Background:
Iatrogenic tracheal injuries are a known but rare and potentially life-threatening complication of endotracheal intubation. We present a case of tracheal laceration after endotracheal intubation ultimately treated with surgical repair.
Case description:
A 32 year-old Caucasian woman, height 160 cm, presented obtunded to the emergency department. Urine toxicology was positive for benzodiazepines, opiates, and tricyclics. Her relevant medical history included bipolar disorder, chronic pain, and opioid dependence, and no history of prior surgery or intubation. She was uneventfully intubated via videolaryngoscopy in the emergency department. Subsequent chest radiograph showed the tip of the endotracheal tube (ETT) projecting over the right main bronchus and the ETT cuff projecting beyond the expected confines of the trachea. On exam she was noted to have extensive subcutaneous emphysema of the neck and chest. Computerized tomography of the chest revealed a 3cm posterolateral tracheal wall laceration initiating 5cm above the carina and extending distally. Surgery consultation recommended conservative management with antibiotic coverage.
On hospital day two the patient became febrile and hypotensive with concern for early mediastinitis, and she was taken to the operating room for primary surgical repair via right posterolateral thoracotomy. Under direct surgical visualization and endobronchial fiberoptic imaging, the ETT was carefully advanced to position the cuff distal to the laceration and into the left main bronchus. After closure of the laceration the ETT was withdrawn and the cuff was positioned proximal to the tracheal repair. Low peak airway pressures were maintained until the patient could be transitioned to spontaneous ventilation. The patient was extubated on hospital day three and was neurologically intact. She was discharged on hospital day fourteen on oral antibiotics and follow-up with mental health services.
Discussion:
Risk factors for post-intubation tracheal injury include: older females (>50 years), small stature (<165cm), emergent or difficult intubation, inappropriate ETT size, cuff hyperinflation, provider inexperience, tube manipulation without cuff deflation, and anatomical abnormalities or tissue frailty [1]. Physical signs include subcutaneous emphysema, chest pain, pneumothorax, and hemoptysis [1]. Injury typically occurs in the membranous trachea just above the carina [2]. Computed tomography often demonstrates abnormally positioned or overinflated ETT balloon and transtracheal herniation of the balloon through the defect (“dumbbell sign”) [3]. Definitive diagnosis is in the operating room or by bronchoscopy. The need for surgical repair is generally based on the degree of injury and the risk for airway obstruction, massive air leak, or mediastinitis [4]. The most likely cause of the tracheal injury in this patient with multiple risk factors was overinflation of the ETT cuff and subsequent passage of ETT tip through the defect.
In conclusion, prevention as well as early diagnosis and management of tracheal tears are critical in preventing adverse outcomes. A high index of suspicion is necessary, especially in the patient with multiple risk factors.
References:
1. A&A Case Reports. 2016;6:230–3.
2. Chest 1997;112:774–8.
3. RadioGraphics 2014;34(7):1824–1841.
4. Eur J Cardiothorac Surg 2009;35:1056–62.
