Tracheal rupture after endotracheal intubation☆

We thank Dr Goldsmith for the stimulating comments [1] concerning our recent study. As a conclusion of this randomised study, we have stated that the Coseal sealant proves to be effective in reducing intra-operative and postoperative air leaks. This is clearly shown by the evidence that the number of patients presenting air-leak cessation in the Coseal group was more than the control group either intra-operatively (85.3% vs 59.4%) or postoperatively at 24 h (80.4% vs 59.4) and at 48 h (76.5% vs 58.4%) with statistically significant differences (intra-operative, p < 0.001; 24 h, p = 0.001; 48 h, p = 0.006). It is true, as Dr Goldsmith points out, that the number of patients without air leak was slightly fewer at 48 h than intraoperatively in both groups with a more evident reduction in the Coseal group ( 8.8% in the Coseal group and 1% in the control group), but these data have no considerable impact on the statistical significance of the differences observed also at 48 h ( p = 0.006), and therefore it should not modify the scientific message reported. Revisionof the records of theCoseal grouppatients showing re-appearance of air leaks at 48 h after initial air tightness has allowed us to establish (as reported in the text) that, in most of them, multiple air-leak sites were visible after resection, requiring the division of the standard quantity of the sealant in smaller doses for each parenchymal area to be sealed. This evidencemay suggest the need for increased dose of sealant in patients with multiple sites of air leakage. Our study showed no significant difference in the duration of hospital stay, as reported in most of the similar studies in literature [2,3]. However, this result should not be surprising since air leaks are not the only cause determining prolonged hospitalisation. In Dr Goldsmith’s opinion the higher rate of postoperative re-appearance of air leaks after intra-operative cessation in the Coseal group patients may explain why there was no significant difference in the duration of hospital stay between the two groups. We believe this phenomenon could not justify the non-significant difference in the length of hospitalisation, because the mean air-leak duration resulted in significantly shorter duration in the Coseal group. It is therefore more likely that other medical and surgical factors may have influenced patients’ recovery.