"Case of the Month"

Varon J, Wenker O: Case of the Month. The Internet Journal of Emergency and Intensive Care Medicine 1997; Vol1 N1: http://www.ispub.com/journals/IJEICM/Vol1N1/casejan.htm

Case Presentation:

Part I:

A 28 year-old woman with history of major depression attempted suicide by ingested a large quantity of tricyclics. She found unresponsive with an empty bottle of imipramine by her family laying on the floor. Upon arrival, the paramedics noted an irregular breathing pattern with a respiratory rate of 4/min, heart rate 156/min and blood pressure of 72/46 mm Hg. She was endotracheally intubated and breath sounds auscultated on both lung fields. Disposable end-tidal CO2 indicated endotracheal intubation. A peripheral intravenous line was placed and administration of intravenous normal saline begun. The patient was then transported to the hospital.

Upon arrival to the hospital, the patient was unresponsive to painful stimulation without spontaneous respirations. Blood pressure was 90/60 mm Hg. Heart rate was 132/min. On physical examination, significant swelling of both arms and neck was noted. The house officer ordered an chest radiograph:

Questions:

1. What should you do next?

2. What are the findings on the chest radiograph?

3. Your presumptive diagnosis.

Part II:

An emergent pulmonary and thoracic surgical consultation were obtained. The results of the initial fiberoptic bronchoscopy are depicted below:

Questions:

1. What does this image show ?

2. What is the treatment of choice ?

Fiberoptic bronchoscopy

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Massive subcutaneous emphysema, right mainstem intubation, large gastric bubble

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Tracheal rupture

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Membranous tracheal rupture

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Treatment of Choice

Early repair of the trachea have been suggested by some authors, particularly in those patients with respiratory or circulatory failure. Several techniques have been suggested including a right thoracotomy and/or cervicotomy. However, on the other hand, d'Odemont reported recently a woman with a large endotracheal laceration following intubation, who with simple supportive therapy healed within 10 days.

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Case discussion

Serious injuries of the trachea during endotracheal intubation are rare but potentially life threatening complications.The first report of tracheal rupture during intubation was done by Georg in 1917, followed by the classic description of "surgical emphysema" by Barrett and Thomas in 1944. Since then, few cases of accidental tracheal disruption have been reported.

The incidence of this condition is difficult to establish because many tracheal lacerations may be undetected clinically. Previous reports have related its occurrence to vigorous repeated attempts at intubation particularly in children, tracheal abnormalities, the use of a stylete and overinflation or rupture of the cuff. In a report by Velly et. al., of 47 traumatic ruptures of the tracheo-bronchial tree, 30 involved the trachea, 11 a main bronchus and 6 a intermediate or lobar bronchus. In only 4 cases, the lesion were discovered following tracheal intubation.

The pathogenesis of intubation-related tracheal rupture is not known, however, several theories have been proposed, such as the excentric inflation of the cuff with a resultant ischemic damage. Extravasation of air into the mediastinum is expected with intrathoracic tracheal rupture. On occasion, like in the case of our patient, large tracheal ruptures have been described. Some of them may present acutely with "surgical emphysema" or may develop it only after a delay. Signs of tracheobronchial catastrophes such as hemorrhage, cyanosis, air leak or compliance changes may be absent in some patients. At times, the diagnosis of tracheal rupture may be difficult to establish. Some authors suggest assessment of the leak pressure in these patients.

Interdisciplinary treatment requires precise documentation of the extent of the injuries, including advanced imaging techniques. If tracheal rupture is suspected, it is essential to establish a diagnosis by bronchoscopy. Removal of the endotracheal tube prior to accurate diagnosis can result in immediate airway obstruction.

Early radiographic signs of tracheal rupture as described by Rollins and Tocino include: orientation of the distal portion of the endotracheal tube to the side relative to the lumen; an overdistended balloon cuff; migration of the balloon towards the endotracheal tube tip and combined subcutaneous emphysema and pneumomediastinum.

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