Tracheal Rupture

Abstract

We previously published a bronchoscopic image of a tracheal tear involving the posterior tracheal wall during an elective surgical procedure.1 We now present a different image in which the entire tracheal was disrupted after emergency endotracheal intubation. A 77-year-old woman presented to an outside institution with atrial fibrillation and respiratory distress requiring urgent intubation. She subsequently developed increasing subcutaneous emphysema prompting x-ray evaluation, which demonstrated pneumomediastinum. Bronchoscopy performed at that time revealed a long membranous tear that extended to the carina. Bilateral chest tubes were placed and the patient was transported to our institution for definitive therapy. On arrival to the intensive-care unit (ICU), a computed tomography (CT) scan was reviewed and revealed extensive disruption of the trachea from above the sternal notch to the carina. The patient was urgently brought to the operating room where a repair was performed after placing the patient on cardiopulmonary bypass for appropriate oxygenation. The bronchoscopic image is presented below in Figure 1.FIGURE 1.: Note the full-thickness tear involving the posterior wall of the midtrachea.Repair was performed through a median sternotomy incision. Postoperatively, the patient was transferred to the thoracic ICU and doing well at the time of this writing. DISCUSSION Although uncommon, tracheal rupture after endotracheal intubation is well described and is said to occur characteristically in elderly females.2–4 Early and emergent repair is imperative to prevent life-threatening complications. Factors predisposing to tracheal laceration are summarized in Table 1.3,4Table 1: Factors Leading to Tracheal Tear or RuptureWomen are more susceptible to iatrogenic tracheobronchial rupture by virtue of their small body size, which puts them at increased risk of placing the tube too far downward in a short and weak membranous trachea.5 The most frequent cause of tracheal injury associated with intubation appears to be excessive cuff to tracheal wall pressure and inadequate tube size.6,7 It is postulated that excessive cuff pressure causes ischemic necrosis with subsequent rupture of the tracheal wall. In most instances, the posterior membranous wall ruptures longitudinally at the junction with the cartilage, and the length of rupture generally corresponds to the length of the cuff. Extensive tearing can be explained by further dissection under positive pressure ventilation.3 Signs of tracheal rupture, commonly subcutaneous emphysema and respiratory distress, appear immediately after intubation. Early radiographic findings include pneumomediastinum, subcutaneous emphysema, and pneumothorax. Pneumothorax occurs only if the tracheobronchial rupture communicates freely with the pleural space. Emergent flexible bronchoscopy is the best means of confirming the diagnosis and determining the exact location and extent of the lesion, which should be performed in the operating room. Aggressive management is essential to avoid life-threatening complications. Immediate complications include tension pneumothorax and anoxia because most of the tidal volume leaks through the tear. Subacute complications include potentially lethal mediastinitis and tracheal stricture.3 Tracheal intubation distal to the lesion or bronchial intubation with a double lumen tube and pleural drainage are of prime importance for control of respiratory distress. A few patients undergoing emergent repair in severe respiratory distress could require cardiopulmonary bypass. In patients with small tears when less than one third of the circumference of the trachea or bronchus is disrupted and in the absence of gross air leak or respiratory embarrassment, conservative management can be opted. However, any patient with a large tear or evidence of respiratory or circulatory compromise, primary surgical repair is the treatment of choice and must be performed at the earliest.3 Authors believe that even if care is applied during intubation, superficial lesions in the transbronchial tree are unavoidable, especially under emergency conditions. Large, iatrogenic disruptions can be avoided by using small endotracheal tubes and double-lumen tubes with carinal spurs should be generally avoided. Continuous monitoring of the cuff pressure is mandatory to overcome the problem of unnoticed cuff distension as a result of diffusion of nitrous oxide.8