Asian Cardiovasc Thorac Ann 2001;9:150-152
© 2001 Asia Publishing EXchange Pte Ltd
Postintubation Tracheal Rupture
Ramazan Kutlu, MD,
Akin Kuzucu, MD1,,
Ömer Soysal, MD1,,
Tamer Baysal, MD,
brahim Karaman, MD,
Ahmet Akbulut, MD
Department of Radiology
1 Department of Cardiovascular and Thoracic Surgery
Inönü University School of Medicine
Malatya, Turkey
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For reprint information contact: Ramazan Kutlu, MD Tel: 90 422 341 0834 Fax: 90 422 341 0834 email: drkutlu{at}inonu.edu.tr Department of Radiology, Inönü University School of Medicine, Turgut Özal Medical Center, Malatya 44069, Turkey.
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Abstract
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Tracheal rupture following endotracheal intubation is an extremely rare emergency that needs expedient diagnosis and treatment. The clinical and radiological features of postintubation tracheal rupture in a 45-year-old woman who underwent vertebral stabilization are described. Primary suture closure was performed successfully via a cervical approach.
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Introduction
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Transmural injury of the membranous portion of the tracheobronchial tree or larynx following endotracheal intubation is extremely rare. Immediate clinical and radiological diagnosis and appropriate treatment are necessary to prevent the development of conditions that adversely affect morbidity and mortality, such as airway obstruction, acute tension pneumothorax, and chronic tracheal stenosis.
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Case Report
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A 45-year-old woman who was earlier involved in a motor vehicle accident and had a fracture of her 7th thoracic vertebra, was referred to the department of cardiovascular and thoracic surgery when she developed cervical subcutaneous emphysema on extubation in the immediate postoperative period after vertebral stabilization. Her records indicated that the endotracheal intubation had been problematic. Diffuse subcutaneous and mediastinal emphysema and loss of the border between the trachea and the esophagus were seen on plain chest radiography (Figure 1
). Computed tomographic scans of the chest (Figure 2) confirmed an irregularity in the membranous portion of the cervical trachea and diffuse mediastinal and subcutaneous emphysema. Bronchoscopy showed a longitudinal tracheal rupture of 7 cm in length, beginning approximately 2 cm below the vocal cords, allowing the esophagus to prolapse into the tracheal lumen. Emergency tracheal repair was undertaken. The trachea was exposed via a collar incision. There was a 7-cm laceration in the membranous part of the trachea, which was repaired with interrupted sutures using 3/0 Vicryl (Ethicon Ltd., Edinburgh, Scotland, UK). Strap muscles were transposed over the suture line. Postoperative bronchoscopy revealed no fistula or narrowing in the repaired part of the trachea and the patient was discharged on the 7th postoperative day. Bronchoscopy performed 2 months later was also normal and showed perfect scarring.
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Figure 1. Posteroanterior chest radiograph showing diffuse subcutaneous emphysema, pneumomediastinum, and loss of the border between the trachea and the esophagus.
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Discussion
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Tracheal rupture is generally seen as a consequence of chest trauma and rarely as a serious complication of intubation procedures. Endotracheal intubation procedures could lead to the development of iatrogenic trauma in the upper respiratory tract, including superficial mucosal tears that may frequently be seen in the mouth, pharynx, and larynx. A large postmortem series following emergency endotracheal intubations showed these types of tears in 18% of cases.1 Although various causes have been implicated in intubation-related tracheal rupture, repeated attempts at intubation together with insufficient experience, an over-inflated cuff, sudden movement of the endotracheal tube, and an inadequate size of tube are among the most frequently cited.2,3 Ruptures are usually located in the membranous portion of the trachea and may extend to the main bronchi. The current practice is that of test inflation of the cuff with 10 to 15 cc of air before intubation and subsequent inflation with 10 cc of air after intubation and, if necessary, the volume may be increased to 15 cc. The preferred endotracheal tubes are those with high volume-low pressure cuffs.4
There are contradictory opinions on whether the over-stretched cuff is the result or cause of the rupture. It is not the absolute cuff volume but the relationship between the pressure of the cuff and tracheal wall pressure that causes the tracheal damage. Normal capillary perfusion pressure of the tracheal mucosa in humans is between 25 and 30 mm Hg. If the cuff pressure exceeds 32 mm Hg, the capillary circulation of the mucosa would be compromised and depending on the duration of intubation, mucosal damage may develop.2 Cuff migration to the tip of the tube could be seen in some cases, possibly due to either continuous air injection into the cuff causing expansion of the distal portion of the cuff, or withdrawal of the tube without complete deflation. Deviation of the tip of the endotracheal tube to the right side on the chest radiograph should also arouse suspicion of tracheal rupture.
