u 1 pacjenta stwierdzono uraz tchawicy w szyjnym odcinku , a u pozostaych 23  w czci piersiowej .
zabieg chirurgiczny obejmowa napraw boniastej czci tchawicy z dostpu poprzez praw torakotomi u 10 chorych ( u 1 do pokrycia uyto mini midzyebrowych ) , samorozpralny metalowy stent zaoono u 1 pacjenta .
i przeyku , u 1  sleeve - lobektomi lew grn , u 1  praw grn lobektomi , u 3 zaoono stent silikonowy y , u 1 przeprowadzono minitracheostomi , a u 5 chorych wczono leczenie zachowawcze .
. most often they result from tracheal intubation , with frequency being reportedly 0.05 - 0.37% [ 13 ] .
risk factors are : emergency intubation , extra - hospital intubation and use of double - lumen tracheobronchial tubes .
other causes of iatrogenic airway injuries include : 
  percutaneous tracheostomy, airway patency restoration using rigid bronchoscopy, mechanical ventilation, surgical procedures on the thyroid gland , oesophagus and lung . 
   percutaneous tracheostomy ,  airway patency restoration using rigid bronchoscopy ,  mechanical ventilation ,  surgical procedures on the thyroid gland , oesophagus and lung .
most published papers are case reports or small case series , and very few present collective reviews [ 47 ] .
diagnostic work - up includes history and physical examination with particular attention to subcutaneous emphysema in the neck , face and chest , coughing , haemoptysis , respiratory distress , pneumothorax and pneumomediastinum .
the most important tool in confirmation of the diagnosis is bronchoscopy , enabling precise assessment of location , size and type of injury .
the mainstay of treatment is surgical repair , although conservative treatment is increasingly popular in selected patients [ 812 ] .
retrospective analysis of hospital records of all patients treated for main airway injuries between 1990 and 2012 .
in the study period , 24 patients were treated for iatrogenic injuries to the trachea or main bronchi .
there were 21 women ( 87.5% ) with the mean age of 61 years ( range : 17 - 84 ) and 3 men with the mean age of 52 years ( range : 49 - 56 ) . in 1 patient
there was an injury in the cervical trachea and in the remaining 23 in the thoracic part of the airway . in 16 patients the injury occurred during tracheal intubation : in 7 it was located in the upper 2/3 of the trachea and in 9 in the lower segment .
injury resulted from rigid bronchoscopy in 1 patient , from oesophagoscopy in 1 , from mediastinoscopy in 1 and was a complication of open surgery in 5 patients ( 4 oesophagectomies and 1 resection of oesophageal diverticulum ) . in 4 patients
the laceration was located in the right main bronchus and in 2 in the left main bronchus .
all 16 injuries related to tracheal intubation happened in other hospitals and included intubation for gynaecological procedures , mastectomy , laparoscopic cholecystectomy and large bowel resection . in 13 patients injury occurred during elective intubation and in 3 during emergency extrahospital intubation .
mean time between injury and bronchoscopic confirmation of the diagnosis was 12 hours ( range : 2 - 48 ) .
the most frequent sign was subcutaneous emphysema , followed by haemoptysis , coughing , and neck or chest pain . in all
patients chest radiogram and ct were obtained on admission to check for pneumomediastinum and mediastinitis , pneumothorax and/or hydrothorax and pneumonia , as well as to gain more detailed information on anatomy .
next , bronchoscopy was performed with assessment of the location , size and depth of injury .
the mechanism was rigid bronchoscopy in 1 patient , rigid oesophagoscopy in 1 , mediastinoscopy in 1 and open surgery in 5 patients ( oesophagectomy in 4 and oesophageal diverticulum resection in 1 ) . in all cases injury
was diagnosed during the procedure and time elapsed until the decision regarding further treatment was < 2 hours . in 12 patients
the length of the tear was 1.5 - 3 cm , in 10 it was 3 - 5 cm , and in 2 patients it was 5 - 8 cm .
the method of treatment was surgical repair in 14 patients , airway stenting in 4 , mini - tracheostomy in 1 and conservative treatment in 5 patients .
the mean time of hospital stay was 9.25 days ( range : 1 - 15 days ) . in 10 patients emergency surgery was necessary due to progressive respiratory insufficiency , pneumomediastinum and pneumothorax .
