Etiology and management of iatrogenic tracheobronchial injuries by double-lumen tubes in thoracic surgeries: a case series of 7 patients

To investigate the risk factors, intraoperative recognition, management strategies, and preventive measures for iatrogenic tracheobronchial injuries associated with double-lumen tube (DLT) intubation during thoracic surgery, we retrospectively reviewed seven cases treated at our multicenter institution (comprising four hospitals) between 2011 and 2021, in conjunction with a comprehensive review of the relevant literature. Our aim was to optimize anesthetic airway management, standardize preoperative airway assessment, facilitate early injury detection, and refine postoperative management to improve patient outcomes. Clinical data from 7 patients (5 males and 2 females) who sustained tracheobronchial injuries related to left-sided DLTs were analyzed. DLTs from two manufacturers (Covidien and Yichang Humanwell) were used. One patient underwent radical esophagectomy, and the remaining six underwent right-sided pulmonary lobectomy. All procedures were performed under general anesthesia by experienced thoracic anesthesiologists. All tracheobronchial injuries were identified either intraoperatively or in the immediate postoperative period and were managed with prompt emergency airway repair. No perioperative mortality or major postoperative complications occurred. All patients recovered uneventfully and were discharged after a mean postoperative stay of 7 days. Iatrogenic tracheobronchial injury associated with left-sided DLTs remains a clinically significant complication. Predisposing factors include small body size, abnormal airway anatomy, excessive bronchial cuff pressure, and surgical manipulation near the carina. Preventive strategies include meticulous preoperative CT-based airway assessment, continuous bronchial cuff pressure monitoring, cuff deflation during tube repositioning or patient repositioning, routine fiberoptic bronchoscopy guidance, and close interdisciplinary collaboration during high-risk surgical steps.