Tracheobronchial rupture is a life-threatening condition. Complications that may ensue include tension pneumo-thorax, mediastinal emphysema, prolapse of the esophagus into the tracheal lumen, acute asphyxia, airway obstruction, sepsis including mediastinitis, pulmonary fibrosis, and chronic tracheal stenosis. Although the importance of early diagnosis is evident, late diagnosis remains a problem due to the low level of clinical suspicion and infrequent number of reliable chest radiographic findings. In all cases, mediastinal or subcutaneous emphysema developed. Pneumothorax is seen in tracheal rupture cases where the rupture is directly related to the pleural space. Pneumo-mediastinum is an important but not a pathognomonic sign of tracheal rupture. It is also seen in alveolar rupture cases secondary to blunt thoracic trauma or positive-pressure ventilation and esophageal rupture.
The length of the tracheal tear and the degree of respiratory insufficiency would in the main determine the propriety of conservative or surgical management. If the patient presents with immediate symptoms, surgery is the treatment of choice. When the tracheal tear is longer than 4 cm and the patient has presented with delayed symptoms, surgery is also recommended. In our case the tear was 7-cm long and the patient had immediate symptoms. When the tear is less than 4 cm and the patient has delayed symptoms and has been stabilized, conservative treatment may be advised.2 Conservative treatment includes broad-spectrum antibiotic therapy, antiseptic antiinflammatory aerosol therapy, and chest tube thoracostomy when needed. Surgical treatment includes a cervical approach to the proximal two-thirds of the trachea. For tears around the carina, especially if they involve a mainstem bronchus, a right thoracostomy would be preferred to repair the rupture. We dissected the cervical trachea completely and repaired it from the outside, but it has been recommended to repair a tear of the membranous part of the trachea through an anterior tracheostomy from the inside.5 By this approach, the risk of injury to the recurrent laryngeal nerves is minimized.
A high index of suspicion and early diagnosis of tracheal rupture is important to reduce the rate of morbidity and mortality in these cases. The presence of subcutaneous emphysema and/or pneumomediastinum following recent tracheal intubation or blunt chest trauma, radiographic evidence of an over-stretched cuff on a plain chest radiograph, and a decrease in the distance of the cuff to the tip of the endotracheal tube call for further examina-tions such as computed tomography scan of the chest and bronchoscopy. These examinations would help to deter-mine the presence and extent of tracheal laceration or rupture. Postintubation tracheal rupture can be avoided by adequate inflation of the cuff, ensuring no movement of the endotracheal tube in situ, and using adequately sized tubes.
Presented at the 4th Turkish Congress of Medical Imaging and Interventional Radiology, Antalya, Turkey, October 26–31, 1999.
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References
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Stauffer JL, Olson DE, Petty TL. Complications and consequences of endotracheal intubation and tracheotomy. A prospective study of 150 critically ill adult patients. Am J Med 1981;70:65–76.[Medline]
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Janni A, Menconi G, Mussi A, Ambrogi MC, Angeletti CA. Postintubation tracheal tear repair by cervicotomy and longitudinal tracheotomy. Ann Thorac Surg 2000; 69:243–4.[Abstract/Free Full Text]
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Abstract
Introduction