interrupted pds 3 - 0 sutures were used to close the tear , and in 1 patient the repair was additionally covered with a pedicled intercostal flap .
suction drainage of the posterior mediastinum and the pleural cavity was routinely used . in all patients on - table
patients were routinely transferred to the intensive care unit , and bronchoscopy was regularly performed in order to clear bronchial secretions .
in 1 patient suture of a 2 cm tear in the left main bronchus and the oesophagus was performed with interrupted pds 3 - 0 sutures and ethibond 2 - 0 sutures . in 1 patient with injury to the right main bronchus and with high operative risk due to
sepsis and renal insufficiency , a self - expanding areo dv stent ( merit medical ) was used . in 3 patients with distal tracheo - bronchial injuries ( in 1 with associated oesophageal injury ) a silicone y stent ( demed mikow )
these stents were removed between the 7 and 10 day after injury . in 1 patient with cervical tracheal injury
one with severe stroke and renal insufficiency and the second one with ischaemic brain damage on admission . two
no complications related to the airway injury were noted in the remaining 20 patients , although one of them had severe neurological deficit due to cardiac arrest at home and prolonged brain ischaemia ; in this patient tracheal repair was successful , but her neurological status did not improve . in all survivors
the follow - up bronchoscopy at 3 months after treatment confirmed complete healing and good patency of the airway .
in the study period , 24 patients were treated for iatrogenic injuries to the trachea or main bronchi .
there were 21 women ( 87.5% ) with the mean age of 61 years ( range : 17 - 84 ) and 3 men with the mean age of 52 years ( range : 49 - 56 ) . in 1 patient
there was an injury in the cervical trachea and in the remaining 23 in the thoracic part of the airway .
in 16 patients the injury occurred during tracheal intubation : in 7 it was located in the upper 2/3 of the trachea and in 9 in the lower segment .
injury resulted from rigid bronchoscopy in 1 patient , from oesophagoscopy in 1 , from mediastinoscopy in 1 and was a complication of open surgery in 5 patients ( 4 oesophagectomies and 1 resection of oesophageal diverticulum ) . in 4 patients
the laceration was located in the right main bronchus and in 2 in the left main bronchus .
all 16 injuries related to tracheal intubation happened in other hospitals and included intubation for gynaecological procedures , mastectomy , laparoscopic cholecystectomy and large bowel resection . in 13 patients injury occurred during elective intubation and in 3 during emergency extrahospital intubation .
mean time between injury and bronchoscopic confirmation of the diagnosis was 12 hours ( range : 2 - 48 ) .
the most frequent sign was subcutaneous emphysema , followed by haemoptysis , coughing , and neck or chest pain . in all
patients chest radiogram and ct were obtained on admission to check for pneumomediastinum and mediastinitis , pneumothorax and/or hydrothorax and pneumonia , as well as to gain more detailed information on anatomy .
next , bronchoscopy was performed with assessment of the location , size and depth of injury .
the mechanism was rigid bronchoscopy in 1 patient , rigid oesophagoscopy in 1 , mediastinoscopy in 1 and open surgery in 5 patients ( oesophagectomy in 4 and oesophageal diverticulum resection in 1 ) . in all cases injury
was diagnosed during the procedure and time elapsed until the decision regarding further treatment was < 2 hours . in 12 patients
the length of the tear was 1.5 - 3 cm , in 10 it was 3 - 5 cm , and in 2 patients it was 5 - 8 cm .
the method of treatment was surgical repair in 14 patients , airway stenting in 4 , mini - tracheostomy in 1 and conservative treatment in 5 patients .
the mean time of hospital stay was 9.25 days ( range : 1 - 15 days ) . in 10 patients emergency surgery was necessary due to progressive respiratory insufficiency , pneumomediastinum and pneumothorax .
interrupted pds 3 - 0 sutures were used to close the tear , and in 1 patient the repair was additionally covered with a pedicled intercostal flap .
suction drainage of the posterior mediastinum and the pleural cavity was routinely used . in all patients on - table
patients were routinely transferred to the intensive care unit , and bronchoscopy was regularly performed in order to clear bronchial secretions .
