Tracheal posterior wall laceration after tracheostomy: progressive nightmare under long-term ventilation. Complex repair with vvECMO support. A case report

Background Iatrogenic tracheal membrane laceration (TML) has been widely described in terms of its acute management. Iatrogenic TML during tracheostomy is a problem that has gone largely unnoticed to date. We describe a case in which the combination of almost all possible complications of TML long time after tracheostomy led to a life-threatening permanent condition.

Methods & Materials Recurrent asphyxia occurred in a 43-year-old female under long-term ventilation for irreversible hypoxaemic respiratory insufficiency. Repeated events of sudden blockade of the ventilation chain occurred with hypoxic and hypercapnic coma due to mediastinal dislocation of the tube tip.

Status on admission: The tracheotomy entrance was massively widened longitudinally with permanent leakage of purulent bronchial secretions. The cuff was permanently blocked with pressures above 80 mmHg. For fear of acute blockage of the cannula during movements, the patient strictly refused any mobilization and demanded sedative medication at short intervals. A flexible bronchoscopy demonstrated a 5 cm O-shaped tracheal posterior wall lesion covered by granulation tissue. At the distal end there was a granulated false way into the posterior mediastinum.

Results Veno-venous extracorporeal membrane oxygenation (ECMO) with cannulation of the right jugular vein and right femoral vein was established to provide oxygenation without ventilation with a blood flow of 4.5L/min.

The trachea was accessed via a collared incision, the cricoid was found to be destroyed and pushed inwards in a U-shape. The trachea was transected at the lower edge of the tracheostomy opening and the posterior wall of the trachea was sharply dissected, exposing the esophagus, the spine and the lateral edges of the posterior tracheal wall. The granulation tissue was removed from the anterior longitudinal ligament using a sharp spoon. The posterior membrane was then sutured and adapted continuously with resorbable monofilament polyglycolic acid suture 3/0 (Maxon^TM, Covidien, Medtronic, USA). This allowed the tracheostomy opening to be significantly narrowed.

After one week, the tracheoflex cannula was replaced by an 8.0 mm rigid speaking cannula with subglottic suction (Tracoe twist plus, TRACOE medical GmbH, Germany).

Conclusion Early recognition and repair of TML after tracheostomy or changing of tracheal cannula is essential to prevent life threatening conditions. vvECMO is a perfect option to allow oxygenation of the patient while preserving a dry operative field.

Publication History

Article published online:
25 August 2025