Tracheal defects, particularly iatrogenic tracheal injuries, can pose complex challenges in clinical practice. Traditional management options, such as surgical repair, may not be suitable for extensive tracheal defects. Innovative approaches like placing a tracheostomy tube within the tracheal limb of a silicone Y stent have shown promise in such cases.1 Iatrogenic tracheobronchial injury can be defined as any lesion occurring in the airway due to invasive medical or surgical procedures. It is a life-threatening complication that requires prompt diagnosis, management, and treatment.2 This article explores an innovative approach involving placing a tracheostomy tube within the tracheal limb of a silicone Y stent. This pioneering technique offers a promising solution to manage complex tracheal injuries effectively.
Understanding Large Tracheal Defects1
Large tracheal defects can result from various causes, including trauma, surgery, or other medical interventions. Such defects often lead to significant respiratory distress, recurrent infections, and a reduced quality of life. Managing these challenging cases requires creative thinking and novel medical techniques. Iatrogenic tracheal rupture is a severe complication that can arise from various medical interventions, including tracheostomy procedures. The management of such ruptures has been a topic of debate within the medical community, given the absence of clear-cut guidelines for treatment. While surgical repair is often considered the standard approach, this article highlights the potential effectiveness of a conservative strategy.
Figure 1: Bronchoscopy view: Reveals a Mediastinal Connection and a Posterolateral Wall Defect
The Role of Silicon Y Stents
Silicone Y stents, crafted from biocompatible silicone material, support and maintain tracheal and bronchial patency. These flexible Y-shaped structures can be inserted into the trachea to bridge defects or strictures, offering structural support while promoting natural healing.1 Y-stents are well-suited for addressing lesions involving the lower trachea, tracheal carina, main-stem bronchi, and secondary carina.3
A unique approach involving a Y-shaped silicone stent with tracheostomy tube placement was employed to facilitate healing and restore respiratory function in the case discussed in this article.1
Figure 2: Tracheostomy tube through the Y stent
- Evaluation: The patient’s tracheal defect was thoroughly assessed using imaging techniques like bronchoscopy or CT scans to determine the nature and extent of the damage.
- Silicone Y Stent Selection: A silicone Y stent was chosen based on the specific patient’s tracheal anatomy and the size of the defect.
- Tracheostomy Tube Insertion: A tracheostomy tube was carefully positioned inside the tracheal limb of the silicone Y stent.
- Placement: The combined assembly of the Y stent and the tracheostomy tube was precisely placed within the trachea to bridge the defect and maintain an open airway.
Patient Profile: A 16-year-old male sustained a traumatic motorcycle accident and was admitted to the emergency department with a Glasgow Coma Scale Score of 5/15. A whole-body CT scan revealed significant injuries, including occipital subdural and epidural hematomas, a left temporal contusion, a right clavicle fracture, and bilateral lung contusions.
Immediate Interventions: Due to the patient’s critical condition, immediate intubation was performed. Emergent surgery, including decompressive hematoma drainage and craniectomy, was carried out to address the occipital hematoma.
Tracheostomy Tube Placement: The patient remained intubated for an extended period due to complications such as fever, hemodynamic instability, and seizures. Ten days after the initial intervention, a percutaneous dilatational tracheostomy was performed. The patient developed severe mediastinal and subcutaneous emphysema and a tension pneumothorax in the right hemothorax during the procedure. Chest tubes were placed, and a flexible bronchoscopy revealed a tracheal laceration in the middle membranous portion of the trachea.
Innovative Approach: To treat the tracheal injury, the end of the tracheostomy tube was placed beyond the damaged area to ensure proper ventilation. However, the patient developed sepsis, which led to the diagnosis of mediastinitis and bilateral pneumonia caused by the ventilator. After stabilizing the patient’s blood flow, they were transferred to the hospital for further treatment.
Rigid Bronchoscopy and Y-shaped Silicone Stent: Upon arrival, the patient underwent rigid bronchoscopy, which revealed a substantial posterolateral tracheal defect measuring 5 cm × 3 cm, approximately 2.2 cm from the carina, communicating with the mediastinum. A Y-shaped (14×10×10) long (7 cm) tracheobronchial silicone stent was inserted to facilitate healing and protect the wound. Additionally, the tracheostomy tube was placed inside the tracheal limb of the Y-stent lumen to ensure ventilation, isolate the mediastinum, and promote spontaneous healing.
Controlled bronchoscopies over the first ten days showed reduced tracheal defect and significant improvement in epithelial repair and tracheal surface regeneration. Copious thick secretions were diligently removed during bronchoscopies using suction and a Fogarty catheter.
Surveillance rigid bronchoscopies were conducted weekly to monitor tracheal healing progress and address tracheobronchial secretions. The Y-stent was removed 30 days after the tracheal defect had completely healed, and the patient’s neurological status allowed this intervention. He was discharged without major complications and gradually resumed daily life without further interventions.
Benefits of the Approach1
- Improved Airway Patency: The silicone Y stent supports the damaged trachea, preventing airway collapse and facilitating normal breathing.
- Simplified Tracheostomy Care: Placing the tracheostomy tube inside the Y-stent streamlines care and maintenance, reducing the risk of complications.
- Enhanced Patient Comfort: Patients often experience improved comfort and an enhanced quality of life with this combined approach compared to traditional treatments.
- Reduced Risk of Infections: The risk of recurrent infections is minimized by stabilizing the airway and promoting natural healing.
This case highlights the effectiveness of a conservative strategy in managing iatrogenic tracheal ruptures. Although surgical repair is the conventional method, it demonstrates that thorough patient evaluation and attentive care can result in successful outcomes, especially in cases where surgery may be difficult or pose a high risk.
Managing large tracheal defects resulting from iatrogenic tracheal rupture requires individualized decision-making. While the choice between conservative and surgical approaches remains a matter of clinical judgment, this case demonstrates that conservative management can be a viable and successful option. Further research and exploration of this approach are essential to refine its applicability and contribute to the evolving landscape of tracheal rupture management.1,2,3
Medical professionals!! We would greatly appreciate your expert opinion on the following case. Your insights and recommendations would be of immense value.
- Mallios D, Krassas A, Iliadis IS, et al. Tracheostomy Tube Inside the Tracheal Limb of Silicon Y Stent in Patient with Large Tracheal Defect. World Journal of Surgery and Surgical Research [Internet]. 2023;6:1491. Available from: https://www.surgeryresearchjournal.com/open-access/tracheostomy-tube-inside-the-tracheal-limb-of-silicon-y-stent-9676.pdf
- Passera E, Orlandi R, Calderoni M, et al. Post-intubation iatrogenic tracheobronchial injuries: The state of art. Frontiers in Surgery. 2023 Feb 13;10. https://doi.org/10.3389/fsurg.2023.1125997
- Sehgal IS, Dhooria S, Madan K, et al. Placement of tracheobronchial silicone Y-stents: Multicenter experience and systematic review of the literature. Lung India. 2017 Jul-Aug;34(4):311-317. doi: 10.4103/0970-2113.209241