in 1 patient suture of a 2 cm tear in the left main bronchus and the oesophagus was performed with interrupted pds 3 - 0 sutures and ethibond 2 - 0 sutures . in 1 patient with injury to the right main bronchus and with high operative risk due to
sepsis and renal insufficiency , a self - expanding areo dv stent ( merit medical ) was used . in 3 patients with distal tracheo - bronchial injuries ( in 1 with associated oesophageal injury )
these stents were removed between the 7 and 10 day after injury . in 1 patient with cervical tracheal injury
one with severe stroke and renal insufficiency and the second one with ischaemic brain damage on admission .
no complications related to the airway injury were noted in the remaining 20 patients , although one of them had severe neurological deficit due to cardiac arrest at home and prolonged brain ischaemia ; in this patient tracheal repair was successful , but her neurological status did not improve . in all survivors
the follow - up bronchoscopy at 3 months after treatment confirmed complete healing and good patency of the airway .
iatrogenic airway injuries related to tracheal intubation are rare , with the incidence of 0.05 - 0.37% [ 13 , 7 , 13 ] . according to schneider et al .
, the incidence is 1/75 000 for standard tube intubation , 5 - 19/10 000 for double - lumen tube intubation , and 1/575 for percutaneous tracheostomies .
however , the real incidence is difficult to assess due to the relatively small number of cases published .
intubation - related injuries occur particularly often during repeated attempts of intubation and if the guide - wire is used , protruding out of the distal end of the tube .
other risk factors include obesity , age > 50 years , physician 's limited experience and re - positioning of the tube with the inflated balloon [ 6 , 10 ] .
also , steroid therapy and any pathology within the trachea or in its surroundings , i.e. tumours , adenopathy , tracheitis , bronchomalacia , tracheal stenosis , chronic obstructive pulmonary disease , kyphosis or kyphoscoliosis , may increase the risk of tracheal injury [ 6 , 14 , 15 ] .
the clinical picture includes subcutaneous emphysema in the neck , face and chest , dyspnoea , coughing , haemoptysis , pneumomediastinum and pneumothorax [ 4 , 6 , 810 , 1618 ] .
there is no consensus regarding the treatment of iatrogenic airway injuries [ 68 , 11 , 17 , 19 , 20 ] .
however , several authors agree on the following criteria of conservative treatment : good general condition , haemodynamic and respiratory stability , limited tear in the upper trachea , no signs of mediastinitis , and no progressive subcutaneous emphysema or pneumomediastinum [ 6 , 8 , 10 , 21 ] .
other authors consider the length and depth of injury as the most important criteria of conservative treatment [ 5 , 17 , 22 ] .
however , this is not contradictory , as deep lacerations are usually associated with progressive pneumomediastinum , mediastinitis and respiratory failure .
cardillo et al . proposed a 4-grade morphological classification of intubation - related tracheal injuries : 
  grade i : tear limited to mucosa or submucosa , no pneumomediastinum or mediastinitis; grade ii : tear of the membranous part with subcutaneous emphysema and/or pneumomediastinum , no oesophageal injury or mediastinitis; grade iiia : full disruption of the tracheal wall , no oesophageal injury or mediastinitis; grade iiib : any tracheal injury associated with oesophageal injury or mediastinitis . 
  
grade i : tear limited to mucosa or submucosa , no pneumomediastinum or mediastinitis ;  grade ii : tear of the membranous part with subcutaneous emphysema and/or pneumomediastinum , no oesophageal injury or mediastinitis ;  grade iiia : full disruption of the tracheal wall , no oesophageal injury or mediastinitis ;  grade iiib : any tracheal injury associated with oesophageal injury or mediastinitis . in patients with grade i - iiia injuries , cardillo et al . used conservative treatment including bronchoscopic application of 1 - 2 ml fibrin glue to seal the injury .
