Nonsurgical Conservative Management of Traumatic Intubation Causing Tracheal Rupture With Pneumomediastinum

Abstract

SESSION TITLE: Imaging SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Tracheobronchial rupture is an uncommon serious complication of endotracheal intubation (1). This case is a rare example of a complete posterior wall tracheal rupture with pneumomediastium that was conservatively treated successfully, without surgical intervention. CASE PRESENTATION: 77 year old female with a past medical history of mitral valve replacement, coronary artery disease s/p CABG, breast cancer, VP shunt, systolic congestive heart failure, hypothyroid and hypertension was found unresponsive and cyanotic at home. Emergency medical services were unable to intubate the patient in the field. She was then intubated in the emergency department upon arrival. Initial vitals 156/77, HR 93, RR14, 100% on Fi02 100%, T 36.6. Her physical exam was unremarkable with no crepitus noted. Initial labs showed WBCs of 22, H/H 11.8/39.2, K 5.5, BUN/Cr 21/1.3. Patient was found to have lucencies surrounding the trachea on chest x ray post intubation. Subsequent CT thorax showed (Image 1) moderate to large volume pneumomediastinum surrounding the trachea and extended upward into the neck with disruption of the right posterolateral tracheal wall. Patient was admitted to the medical intensive care unit and bronchoscopy was performed that showed a 5 cm posterior tracheal tear about 2 cm from the carina (Image 2). The tracheal injury most likely occurred due to her difficult intubation. Patient was treated empircally with vancomycin, pipercillin/tazobactam, metronidazole, serial x rays and low PEEP and tidal volume ventilation. She was extubated once her mental status had improved. The patient was successfully treated and repeat bronchoscopy showed complete resolution of the tracheal laceration. DISCUSSION: Early surgical repair is the preferred treatment for large tracheal tears with extensive subcutaneous emphysema however this option may not be feasible for elderly patients with medical comorbidities (2). These patients can be treated with empiric antibiotics, serial imaging, and low pressure mechanical ventilation. CONCLUSIONS: Patients with a large intubation induced tracheal tear with signs of respiratory failure, mediastinitis or esophageal injury can be successfully medically managed conservatively without surgical intervention. Reference #1: Conti M, Pougeoise M, Wurtz A, et al. Management of postintubation tracheobronchial ruptures. Chest 2006;130:412-8. Reference #2: Chang Cheng-Yu et al. Conservative Treatment of Severe Tracheal Laceration After Endotracheal Intubation. Respir Care 2011;56(6):861-862. DISCLOSURE: The following authors have nothing to disclose: Catherine Stadler, Jagadish Akella No Product/Research Disclosure Information