Gabor S, Renner H, Pinter H, Sankin O, Maier A, Tomaselli F, Smolle Jüttner F M
Department of Thoracic and Hyperbaric Surgery, University Medical School of Graz, Auenbruggerplatz 29, A-8036 Graz, Austria.
Eur J Cardiothorac Surg. 2001 Aug;20(2):399-404. doi: 10.1016/s1010-7940(01)00798-9.
Ruptures of the tracheobronchial tree present a life-threatening situation. Nevertheless, therapy is still controversial. Though conservative treatment by antibiotics and intubation with the cuff inflated distal to the tear is favored by some authors, surgical repair is unavoidable in many cases.
We present a series of 31 patients (mean age 43.6 years, range 8--72 years) with iatrogenous or post-traumatic tracheobronchial ruptures treated since 1975. Fifteen ruptures were longitudinal tears of the trachea, not extending lower than a distance of 3 cm from the bifurcation, 11 involved the bifurcation and/or the main bronchi. The total length of the longitudinal tears ranged from 2 to 12 cm, five were transverse near complete abruptions of the trachea or main bronchi. Involvement of the full thickness of the wall with free view into the pleural space or to the esophageal wall was present in 29 cases. Twenty-nine out of the 31 patients underwent surgical repair and two were treated conservatively. The length and depth of the lesion, the degree of subcutaneous emphysema, pneumothorax and/or pneumomediastinum as well as clinical signs suggesting incipient mediastinitis were considered when making the decision for surgery.
Twenty-five out of the 29 patients experienced an uneventful recovery. Four patients died of sepsis unrelated to the tracheobronchial trauma. One of the two patients who underwent conservative therapy also recovered uneventfully. The other one died because of multi-organ failure due to underlying myocardial infarction.
Conveniently localized short lacerations, especially if they do not involve the whole thickness of the tracheal wall, can be treated with antibiotics and intubation with the cuff inflated distal to the tear, avoiding high intra-bronchial pressures also after eventual extubation. In all other cases surgical repair is to be preferred.
气管支气管树破裂是一种危及生命的情况。然而，治疗方法仍存在争议。尽管一些作者倾向于采用抗生素保守治疗以及在撕裂处远心端充气的情况下进行插管，但在许多情况下手术修复是不可避免的。
我们报告了自1975年以来治疗的一系列31例医源性或创伤后气管支气管破裂患者（平均年龄43.6岁，范围8 - 72岁）。15例为气管纵向撕裂，撕裂部位距气管隆突不超过3 cm，11例累及气管隆突和/或主支气管。纵向撕裂的总长度为2至12 cm，5例为气管或主支气管近乎完全截断的横向撕裂。29例患者的气管壁全层破裂，可直视胸膜腔或食管壁。31例患者中有29例行手术修复，2例采用保守治疗。决定是否手术时考虑了病变的长度和深度、皮下气肿、气胸和/或纵隔气肿的程度以及提示早期纵隔炎的临床体征。
29例手术患者中有25例恢复顺利。4例患者死于与气管支气管创伤无关的败血症。2例保守治疗患者中有1例也顺利康复。另1例因潜在心肌梗死导致多器官功能衰竭死亡。
位置方便且较短的撕裂伤，特别是如果未累及气管壁全层，可采用抗生素治疗并在撕裂处远心端充气的情况下进行插管，即使在最终拔管后也应避免高支气管内压。在所有其他情况下，手术修复更为可取。
