Nov 6, 2017 - Tracheal rupture is a rare complication of tracheal intubation. ... such as oesophageal resection in which the oesoph- agus is separated from ...
British Journal of Anaesthesia 1994; 73: 550-551
Tracheal rupture after tracheal intubation J. VAN KLARENBOSCH, J. MEYER AND J. J. DE LANGE
Summary Tracheal rupture is a rare complication of tracheal intubation. We present a case of tracheal rupture which was diagnosed 20 h after a smooth intubation sequence and uncomplicated anaesthesia. Possible causes are discussed with reference to cases described previously. (Br. J. Anaesth. 1994; 73: 550-551) Key words Intubation tracheal Airway, complications.
Case report A 54-yr-old man was scheduled for extirpation of the superficial part of the left parotid gland. Routine indirect laryngoscopy had shown a cyst on the left side of the vallecula but no additional abnormalities were noticed in the larynx. He smoked 25 cigarettes each day and had a chronic non-productive cough. Medical history, physical examination and laboratory investigation showed no further abnormalities. No preoperative chest x-ray was performed. After induction of anaesthesia with fentanyl, thiopentone and suxamethonium, oral intubation was performed using a "lo-pro" tube, size 9.0 (Mallinckrodt Laboratories, Ireland), as the vocal cords were easily visible. A few minutes later, at the request of the surgeon, the trachea was reintubated with a preformed oral tube of the same size with an intermediate volume cuff (RAE Mallinckrodt). Anaesthesia was maintained with 70 % nitrous oxide in oxygen, fentanyl, vecuronium and 0.3 % isoflurane. Cuff pressure was monitored and maintained at 20 cm H2O using a cuff pressure gauge (Mallinckrodt). During operation no unexpected events occurred and after its conclusion the trachea was extubated and the patient taken to the recovery room. No adverse events were noticed in the recovery room and the patient had no complaints. The night after operation he started coughing and produced bloody mucus. He complained of chest pain and body temperature increased to 39.1 °C. Indirect laryngoscopy showed an intact vallecula cyst and superficial erosions of the mucous membrane of the larynx. Because of clinical suspicion of an airway infection, antibiotics were prescribed. The next morning the patient's head and neck were swollen. Chest x-ray showed subcutaneous emphysema of the head, neck and upper thorax, and also mediastinal emphysema. Bronchoscopy revealed tracheal rupture extending from 3 cm below the vocal cords proximal to the right main bronchus. The
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tracheal rupture was repaired via a right-sided thoracotomy. He was treated with antibiotics after operation and with mechanical ventilation for 7 days. He made a full recovery and left the hospital 1 week later. Discussion Rupture of the trachea as a complication of tracheal intubation is rare. The literature on this subject consists only of case histories. In almost all cases published to date, the cause was obvious; cuffinduced tracheal rupture by means of acute overdistension and rupture of the cuff [1], and the cuff acting as a distending force [2,3]. Also, circumstances affecting tracheal anatomy and rigidity [2], such as oesophageal resection in which the oesophagus is separated from the membranous portion of the trachea, and the presence of metastatic lymph nodes in the mediastinum, can make the trachea more vulnerable. The use of a stiff red rubber tube, especially with an asymmetric cuff, can cause injury [4]. At least two cases have been reported in which difficult intubation was considered to be the cause of tracheal rupture [5, 6]. In contrast with bronchial intubation using a double-lumen tube [7], tracheal rupture has never been reported after tracheal intubation using a stylet inside the tube. Two cases of oesophageal rupture has been described after intubation with a stylet inside the tube [8,9] and recently a case of haemopneumothorax after bougie-assisted intubation was reported [10]. In our patient, the reason for the tracheal rupture is not clear. Cuff-induced injury to the trachea can be avoided by monitoring cuff pressure or by filling the cuff with a mixture of oxygen and nitrous oxide to prevent diffusion of nitrous oxide into the cuff [11]. We maintained cuff pressure at 20 cm H 2 O; tracheal injury can occur at pressures greater than 27 cm H2O [11] and therefore it is unlikely that cuff injury occurred in our patient. At first we assumed that puncture of the mucous membrane of the trachea by the tip of the tube was the primary cause and that postoperative coughing enlarged the lesion into a large tracheal tear. This hypothesis implies that during smooth intubation the posterior wall of the trachea may be punctured. To test this hypothesis, while performing orotracheal J. VAN KLARENBOSCH, MD, J. MEYER, MD, J. J. DE LANGE, MD, PHD,
Department of Anaesthesiology, Academic Hospital Vrije Univeniteit, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands. Accepted for publication: April 7, 1994.
Tracheal rupture after intubation
intubation in several patients, we used afibrescopein the tube to watch the tip entering the trachea. We observed that when the tube was positioned in the trachea, the tip pointed at the anterior or lateral tracheal wall but not at the posterior wall, so puncture of this part of the trachea seems very unlikely. A more probable explanation for the tracheal rupture described here is that superficial injury of the larynx or trachea by intubation, which is not uncommon [12, 13], caused irritation and coughing in the postoperative period. Our patient was a heavy smoker at risk of postoperative coughing and possibly had low grade chronic tracheobronchial inflammation making the trachea more vulnerable. Severe coughing may lead to tracheal rupture, as has been described previously after expulsive efforts to remove a foreign body in the trachea [14]. As far as we know, this is the first description of postoperative tracheal rupture in which severe coughing was probably the main cause. References 1. De Lange JJ, Booij LHDJ. Tracheal rupture. Anaesthesia 1985; 40: 211-212. 2. Smith BAC, Hopkinson RB. Tracheal rupture during anesthesia. Anaesthesia 1984; 39: 894-898.
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551 3. Orta DA, Cousar JE, Yergin BM, Olsen GN. Trachea] laceration with massive subcutaneous emphysema: a rare complication of endotracheal intubation. Thorax 1979; 34: 665-669. 4. Eaton JM. Tracheal rupture. Anaesthesia 1985; 40: 212. 5. Bein T, Lenhart FP, Berger H, Schilling V, Briegel J. Haller M, Forst H. Ruptur der Trachea bei erschwener Intubation. Anaesthetist 1991; 40: 456-^57. 6. d'Odemont JP, Pringot J, Goncette L, Goenen M, Rodensein DO. Spontaneous favorable outcome of tracheal laceration. Chest 1991; 99: 1290-1292. 7. Wagner DL, Gammage GW, Marshall LW. Tracheal rupture following the insertion of a disposable double-lumen endotracheal rube. Anesthesiology 1985; 63: 698-700. 8. O'Neill JE, Giffin JP, Cotrell JE. Pharyngeal and esophageal perforation following endotracheal intubation. Anesthesiology 1984; 60: 487^88. 9. Johnson KG, Hood DD. Esophageal perforation associated with endotracheal intubation. Anesthesiology 1986; 64: 281-283. 10. Smith BL. Haemopneumothorax following bougie-assisted tracheal intubation. Anaesthesia 1994; 49: 91. 11. Raeder JC, Borchgrevink PC, Sellevold OM. Tracheal tube cuff pressures. Anaesthesia 1985; 40: 444-447. 12. Kambic V, Radsel Z. Intubation lesions of the larynx. British Journal of Anaesthesia 1978; 50: 587-590. 13. Stout DM, Bishop MJ, Dwersteg JF, Cullen BF. Correlation of endotracheal tube size with sore throat and hoarseness following general anesthesia. Anesthesiology 1987; 67: 419-421. 14. Nach RL, Rothman M. Injuries to the larynx and trachea. Surgery, Gynecology and Obstetrics 1943; 76: 614-622.
