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 . .