Tracheal Rupture and Emergency Airway Management: About a Case

Abstract

INTRODUCTION: Post intubation tracheal rupture is very uncommon but has a great associated morbidity and mortality. Its incidence varies widely between publications and is estimated around 5/100.000 with standard tracheal tube (STT) and around 500-1900/100.000 with double lumen tube (DLT), although probably underestimated. Despite its relatively low incidence, airway management is paramount and could get extremely complex. CASE DESCRIPTION: Previously healthy 36 years old woman admitted at the ICU with bilateral pneumonia and respiratory insufficiency. Intubation and mechanical ventilation were required. Over the next 6 hours the patient status deteriorates and develops subcutaneous emphysema, pneumothorax and pneumomediastinum with hemodynamic instability. An emergency CT informs of a subcarinal tracheal rupture. With these findings and the general state worsening, a surgical approach is taken. Upon patient's arrival in the operating room, high inspiratory pressures are required and persistent aerial leak in the ventilator system is detected. Peripheral pulse oxymetry stabilizes around 88%. A fibrobronchoscopy is performed to advance the tube cuff lower from the rupture, but it fails as the trachea is filled with blood and dense mucus. As an alternative, the STT is switched with a left 35 Fr DLT with an exchanger in the means of isolating left bronchus and proceed with the surgery. After successfully isolating the left bronchus and positioning the patient for surgery, the DLT migrates and progressive oxygen desaturation and hemodynamic instability follow (with pulse oximetry below 30%, severe bradycardia and hypotension). It is in this critical moment that a 5mm STT is handed to the surgeon to pass it through the rupture thus isolating the left bronchus and allowing ventilation and reversing the critical state. After stabilization and in lateral decubitus, GlideScope was used to advance a 7,5mm STT to the tracheal rupture, where it was grasped and manually advanced to the left bronchus by the surgeon. This allowed effective ventilation and the reparation of the tracheal rupture. DISCUSSION: In the context of the COVID-19 pandemic, tracheal complications are on the rise due to prolonged intubation and ventilation times. Although infrequent, tracheal rupture is an extreme example of emergency airway management. This particular case required an unconventional approach as previous measures to te the airway had failed. Diagnosis should be confirmed through fiberoptic bronchoscopy and given the size of the rupture and patient's hemodynamic instability, if performed earlier, it could have given a definitive diagnosis and prevented further instability by advancing the STT bypassing the injury.