European Journal of Cardio-thoracic Surgery 27 (2005) 523–525
www.elsevier.com/locate/ejcts
Case report
Bluntly traumatic tracheal transection: usefulness of percutaneous
cardiopulmonary support for maintenance of gas exchange
Takeshi Kawaguchi*, Keiji Kushibe, Makoto Takahama, Shigeki Taniguchi
Department of Thoracic and Cardiovascular Surgery, Nara Medical University School of Medicine, 840, Shijo-cho, Kashihara, Nara 634-8522, Japan
Received 12 September 2004; received in revised form 1 December 2004; accepted 6 December 2004
Abstract
Respiratory management of tracheal injuries is a crucial key to successful treatment. We present herein a patient with a traumatic tracheal
transection in whom we confronted difficulty in airway management after false intratracheal intubation. No associated injuries were seen in the
patient, then, primary repair of the trachea was carried out under ventilatory support via percutaneous cardiopulmonary support system (PCPS).
For a short period in the application of PCPS, the use of a heparin-coated circuit made systemic heparinization unnecessary during and after
operation, and the outcome was satisfactory. In a carefully selected patient, ventilatory support via PCPS is useful.
q 2005 Elsevier B.V. All rights reserved.
Keywords: Tracheal injury; False intubation; Percutaneous cardiopulmonary support (PCPS)
1. Introduction
Blunt tracheobronchial injuries are rare but can be lifethreatening. The incidence of blunt injuries of cervical
trachea is reportedly 4% in a review of blunt airway trauma
[1]. Early diagnosis and prompt treatment produce the best
outcome. Although the therapeutic strategy has been fully
described previously [1–3], we encountered a patient whose
tracheal injury we thought was difficult to repair using a
direct intubation of distal airway via neck incision. We had a
gratifying result with the repair by the use of percutaneous
cardiopulmonary support system (PCPS).
2. Case report
A 17-year-old man sustained a blunt cervical injury when
his neck caught on a cable while riding a motorcycle in the
dark. On arrival at our emergency room, he was drowsy and
had respiratory distress with labored breath. Subcutaneous
emphysema was noted around his neck and anterior chest
wall. Arterial blood gas analysis under inhalation of 10 l/min
oxygen with facial mask was as follows: PaO2 79.1 mm Hg,
PaCO2 139.4 mm Hg, pH 6.98. Chest X-ray showed pneumomediastinum, bilateral pneumothorax, and subcutaneous
emphysema.
* Corresponding author. Tel.: C81 744 22 3051; fax: C81 744 24 8040.
E-mail address: [email protected] (T. Kawaguchi).
1010-7940/$ - see front matter q 2005 Elsevier B.V. All rights reserved.
doi:10.1016/j.ejcts.2004.12.021
In the emergency room, he was intubated orotracheally,
and chest drainage tubes were introduced. Both lungs
expanded and air leakage through the chest tubes immediately stopped. However, a high peak inspiratory pressure
persisted and he could not be effectively ventilated.
Bronchoscopic examination via the endotracheal tube
confirmed that the trachea was disrupted and the tip of
the tube was dislocated instead of being inserted completely
into the distal segment of the disrupted trachea. We could
not guide the tube tip to the lumen of the distal segment of
the trachea. Chest computed tomography (CT) revealed
tracheal separation, and the distal segment was identified
deeply just below the sternal notch (Fig. 1). We thought that
these findings made it difficult to accomplish respiratory
improvement expeditiously by direct intubation into the
distal trachea because of difficulty in identifying the distal
trachea quickly. Further systemic work-up detected no other
injuries. We decided, therefore, the application of PCPS to
secure expeditious establishment of ventilation, taking into
account no associated complication precluding use of PCPS.
The patient was taken to the operating room with manual
ventilation. Then, jet ventilation was applied and PCPS was
instituted 15 min later. The right femoral artery and vein
were surgically cannulated as a blood access. Systemic
heparinization was not performed with the use of a heparincoated circuit and anticipation of a short period in the
application of PCPS. The flow rate was 3.7–5.2 l/min during
PCPS.
