D24-06 From Tear to Repair: Airway Stents and ECMO in Complex Tracheal Injury

Abstract Introduction Tracheobronchial injuries are rare but potentially fatal complications of endotracheal intubation, occurring in approximately 1 in 20,000 elective intubations. Risk increases in emergent settings and in patients with altered anatomy or physiology. Obese patients pose unique challenges due to difficulties in airway access, ventilation mechanics, and procedural risk. Here we present a case of iatrogenic tracheal injury in a patient with morbid obesity, successfully managed with veno-venous extracorporeal membrane oxygenation (VV-ECMO) and metallic Y-stenting. Case Description A 53-year-old woman with class III obesity (BMI 51.3 kg/m²), obstructive sleep apnea, and recent history of saddle pulmonary embolism presented to the hospital with lethargy and progressive hypercapnic respiratory failure nonresponsive to noninvasive ventilation. She was ultimately intubated, though imaging raised suspicion for tracheal injury; bronchoscopy was performed, confirming a near full-thickness tear of the posterior trachea extending from just below the cricoid to 1cm above the main carina. She was transferred to our tertiary care center for multidisciplinary team assessment. Surgical repair was deferred due to poor candidacy, and she was placed on VV-ECMO to offload positive pressure ventilation and allow tracheal healing. After developing hemoptysis on ECMO day 6, she underwent rigid bronchoscopy with successful placement of a metallic Y stent with proximal extension to cover the injury. Following ECMO decannulation, she underwent tracheostomy placement. Her hospital course was complicated by VAP, candidemia, ischemic colitis, and progressive renal failure, and she ultimately succumbed to her illness. Despite the complications of critical illness, her tracheal injury was effectively managed without surgical repair. Discussion Tracheal tears are rare, high-morbidity injuries, often iatrogenic and associated with intubation, especially in female patients and those with risk factors including short stature and obesity. Management depends on injury location, severity, and patient-specific factors. Endobronchial stenting provides a non-surgical option by mechanically covering the defect and promoting mucosal healing when surgical repair is contraindicated. This case illustrates the complex management of tracheal injury in a high-risk patient. Stenting successfully preserved airway integrity in an anatomically challenging patient. VV-ECMO is increasingly used in high-risk airway procedures as prophylactic support. In our patient, it served as a bridge to stabilization and airway rest, enabling safe stent placement while avoiding ventilation-induced propagation of the tear. ECMO should be considered in airway injuries where conventional ventilation risks exacerbating damage, especially in patients with high BMI or limited surgical options, as both a temporizing measure and a platform for procedural rescue. This abstract is funded by: None