Non-surgical treatment of severe trachea injury due to tracheal intubation—a case report

Introduction

Tracheal injuries are most commonly caused by blunt or penetrating trauma; however, with advances in medical technology, medical tracheal injuries may occur during neck surgery, tracheal intubation), or bronchoscopy (1). The incidence of airway injury for all endotracheal intubations (ETIs) was estimated at 0.005% (2). The incidence of tracheal injury has been reported to be between 0.05% and 0.19% with dual lumen tube intubation (3). In addition, it has been found that females appear to be a significant risk factor for the development of airway tears after intubation (4).

General surgical treatment includes repair, end-to-end anastomosis, sleeve resection, lobectomy or total lung resection, and autologous tissue repair or reconstruction (5). There are few reports of tracheal injuries due to tracheal intubation, and most advocate direct suture repair of lacerations through right thoracotomy. A case of a membranous tracheal laceration that was repaired with the esophagus as a muscular patch, tracheotomy, and upper mediastinal cavity drain has also been reported. In conclusion, the nonsurgical treatment option we chose has not been previously described. We present this article in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-334/rc).

Case presentation

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient for publication of this case report and accompany images. A copy of the written consent is available for review by the editorial office of this journal.

This was a 52-year-old female patient who was admitted to the hospital, for recurrent cough and sputum for more than 6 months with 3 days of exacerbation. The patient had a long history of working in lumber and stone mills. On admission, the patient was examined with rough respiratory sounds in both lungs, and a few wet rales heard in both lower lungs.

The patient’s chest computed tomography (CT) before admission showed scattered patchy flocculent, nodular, and striated fuzzy shadows in both lungs, which were considered inflammatory lesions and were new from the previous; fiberoptic bronchoscopy revealed massive carbon end deposits in the right and left bilateral bronchi and luminal secretions (Figure 1). Combined with the patient’s symptoms, previous occupational history, and CT manifestations. The diagnosis of silicosis was currently considered.

Figure 1 Bronchoscopy findings. (A) Left main bronchus; (B) right main bronchus. The red circles show a large amount of carbon end deposits.

Combining the patient’s symptoms, physical examination findings, and relevant laboratory tests, we decided to perform lavage therapy of both lung lobes. Before performing total lung lavage under general anesthesia, we provided respiratory support for the patient via double-lumen ETI. A left lung lavage was performed under general anesthesia, and a large number of tiny deposits were seen in the recovered fluid. Suddenly, we noticed a persistent air leak in the tracheal lumen and stopped the operation immediately. A bedside fiberoptic view of the airway lumen showed a tear in the membranous portion of the main bronchus (Figure 2). The length of the tear can be seen extending from the opening of the airway all the way to the carina. There w a distinct rupture in the membranous part of the airway, and the mediastinal tissue that moves rhythmically with exhalation can be observed at the broken end. So, we immediately removed the endotracheal tube, replaced it with mask ventilation, and adjusted the ventilator parameters.

Figure 2 Tracheal lacerations following tracheal intubation. (A) Arrow pointing to tracheal membrane tear. (B) Arrow pointing to mediastinum.

After resuscitation, the patient’s vital signs were stable, she was transferred to intensive care unit (ICU) for further observation. After thorough multidisciplinary discussions, it was ultimately decided to implement nasopharyngeal airway-assisted ventilation. This approach aims to maintain airway patency while minimizing spontaneous respiratory effort and reducing the membranous portion of the airway activity. The nasopharyngeal tube we utilized is a simple, convenient, and hollow double-ended tube made of soft material. It is a non-endotracheal ventilation tube placed outside the vocal cords. It forms a passage in the nasopharynx, providing support to the collapsed soft tissues while achieving the goals of relieving airway obstruction, suctioning sputum, and maintaining airway patency. The nasopharyngeal tube causes less stimulation to the pharynx compared to an oropharyngeal airway. The type we used is illustrated below (Figure 3), and it does not include a nasopharyngeal tube cuff. After insertion from the nasal cavity into the pharyngeal cavity, the pharyngeal end is positioned within 3 cm above the epiglottis. Also, treatment with analgesic sedation, anti-infection, expectoration, and maintenance of water-electrolyte balance.

Figure 3 The nasopharyngeal tube model we used is shown in this figure.

At the same time, we also provided the patient with treatments such as analgesia and sedation, anti-infection treatment with piperacillin/tazobactam, expectoration, and maintenance of water and electrolyte balance.

Repeat chest CT scan: less resorption of the lesions in the upper lingual and hypoglossal segments of the left upper lobe of the lung compared to the previous. No obvious mediastinal emphysema was seen. Repeat tracheoscopy: tracheal membranes are covered with bloody secretion, ducts clear. Few secretions in the right and left bronchi, and no bleeding is seen (Figure 4).

Figure 4 On the 9th day after tracheal injury. (A) Arrow pointing to the superior part of the partially healed tracheal membrane. (B) Arrow pointing to the distal part of the partially healed tracheal membrane.

Subsequently, we performed a fiberoptic bronchoscopy again, which showed that the airway lumen was unobstructed, the injury to the membranous part of the trachea had healed well, and there was no bleeding observed (Figure 5). Up to this point, the lacerated membranous portion of the airway had achieved near-complete healing. The patient remained asymptomatic and was discharged in stable condition.