Under PCPS assisted with jet ventilation, a collar incision
was made in the neck. The platysma and infrahyoid muscles
were divided to expose the trachea, which was transected
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T. Kawaguchi et al. / European Journal of Cardio-thoracic Surgery 27 (2005) 523–525
22.3 mm Hg, pH 7.61. The patient was easily weaned from
PCPS immediately after operation. The total cardiopulmonary bypass time was 126 min.
The patient was weaned from the mechanical ventilation
on the second postoperative day. While left vocal cord
paresis was noted, the patient had no respiratory or
swallowing discomfort. He was discharged on the 51st
postoperative day after closure of the tracheal stoma.
3. Discussion
Fig. 1. Computed tomographic scan revealing discontinuity of the cervical
trachea. (a) The endotracheal tube (arrow) is seen within the proximal
trachea. (b) The tip of the endotracheal tube (arrow) is located outside of the
distal trachea (arrowhead).
between the fifth and sixth tracheal cartilages, just below
the thyroid. The endotracheal tube was found to be
dislocated between the two ends of the disrupted trachea.
The tracheal cartilage was completely divided but the
airway barely kept continuity with the membranous portion
and the peribronchial connective tissue. The tube was
withdrawn and the distal trachea was grasped. After
mobilization of the proximal and distal segments of the
trachea, an end-to-end anastomosis was performed in an
interrupted fashion using 4–0 monofilament absorbable
sutures. Because the bilateral recurrent nerves could not
be identified, the tracheal stoma was made at the level of
the anastomosis to protect the airway. During the procedure, the arterial blood gas analysis obtained from the
right radial artery was as follows: PaO2 58.5 mm Hg, PaCO2
Primary repair is the gold standard for tracheobronchial
injuries, and the crucial key to successful treatment is
airway management before and during operation [1–4].
On arrival at hospital, most patients have some degree of
respiratory compromise and require prompt control of the
airway. Orotracheal intubation is the most frequent method
used. It is faster and less invasive when compared with
emergent tracheostomy. Because, however, ‘false’ intubation may result from ‘blind’ intubation, the use of a
bronchoscope to guide the endotracheal tubeis recommended. Direct intubation of the distal airway via
the neck is another option in patients with penetrating
trauma [4].
However, the previous recommendations do not imply
that every case can be secured by these methods. In our
patient, we thought that we could not guide the dislocated
tube to the proper position without further compromise of
ventilatory condition. Furthermore, expeditious establishment of the airway directly via the neck without respiratory
assist was risky because the distal trachea was located
deeply in the anterior neck. These were the main reasons for
usage of PCPS.
Cardiopulmonary bypass (CPB) for ventilatory support
during pulmonary surgery has been reported previously and
its indications are controversial [5]. Especially, its application for trauma patients has been precluded because of
the potential for bleeding due to systemic heparinization,
and there are few reports discussing such cases [1].
However, heparin can be reversed by protamine sulfate,
and usage of heparin-coated equipment can reduce the
amount of heparin required [6]. Thus, we believe that CPB
can be used for carefully selected trauma patents without
hemorrhagic complication. In addition, PCPS system has
widened indications for use of extracorporeal circulation
[7]. However, its application for ventilatory support in
tracheobronchial injuries has not been investigated
sufficiently.
In our case, we considered that the benefit from PCPS
surpassed its risk, and, indeed, no complication was
experienced. One of the reasons for the absence of
complications may have been the shortness of the PCPS
running time. Woods et al. [8] reported that the complications of extracorporeal perfusion were related to its
duration. If there are no other cardiopulmonary problems,
ventilatory support by PCPS should be necessary only for a
short period during which the airway is re-established. In
such cases, the outcome will be gratifying even if PCPS is
used. Furthermore, its use may enhance the precision of
T. Kawaguchi et al. / European Journal of Cardio-thoracic Surgery 27 (2005) 523–525
the anastomosis by allowing an unhurried surgical procedure
without fear of respiratory insufficiency.
We selected veno-arterial bypass for ventilatory support.
It was promptly established and hypercapnia was significantly corrected. However, improvement of the systemic
oxygenation was not sufficiently, resulting from competition
between pump flow and native cardiac outflow. In this point,
veno-venous bypass might be advantageous. However, venovenous bypass might produce circulatory collapse. It may be
difficult to determine which is more appropriate for trauma
patients.
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