, in patients with grade iiib injuries surgical repair via right thoracotomy should be performed , supplemented with broad - spectrum antibiotics , anti - cough medication and parenteral nutrition .
there was a strong predominance of women ( 85.7% ) , which corresponds to the structure of our group .
elective intubation was the cause of injury in 65.9% of patients , emergency intubation in 27.4% , and in the remaining 12 patients no data in this regard were available .
as the number of elective intubations largely exceeds the emergency ones , the results confirm very high risk of tracheal injury associated with emergency intubation . in 53.3% of cases
a single - lumen tube was used , and in the remaining 46.7% a double lumen tube . again , due to the relatively small number of intubations with double - lumen tubes , the results confirm the high risk associated with their use . in 17% of patients ,
injury was diagnosed during the procedure and in the remaining 83% with a delay of up to 240 hours .
the most common symptoms included subcutaneous emphysema ( 64% ) , followed by pneumomediastinum , pneumothorax , dyspnoea and haemoptysis .
emergency intubation , advanced patient age and delay in diagnosis were associated with increased mortality . according to other authors ,
factors increasing mortality include delay in diagnosis > 20 hours , difficult intubation , age > 60 years , female gender and obesity [ 10 , 19 ] . in our group ,
2 patients died within the first 24 hours ; both underwent emergency extra - hospital intubation due to cardiac arrest and had severe neurological pathology .
the remaining two patients in our group died due to severe sepsis and multi - organ failure after oesophageal resection .
the direct cause of all deaths in our group was not related to the airway injury . in the study of 19 patients with iatrogenic airway injuries , hofmann reported mortality of 42% .
regarding conservative treatment , the results presented by minambres are in concordance with other authors , who believe that it should be used in cases of small lacerations and with no progressive general symptoms [ 8 , 9 , 11 , 21 ] .
used a self - expanding stent for 4 cm laceration of the membranous part of the trachea ; a similar stent was used in one of our patients .
self - expanding metallic stents are not widely used , because they cause damage to the airway mucosa and their removal is difficult .
we also implanted a silicone y stent in 2 patients with laceration of the membranous part of the lower trachea .
the treatment was successful and the stents were removed on the 7 and 10 day ; follow - up bronchoscopy confirmed healing of the laceration .
a third y stent was successfully used in a patient with injury to the right main bronchus and the oesophagus .
our results with airway stenting in patients with iatrogenic injuries to the trachea and main bronchi are similar to those reported by other authors [ 18 , 23 ] .
most authors agree that open surgical repair is required in case of full - thickness airway injury with pneumothorax , pneumomediastinum , progressive respiratory insufficiency or technical difficulties in ventilation [ 4 , 5 , 15 , 19 , 22 , 24 ] , whilst stenting should be used in medically inoperable patients [ 18 , 23 ] . in order to limit surgical trauma
, some authors advocate the use of minimally invasive techniques [ 12 , 20 , 24 , 25 ] .
welter presented endoscopic repair of lacerations of the membranous part of the trachea using a videotracheoscope and endoscopic instruments , with general anaesthesia and jet ventilation .
videobron - choscope - assisted repair of tracheal laceration was presented by okada et al . .
 introductioniatrogenic tracheobronchial injuries are rare.aimto analyse the mechanism of injury , symptoms and treatment of these patients.material and methodsretrospective analysis of hospital records of all patients treated for main airway injuries between 1990 and 2012 was performed.resultsthere were 24 patients , including 21 women and 3 men . 
 mean time between injury and initiation of treatment was 12 hours ( range : 2 - 48 ) . in 16 patients the injury occurred during tracheal intubation , in 1 during rigid bronchoscopy , in 1 during rigid oesophagoscopy , in 1 during mediastinoscopy and in 5 during open surgery . 
 mean length of airway tear was 3.8 cm ( range : 1.5 - 8 ) . in 1 patient 
 there was an injury to the cervical trachea and in the remaining 23 in the thoracic part of the airway . 
 the treatment included repair of the membranous part of the trachea performed via right thoracotomy in 10 patients ( in 1 patient additionally coverage with a pedicled intercostal muscle flap was used ) , a self - expanding metallic stent in 1 patient , suture of the right main bronchus and the oesophagus in 1 , left upper sleeve lobectomy in 1 , right upper lobectomy in 1 , implantation of a silicone y stent in 3 , mini - tracheostomy in 1 , and conservative treatment in 5 patients.conclusionsintubation is the most frequent cause of iatrogenic main airway injuries . 
 patients with these life - threatening complications require an individualised approach and treatment in a reference centre . 
Wprowadzenie
Cel
Materia i metody
Wyniki
Wnioski
Introduction
Material and methods
Results
Characteristics of the analysed group
Mechanism of injury and diagnostics
Treatment and results
Discussion
Conclusions
Disclosure