Figure 5 On the 21th days after the tracheal injury. (A) Arrow pointing to the healed portion of the injury observed at the tracheal opening. (B) Arrow pointing to the well-healed tracheal membrane.

Discussion

To the best of our knowledge, this is one of the few cases reporting successful non-surgical management of severe tracheal injury caused by intubation. Non-surgical treatment modalities can not only reduce secondary tracheal injury caused by invasive examinations but also fully leverage the trachea’s self-repair capacity to achieve complete spontaneous healing of the trachea.

Endotracheal intubation related medical injuries tend to be longitudinal tears involving the membranous portions of the cervical and thoracic segments of the trachea. The site of injury to the airway caused by a sudden increase in pressure is mostly located in the membranes (6). Overinflation of the tracheal intubation sleeve has also been reported to support that it is the main cause of acute intubation-related tracheal rupture (7). Therefore, we think that the airway tear that occurred in this patient after tracheal intubation was mainly caused by tracheal tube cuff air pressure. Failure to accurately control the pressure when the airbag is inflated results in a sudden rise in pressure and a tear in the trachea due to excessive compression. In addition, we also considered the following reasons: double-lumen ETI has a significantly higher rate of tracheal injury compared with single-lumen ETI because of the larger diameter of the tube, the need for intraoperative bronchoscopic positioning, and the need for repetitive intubation maneuvers.

Based on the morphological classification of airway injury in adult patients with tracheobronchial tears after intubation proposed by relevant studies, this patient was classified as category IIIA (complete tear with protrusion of esophageal or mediastinal tissue without esophageal injury or mediastinitis) (4). These types of tracheal injuries require multidisciplinary evaluation for the need for surgery or minimally invasive interventions such as stent placement.

To date, there are no definitive guidelines for surgical repair of airway injuries, and it is generally accepted that patients with tracheal injuries greater than 4 cm, as well as those with clinical deterioration, should undergo surgical treatment (8). If a pneumothorax or subcutaneous emphysema is appropriately treated, the goals of surgery are to close the defect to restore effective ventilation, to prevent mediastinitis secondary to airway contamination, and to reduce the risk of complications or long-term tracheal stenosis (4). No significant pneumothorax or subcutaneous emphysema occurred in this patient, and it was assessed by the surgeon that performing a thoracotomy may increase the risk of developing a bronchopleural fistula. Therefore, surgery is not the best treatment option for this patient.

In addition, with the increasing development of minimally invasive respiratory interventions, the temporary placement of coated metal stents under bronchoscopy has been progressively applied to the treatment of airway injuries. The metal stent itself creates mechanical compression of the trachea and facilitates hemostasis of the notch while assisting ventilation. However, the patient’s tracheoscopy revealed an almost fractured membrane with a deep injury. If a metal stent is placed, the stent itself puts pressure on the trachea, which is likely to result in a deeper tear. In addition, there are complications after stent placement such as infection, migration, granulation tissue formation leading to tracheal stenosis, and mucus plugging, which delays the self-repair of the trachea (9). Therefore, we are dropping this option.

There is much controversy regarding the conservative treatment of intubated airway injuries. It has been noted that patients need to be in a stable physical condition to qualify for conservative treatment (1,10,11). On the contrary, it has been suggested that poor general condition of the patient implies higher risk of surgery and more deserving of conservative treatment (12,13). This shows that it is even more important to individualize treatment for the management of airway injury after intubation.

In most cases, the conservative treatment of choice is natural healing supplemented by intravenous antibiotics. In addition, it can be combined with closed chest drainage and negative pressure suction, which not only promotes ipsilateral lung reopening, but also absorbs surrounding tissue and fills the fissure (14). The use of tracheoscopic drops of fibrin sealant to cover the trauma and Tissucol fibrin glue to promote tissue closure and regeneration has also been reported (4). This may have a stronger restorative effect in patients with grade II or III lesions, but the exact efficacy is unclear.

For this patient, the respiratory motility was greater in the calm breathing state, resulting in an active airway membrane tear. Therefore, how to reduce the respiratory activity and make the airway fully rest to get self-healing while ensuring the patient’s normal ventilation is an urgent problem for us to solve. Ultimately, we chose to use a nasopharyngeal tube to assist with breathing. The patient is sedated in the awake state and rests completely flat, with the aim of reducing the patient’s respiratory mobility so that the torn membranous part of the trachea is connected to the mediastinum and the voluntary repair of the airway is fully utilized.

The transnasal endotracheal tube not only can fully ensure the patient’s ventilation and avoid the respiratory depression caused by sedative drugs, but also has the advantage of protecting the trauma surface and slowing down the respiratory activity, which in turn reduces the further damage to the airway, compared with the surgical procedures, ETI, respiratory machine, and the placement of overlaying metal stents. It is no less innovative for tracheal intubation airway tear treatment.

Conclusions

In the past, surgical procedures and minimally invasive respiratory interventions were prevalently used to treat airway injuries. However, after treating this patient and drawing lessons from this experience, we believe that it is very feasible to enable the airway to achieve complete self-repair by utilizing non-surgical conservative treatment in a reasonable and skillful manner.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-334/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-334/prf

Funding: The study was supported by the Natural Science Foundation of Sichuan Education Department (No. 17ZB0134).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-334/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient for publication of this case report and accompany images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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