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el paciente present&#243; empeoramiento generalizado con acidosis respiratoria&#44; hipercapnia<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>100<span class="elsevierStyleHsp" style=""></span>mmHg&#44; PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>200<span class="elsevierStyleHsp" style=""></span>mmHg&#44; gran dificultad para la ventilaci&#243;n y tendencia a la hipotensi&#243;n arterial&#46; La radiograf&#237;a de t&#243;rax mostr&#243; infiltrados alveolo-intersticiales bilaterales y en la broncoscopia se objetiv&#243; una rotura traqueal de 2<span class="elsevierStyleHsp" style=""></span>cm de longitud en tercio distal con tubo orotraqueal abocado a la zona de lesi&#243;n&#44; por lo que se progres&#243; el tubo a trav&#233;s del fibrobroncoscopio colocando el extremo distal en el bronquio principal derecho &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>B&#41;&#46; A pesar de esta maniobra&#44; persisti&#243; mala situaci&#243;n respiratoria compatible con s&#237;ndrome de distr&#233;s respiratorio agudo &#40;SDRA&#41;&#44; por lo que se decidi&#243; terapia de soporte con membrana de oxigenaci&#243;n extracorp&#243;rea veno-venosa &#40;ECMO-VV&#41;&#46; Tras lograr la estabilizaci&#243;n hemodin&#225;mica y respiratoria del paciente&#44; se coloc&#243; <span class="elsevierStyleItalic">stent</span> traqueal autoexpansible de nitinol completamente recubierto y se reubic&#243; el tubo orotraqueal a nivel de la pr&#243;tesis permitiendo recuperar la ventilaci&#243;n bipulmonar &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>C&#41;&#46; Tras 13 d&#237;as de soporte se retir&#243; el sistema ECMO y se realiz&#243; traqueostom&#237;a asistida por broncoscopia&#46; El paciente permaneci&#243; estable&#44; y tras casi 3 meses de ingreso hospitalario&#44; fue dado de alta una vez decanulado y retirada la endopr&#243;tesis mediante broncoscopia&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Las lesiones traqueobronquiales secundarias a traqueostom&#237;a son poco frecuentes&#44; con una prevalencia en torno al 0&#44;2-0&#44;7&#37;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a>&#46; En el caso presentado&#44; el antecedente de f&#237;stula tr&#225;queo-esof&#225;gica distal reparada y la consiguiente distorsi&#243;n de la <span class="elsevierStyleItalic">pars</span> membranosa traqueal a dicho nivel pudieron dificultar el procedimiento y propiciar la lesi&#243;n&#46; Las pr&#243;tesis autoexpandibles representan una buena opci&#243;n terap&#233;utica&#44; especialmente en pacientes con un alto riesgo quir&#250;rgico o en los que el tratamiento conservador no es efectivo<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">El SDRA asocia una mortalidad del 45-55&#37;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a>&#46; La estrategia de ventilaci&#243;n pulmonar protectora mediante bajos vol&#250;menes corrientes y la pronaci&#243;n del paciente son las &#250;nicas medidas terap&#233;uticas que ha demostrado mejorar la supervivencia<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a>&#46; 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Carta al Director
Síndrome de distrés respiratorio agudo secundario a rotura traqueal postraqueostomía tratado con membrana de oxigenación extracorpórea venovenosa y prótesis endotraqueal
Acute respiratory distress due to post-tracheostomy tracheal rupture treated with venovenous extracorporeal membrane oxygenation and endotracheal prosthesis
M. Teresa Gómez-Hernández
Corresponding author
mteresa.gomez.hernandez@gmail.com

Autor para correspondencia.
