Background: Tracheal injury is a known complication following intubation. The incidence of complication after prolonged intubation has been estimated at anywhere from 4–19%[1]. The most common injuries seen include mucosal lacerations, tracheal stenosis and even tracheal rupture. Tracheal ring fracture is a rare complication and has been reported after tracheostomy and external laryngeal manipulation for endotracheal intubation[2], however to our knowledge there has never been a report of tracheal ring fracture secondary to prolonged intubation alone. Risk of tracheal injury is increased in the setting of emergency intubation and multiple intubation attempts, however the primary mechanism of laryngotracheal injury after intubation is thought to be secondary to overinflation of the tracheal cuff and pressure exerted by the cuff on the tracheal wall[3]. Animal studies have shown ischemia of the tracheal mucosa at pressures exceeding 30 mm Hg[4]. Factors that may predispose a patient to injury of membranous parts of the trachea after intubation include weakness of the membranous trachea, distortion of the trachea secondary to mass compression, steroid therapy, chronic obstructive pulmonary disease and tracheomalacia1.
Case Description: We present a case of a 21-year-old male who presented to the Emergency Department with worsening shortness of breath and difficulty breathing. Approximately one month prior to presentation he had been intubated at an outside hospital for 8 days. He reported sore throat and some difficulty breathing since then. Past medical history was significant for anxiety, depression, asthma and prior history of methamphetamine abuse. A CT of the neck revealed a fracture of the first upper cervical tracheal ring with resulting cervical tracheal stenosis, the most narrow portion measuring approximately 6mm in diameter. He was taken to the OR for balloon tracheal dilation. The case was done under general anesthesia using jet ventilation and a total intravenous anesthetic with propofol and remifentanil infusions. Postoperatively he reported an improvement in symptoms, though ultimately had a recurrence in his shortness of breath and subsequently required tracheal resection, which was complicated by anastomotic dehiscence that required reoperation.
Discussion: This case illustrates an uncommon tracheal injury associated with intubation. It was hypothesized that both chronic steroid use in the setting of asthma exacerbations and prior methamphetamine use may have increased his risk of tracheal injury. Anesthesiologists and critical care providers should be aware of the risk for development of post intubation tracheal injuries. Early diagnosis of tracheal injury is crucial for protection of the airway and timely management.
[1] Murr AH, Amin MR. Chapter 34. Laryngeal Trauma. In: Lalwani AK. eds.CURRENT Diagnosis & Treatment in Otolaryngology—Head & Neck Surgery, 3e New York, NY: McGraw-Hill; 2012. http://accessmedicine.mhmedical.com.ucsf.idm.oclc.org/content.aspx?bookid=386§ionid=39944072. Accessed March 12, 2017.
[2] Chen KT, Lee SC, Ko TL, Wang KC, Chang Y. Tracheal Ring Fracture as a Consequence of External Laryngeal Manipulation During Endotracheal Intubation. Acta Anaesthesiologica Taiwanica. 2009;47(2): 103-105.
[3] Singh P, Wojnar M, Malhotra A. Iatrogenic tracheal laceration in the setting of chronic steroids. Journal of Clinical Anesthesia. 2017; 37: 38-42.
[4] Bishop MJ. Mechanisms of Laryngotracheal Injury Following Prolonged Tracheal Intubation. Chest. 1989;96(1): 185-186.
