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A Case of Tracheal Injury After Emergent Endotracheal Intubation: A Review of the Literature and Causalities

2001; Lippincott Williams & Wilkins; Volume: 93; Issue: 5 Linguagem: Inglês

10.1097/00000539-200111000-00047

1526-7598

Elliott H. Chen, Zhanna M. Logman, Peter S. A. Glass, Thomas V. Bilfinger,

Pneumothorax, Barotrauma, Emphysema

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. Case Report 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. Discussion 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).Table 1: Risks for Tracheal Lacerations as Described in the Current LiteratureIn 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.