, María Rodríguez-Pérez, Gonzalo Varela-Simó
Departamento de Cirugía Torácica, Hospital Universitario de Salamanca, Salamanca, España
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          "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A&#41; Imagen de TAC con importante enfisema subcut&#225;neo y neumomediastino&#46; B&#41; Radiograf&#237;a de t&#243;rax port&#225;til que evidencia enfisema subcut&#225;neo&#44; infiltrado alv&#233;olo-intersticial bilateral e intubaci&#243;n selectiva derecha&#46; C&#41; Radiograf&#237;a de t&#243;rax port&#225;til&#44; varios d&#237;as despu&#233;s de la colocaci&#243;n de endopr&#243;tesis traqueal&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Presentamos el caso de un var&#243;n de 36 a&#241;os con antecedentes de retraso mental leve&#44; y atresia esof&#225;gica con f&#237;stula traqueo-esof&#225;gica distal tratada quir&#250;rgicamente al nacer&#44; que ingres&#243; en la UCI por cuadro de obstrucci&#243;n intestinal de probable origen medicamentoso e insuficiencia respiratoria global secundaria a broncoaspiraci&#243;n&#44; que precis&#243; intubaci&#243;n orotraqueal &#40;IOT&#41;&#46; Tras 12 d&#237;as de ingreso se realiz&#243; traqueostom&#237;a percut&#225;nea dilatacional&#46; A las 48<span class="elsevierStyleHsp" style=""></span>h del procedimiento el paciente present&#243; importante enfisema subcut&#225;neo y neumomediastino &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>A&#41;&#44; por lo que se procedi&#243; a la retirada de la c&#225;nula traqueal y re-IOT&#46; Progresivamente&#44; el paciente present&#243; empeoramiento generalizado con acidosis respiratoria&#44; hipercapnia<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>100<span class="elsevierStyleHsp" style=""></span>mmHg&#44; PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>200<span class="elsevierStyleHsp" style=""></span>mmHg&#44; gran dificultad para la ventilaci&#243;n y tendencia a la hipotensi&#243;n arterial&#46; La radiograf&#237;a de t&#243;rax mostr&#243; infiltrados alveolo-intersticiales bilaterales y en la broncoscopia se objetiv&#243; una rotura traqueal de 2<span class="elsevierStyleHsp" style=""></span>cm de longitud en tercio distal con tubo orotraqueal abocado a la zona de lesi&#243;n&#44; por lo que se progres&#243; el tubo a trav&#233;s del fibrobroncoscopio colocando el extremo distal en el bronquio principal derecho &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>B&#41;&#46; A pesar de esta maniobra&#44; persisti&#243; mala situaci&#243;n respiratoria compatible con s&#237;ndrome de distr&#233;s respiratorio agudo &#40;SDRA&#41;&#44; por lo que se decidi&#243; terapia de soporte con membrana de oxigenaci&#243;n extracorp&#243;rea veno-venosa &#40;ECMO-VV&#41;&#46; Tras lograr la estabilizaci&#243;n hemodin&#225;mica y respiratoria del paciente&#44; se coloc&#243; <span class="elsevierStyleItalic">stent</span> traqueal autoexpansible de nitinol completamente recubierto y se reubic&#243; el tubo orotraqueal a nivel de la pr&#243;tesis permitiendo recuperar la ventilaci&#243;n bipulmonar &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>C&#41;&#46; Tras 13 d&#237;as de soporte se retir&#243; el sistema ECMO y se realiz&#243; traqueostom&#237;a asistida por broncoscopia&#46; El paciente permaneci&#243; estable&#44; y tras casi 3 meses de ingreso hospitalario&#44; fue dado de alta una vez decanulado y retirada la endopr&#243;tesis mediante broncoscopia&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Las lesiones traqueobronquiales secundarias a traqueostom&#237;a son poco frecuentes&#44; con una prevalencia en torno al 0&#44;2-0&#44;7&#37;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a>&#46; En el caso presentado&#44; el antecedente de f&#237;stula tr&#225;queo-esof&#225;gica distal reparada y la consiguiente distorsi&#243;n de la <span class="elsevierStyleItalic">pars</span> membranosa traqueal a dicho nivel pudieron dificultar el procedimiento y propiciar la lesi&#243;n&#46; Las pr&#243;tesis autoexpandibles representan una buena opci&#243;n terap&#233;utica&#44; especialmente en pacientes con un alto riesgo quir&#250;rgico o en los que el tratamiento conservador no es efectivo<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">El SDRA asocia una mortalidad del 45-55&#37;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a>&#46; La estrategia de ventilaci&#243;n pulmonar protectora mediante bajos vol&#250;menes corrientes y la pronaci&#243;n del paciente son las &#250;nicas medidas terap&#233;uticas que ha demostrado mejorar la supervivencia<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a>&#46; En este contexto&#44; el soporte con ECMO-VV proporciona una adecuada oxigenaci&#243;n y ventilaci&#243;n&#44; lo que permite mantener un apoyo ventilatorio m&#237;nimo&#44; reduciendo as&#237; el barotrauma asociado a la ventilaci&#243;n mec&#225;nica<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">En el caso expuesto&#44; la imposibilidad para ventilar correctamente al paciente&#44; combinada con las lesiones secundarias a aspiraci&#243;n hicieron necesario el soporte de la funci&#243;n pulmonar con ECMO-VV antes de poder llevar a cabo la colocaci&#243;n de la endopr&#243;tesis traqueal&#46; Este caso pone de manifiesto la utilidad del ECMO en el manejo de pacientes adultos con SDRA&#44; as&#237; como su utilidad como puente al tratamiento definitivo de la rotura traqueal&#46;</p></span>"
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Article information
ISSN: 03002896
Original language: Spanish
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