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© 2001 International Anesthesia Research Society
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Abstract |
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 Top Abstract IntroductionCase ReportDiscussionReferences |
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IMPLICATIONS: Tracheal lacerations are rare, but potentially fatal, complications of intubations. Diagnosis of such conditions is difficult, and thus a high level of suspicion must be kept. We present a case and review the literature for factors that indicate high-risk patients.
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Introduction |
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TopAbstractIntroductionCase ReportDiscussionReferences |
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Tracheal lacerations are a rare, but serious, complication after orotracheal intubation (1). A high level of suspicion must be kept when presented with the classic symptoms of mediastinal subcutaneous emphysema and respiratory distress (2).
In the past, operative management of such injuries was the norm; but in the recent literature, nonoperative management in certain cases has been advocated with excellent clinical outcomes (1,3–6). Statistically, women are more predisposed to this than men. Further risk factors include poor medical condition, short stature, and the use of corticosteroids (7). Unfortunately, the presence or absence of these conditions is rarely addressed in the literature.
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Case Report |
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TopAbstractIntroductionCase ReportDiscussionReferences |
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An 80-yr-old woman with a history of myasthenia gravis presented to the emergency room intubated after respiratory arrest at home. The patient was 147 cm, 39.2 kg; her medical history included rheumatoid arthritis, hypertension, and depression. A chest radiograph on admission revealed a right-sided pneumothorax and subcutaneous air.
The patient received multiple chest tubes and was taken to the medical intensive care unit. An air leak, however, continued to be present. Widespread subcutaneous emphysema was evident on physical examination. A bronchoscopy was performed, revealing a V-shaped tear of the membranous portion of the trachea at 1.5 cm proximal to the carina. A computed topography scan confirmed this finding and also revealed a moderate amount of mediastinal fluid.
As the patient had unresolving subcutaneous air, an increased white blood cell count creating a possibility of mediastinitis, and continued ventilator dependence, a decision was made with the family to take the patient to the operating room for exploration and repair.
The trachea was approached through a right thoracotomy. No inflammatory tissues or purulence were noted. The injury was closed using interrupted buttressed sutures; a mediastinal pleural flap was raised to cover the suture line. A tracheostomy was performed for anastomotic protection. Postoperatively, the patient’s respiratory status improved. She was weaned off the ventilator over the next 14 days.
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Discussion |
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TopAbstractIntroductionCase ReportDiscussionReferences |
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Tracheal rupture after endotracheal intubation is a rare occurrence. Most retrospective reviews focus on elective intubations by experienced anesthesiologists and show an incidence of <1% (8). These accounts fail to include intubations performed in the emergency room or outside the hospital in emergent settings. Such a rare occurrence makes definitive, prospective studies impossible. Our review is likewise limited to retrospective observations.
In our review of 56 previously reported cases, many factors were found on a consistent basis. For one, 85.7% (48 of 56) patients were female. Sixty-six percent (37 of 56) of these patients were also older than 50 years. The location of these injuries has also been consistent. The membranous portion of the trachea was the site of injury in 98.2% (55 of 56) of the cases with involvement of the carina in 78.6% (44 of 56) of the time.
There are multiple factors leading to this injury. Operator errors (multiple attempts, inexperienced physicians), equipment selection (inappropriate use of stylets, cuff overinflation, malposition of the tube, improper tube size), patient actions (abrupt movements, excessive coughing), and anatomic factors (steroid-weakened membranes, chronic obstructive pulmonary disease, tracheomalacia) all contribute to this problem (7,9–13).
What has not been studied, however, is the preponderance of female patients. Perhaps predilection toward female patients is a result of equipment selection. Women tend to be shorter, and improperly large tubes might often be selected for them. Furthermore, female tracheal diameters might be smaller in diameter than men, making them vulnerable to cuff overinflation. Other contributing factors that are not reported are degree of illness, presence of kyphosis, and the use of nitrous oxide.
In our review of the literature, questions that have been addressed lie mainly in the location of the laceration, efficacy of repair techniques, and selection of operative versus nonoperative management. The underlying causes of the process, however, are not routinely reported. Although we were able to pinpoint some definite patterns in this patient population, the lack of uniform reporting makes conclusions difficult (Table 1).
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In a process so rare, more routine reporting of possible epidemiological factors must be included in future papers. This would include body measurements (height/weight/age), premorbid conditions, medications, endotracheal tube size, identification of the intubating person’s level of expertise, and how far the endotracheal tube was placed into the airway. Only after these numbers are uniformly reported can more exact conclusions be made in regard to the cause of these iatrogenic tracheal lacerations.
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References |
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TopAbstractIntroductionCase ReportDiscussionReferences |
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Marquette CH, Bocquillon N, Roumilhac D, et al. Conservative treatment of tracheal rupture. J Thorac Cardiovasc Surg 1999; 117: 399–401.
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Kaloud H, Smolle-Juettner F, Prause G, List W. Iatrogenic ruptures of the tracheobronchial tree. Chest 1997; 112: 774–8.
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Jougon J, Ballester M, Choukroun E, et al. Conservative treatment for postintubation tracheobronchial rupture. Ann Thorac Surg 2000; 69: 216–20.
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Ross HM, Grant FJ, Wilson RS, Burt ME. Nonoperative management of tracheal laceration during endotracheal intubation. Ann Thorac Surg 1997; 63: 240–2.
[Abstract/Free Full Text] - Zettl R, Waydhas C, Biberthaler P, et al. Nonsurgical treatment of a severe tracheal rupture after endotracheal intubation. Crit Care Med 1999; 27: 661–3.[Web of Science][Medline]
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Massard G, Rouge C, Dabbagh A, et al. Tracheobronchial lacerations after intubation and tracheostomy. Ann Thorac Surg 1996; 61: 1483–7.
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Marty-Ane C, Picard E, Jonquet O, Mary H. Membranous tracheal rupture after endotracheal intubation. Ann Thorac Surg 1995; 60: 1367–71.
[Abstract/Free Full Text] - Borasio P, Francesco A, Chiampo G. Post-intubation tracheal rupture: a report on ten cases. Eur J Cardiothorac Surg 1997; 12: 98–100.[Abstract]
- Evagelopoulos N, Tossios P, Wanke W, Krian A. Tracheobronchial rupture after emergency intubation. Thorac Cardiovasc Surg 1999; 47: 395–7.[Web of Science][Medline]
- Berry M, Van Schil P, Van Meerbeeck J, et al. Surgical treatment of iatrogenic tracheal lacerations. Acta Chir Belg 1997; 97: 308–10.[Web of Science][Medline]
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Angelillo-Mackinlay T. Transcervical repair of distal membranous tracheal laceration. Ann Thorac Surg 1995; 59: 531–2.
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d’Odemont J, Pringot J, Goncette L, et al. Spontaneous favorable outcome of tracheal laceration. Chest 1991; 99: 1290–2.
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van Klarenbosch J, Meyer J, de Lange JJ. Tracheal rupture after tracheal intubation. Br J Anaesth 1994; 73: 550–1.
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