IATROGENIC TRACHEAL RUPTURE POST ENDOTRACHEAL INTUBATION CAUSING PNEUMOMEDIASTINUM IN A DOWN SYNDROME PATIENT

Abstract

SESSION TITLE: Medical Student/Resident Procedures Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Tracheal rupture is a rare, infrequent complication associated with endotracheal intubation. The complication rate is approximately 1:20,000, and is associated with significant increased morbidity and mortality. Our case describes the importance of early recognition and intervention, which can lead to improved clinical outcome. CASE PRESENTATION: Patient is a 77 year-old female with Down’s syndrome and atrial fibrillation who presented with decreased appetite, hypoxia, hypothermia, and hypotension. She was found to have pulmonary edema secondary to acute pancreatitis. CT chest showed bilateral pleural effusions and bibasilar pneumonia. She was started on broad spectrum antibiotics, norepinephrine, and oxygen. Patient subsequently required mechanical ventilation for worsening respiratory distress. Post intubation CXR noted appropriate ET tube placement, without any subcutaneous emphysema. However, she was difficult to oxygenate and ventilate. Repeat CT chest was obtained which showed bilateral subcutaneous emphysema. Bronchoscopy at bedside revealed a 2 cm tracheal tear secondary to traumatic intubation leading to significant pneumomediastinum. Bilateral thoracostomy tubes were placed with initial improvement in her oxygenation. Over the next day, she was unable to be liberated from the ventilator. Another CT chest showed progressive pneumomediastinum and thoracostomy tubes were found to be kinked. Subsequently, thoracostomy tubes were removed and pigtail catheters were inserted. Interventional pulmonology then evaluated the patient and had been planning for a tracheostomy inferior to the site of rupture, however after the placement of the pigtail catheters, the patient’s clinical status markedly improved. Further imaging showed resolution of the emphysema. She was further extubated and discharged back to her facility. DISCUSSION: Upon reviewing post intubation CXR, there were subtle signs of subcutaneous air outside the trachea, which reinstates the importance of reviewing all images closely. However, as noted, this patient continued to have poor oxygenation, which should raise a concern for tracheal injury post intubation. Patients with Down’s Syndrome also have several anatomical abnormalities that can lead to difficult intubation, including macroglossia, short neck, and narrower tracheas. The pediatric literature suggests that an ETT 2 sizes smaller than normal should be considered, however to the best of our knowledge, there are no guidelines in the adult patient with Down’s Syndrome CONCLUSIONS: Our case is uncommon, as the incidence of airway injury is estimated to be 0.005% for all ET intubations. This case conveys the need to have high suspicion for tracheal injury in the setting of clinical symptoms after intubation, despite initial review of the imaging appearing normal. Early recognition of traumatic complications can lead to early intervention and favorable outcomes Reference #1: Aboussouan LS, O'Donovan PB, Moodie DS, Gragg LA, Stoller JK. Hypoplastic trachea in Down's syndrome. Am Rev Respir Dis. 1993;147(1):72-75. doi:10.1164/ajrccm/147.1.72 Reference #2: Shott SR. Down syndrome: analysis of airway size and a guide for appropriate intubation. Laryngoscope. 2000;110(4):585-592. doi:10.1097/00005537-200004000-00010 Reference #3: Singh S, Gurney S. Management of post-intubation tracheal membrane ruptures: A practical approach. Indian J Crit Care Med. 2013;17(2):99-103. doi:10.4103/0972-5229.114826 DISCLOSURES: No relevant relationships by Kia Ghiassi, source=Web Response No relevant relationships by Prateek Juneja, source=Web Response No relevant relationships by Jack Kanoff, source=Web Response No relevant relationships by Sunil Ramaswamy, source=Web Response