Management of Postintubation Tracheobronchial Ruptures* Massimo Conti, MD; Marie Pougeoise, MD; Alain Wurtz, MD; Henri Porte, MD, PhD; Franc ¸ois Fourrier, MD, FCCP; Philippe Ramon, MD; and Charles-Hugo Marquette, MD, PhD Study objectives: To determine whether nonoperative management can be applied to iatrogenic postintubation tracheobronchial rupture (TBR). Design: Prospective cohort study. Patients and interventions: Thirty consecutive patients with TBR complicating intubation between June 1993 and December 2005 entered the study. Patients not receiving mechanical ventilation at time of diagnosis were treated nonsurgically. Patients receiving mechanical ventilation who were judged operable underwent surgical repair, while nonoperable candidates had their TBR bridged by endotracheal tubes. Results: Fifteen patients not requiring mechanical ventilation underwent simple conservative management. TBR length measured 3.85  1.46 cm (mean  SD). Eight TBRs showed full-thickness rupture with frank anterior intraluminal protrusion of the esophagus. In three patients, transient noninvasive positive pressure ventilatory support (NIV) was necessary. All lesions healed without sequelae. Two patients receiving mechanical ventilation underwent surgical repair and died. Thirteen patients receiving mechanical ventilation were considered at high surgical risk, and TBR bridging was attempted as salvage therapy. Complete bridging was achieved in five patients by simply advancing the endotracheal tube distal to the injury. Separate bilateral mainstem endobronchial intubation was necessary in six patients whose TBRs were too close to the carina. Nine of 13 patients (69%) treated with nonoperative therapy completely recovered. Conclusion: We conclude that conservative nonoperative therapy should be considered in patients with postintubation TBR who are breathing spontaneously, or when extubation is scheduled within 24 h from the time of diagnosis, or when continued ventilation is required to treat an underlying respiratory status. Surgical repair should be reserved for cases in which NIV or bridging the lesion is technically not feasible. (CHEST 2006; 130:412– 418) Key words: injury; intubation; mechanical ventilation; rupture; surgery; trachea Abbreviations: NIV = noninvasive positive pressure ventilatory support; TBR = tracheobronchial rupture T racheobronchial rupture (TBR) is an uncommon but potentially serious complication of endotra- cheal intubation. Iatrogenic TBR should be differenti- ated from tracheobronchial injuries of traumatic origin since it has different mechanisms leading to different morphologic appearance and therapeutic options. 1 Traumatic TBR is usually the result of blunt chest trauma and appears as horizontal or irregularly shaped disruptions involving the main carina and often extend- ing into the main bronchi. Iatrogenic TBR, in contrast, usually presents as longitudinal lacerations of the pos- *From the Clinique de Chirurgie Thoracique (Drs. Conti, Wurtz, and Porte), Clinique d’Anesthe ´ sie Cardio-Thoracique (Dr. Pou- geoise), Service de Re ´ animation Polyvalente (Dr. Fourrier), and Clinique des Maladies Respiratoires (Drs. Marquette and Ramon), CHRU Lille, Lille, France. The authors report that they have no conflicts of interest related to this paper. Manuscript received November 19, 2005; revision accepted January 30, 2006. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: Charles-Hugo Marquette, Clinique des Mal- adies Respiratoires, Ho ˆ pital Albert Calmette, CHRU de Lille, 59037 Lille cedex, France; e-mail: c-marquette@chru-lille.fr DOI: 10.1378/chest.130.2.412 Original Research CRITICAL CARE MEDICINE 412 Original Research