrosis or great vessel bleeding postoperatively, and obtains an improved prognosis in the surgical treatment of esophageal carcinoma at the cervicothoracic junction.     

A case of long-term respiratory management following resection of a huge facial hemangioma]

A 49 year-old-woman was scheduled for resection of a huge hemangioma of the face and neck region. After the resection, severe edema developed on the tongue, larynx, and pharynx even leaving no space between the tracheal tube and these tissues. Prolonged respiratory management with endotracheal tube intubation was needed to maintain the upper airway for more than three weeks. Tracheostomy was performed 27 days after the operation. Two weeks later, the edema of the upper airway subsided. Thereafter her clinical course was uneventful, and she was discharged 22 days after the tracheostomy. Resection of a huge facial and neck hemangioma should be carefully managed as it can be followed by unexpected severe postoperative upper airway edema leading to suffocation.     

Permanent tracheostomy

A technique designed to create a permanent, wide open, and stable tracheal stoma is based on two corresponding U-shaped flaps: one from the anterior tracheal wall, the other from the skin in the suprasternal notch. The method described in this article has proved to be efficient, practical, well tolerated, and readily reversible. Its applications when indicated may reduce the side effects and complications associated with tracheostomy. Our clinical experience with this technique covers eight patients who tolerated the procedure well. The follow-up period exceeds 2 years.     

The prevention of pulmonary aspiration with control of tracheal wall pressure using a silicone cuff

A prospective open randomized controlled study was performed to assess the ability of Euromedical ILM endotracheal tube cuff (silicone cuff) to prevent pulmonary aspiration. The inflation characteristics of this silicone cuff enables the control of tracheal wall pressure. The silicone cuffed tube was shortened and an adjustable flange was used to convert it to a cuffed tracheostomy tube. Twelve patients requiring a tracheostomy on a four-bed intensive care unit (ICU) in a district general hospital received either a silicone or a Shiley cuffed tracheostomy tube. Tracheal wall pressures of both cuffs were maintained at 30 cm H2O with a constant pressure inflation device. Blue food dye was instilled once daily into the subglottic space through a fine catheter above the cuff. There were six patients in the Shiley group and six patients in the silicone cuff group. Dye leaked to the trachea in six (100%) of the Shiley group compared with none (0%) of the silicone cuff group (P = 0.001). This study confirms the effectiveness of this silicone cuff at preventing aspiration and the high incidence of leakage with the conventional high-volume low-pressure tracheostomy tube cuff.     

Upper esophagectomy with pharyngolaryngectomy for esophageal carcinoma at the cervicothoracic junction

The choice remains controversial as to which surgical procedure should be selected for carcinomas situated in the esophagus at the cervicothoracic junction involving the trachea. After mediastinal tracheostomy associated with pharyngolaryngoesophagectomy and thoracic esophagectomy, numerous reports have previously described severe post-operative complications, such as tracheal necrosis and rupture of the great vessels in the neck. To prevent such complications, we have developed the procedure called “upper esophagectomy” followed by a free jejunal graft and mediastinal tracheostomy through either manuburectomy or upper median sternotomy. We have established that this procedure maintains the vascular networks between the trachea and the esophagus, avoids an occurence of tracheal necrosis or great vessel bleeding postoperatively, and obtains an improved prognosis in the surgical treatment of esophageal carcinoma at the cervicothoracic junction.     

A two-year-old child with tracheal stenosis due to tracheostomy treated by end-to-end anastomosis of the trachea

Successful operation performed on a 2-year-old boy with tracheal stenosis due to long-term intubation was reported. He was admitted to our department 1 year after a neurosurgical operation. Endoscopically, destruction of cartilage rings was observed just above the site of tracheostomy, and the tracheal wall was collapsed without a help of tracheal tube. Reconstruction of the trachea by circumferential resection and end-to-end anastomosis was done. During the operation, the patient was uniformly ventilated by tracheal tube through nasal intubation. After the operation, tracheal intubation was continued for 7 days, and anterior fixation of neck for 8 days. The postoperative course was uneventful and the patient remains asymptomatic 8 months after operation.     

Tracheal stenosis complicated with tracheoesophageal fistula.

OBJECTIVE: The aim of the present study was to evaluate the results of surgical treatment in patients with simultaneous occurrence of postintubation tracheal stenosis (TS) and tracheoesophageal fistula (TEF). METHODS: In the group of 51 patients with postcannulation tracheal stenosis who underwent segmental resection, TEF was identified simultaneously in five (10%) of them. The mean age of the TS-TEF patients was 43 years (range 35-60 years). The patients underwent a single-stage operation during which TEF was sealed and resection of the stenotic tracheal segment was performed. RESULTS: The cause of TEF and of TS was artificial pulmonary ventilation by tracheostomy tube (n=4) or by endotracheal tube (n=1) with a simultaneous insertion of nasogastric tube. In one of the patients with tracheostomy the fistula resulted from an injury to the pars membranacea tracheae and the esophageal wall during tracheostomy. All the patients were respiring spontaneously before the surgical treatment. The mean length of the fistula was 24.0 mm (range 15-30 mm), the fistulae were located at the junction of the upper and middle third of the trachea. The mean length of the resected tracheal segment was 29.6 mm (range 26-32 mm). Postoperative complications were not observed in the group of the TS-TEF patients, none of them died. CONCLUSIONS: The method of choice of the surgical treatment of TEF associated with TS is a single-stage procedure in the patient who respires spontaneously.