Andrzej Nestorowicz, Franciszek Furmanik, Marek Siwicki, Edyta Kotlińska
Tracheal rupture caused by a double-lumen endotracheal tube
Chair and Department of Anaesthesiology and Intensive Therapy,
Head: prof. A. Nestorowicz Chair and Department of Thoracic and Cardiac Surgery,
Head: prof. S. Jabłonka, Medical Academy of Lublin, Poland
Airway rupture has been always recognized as a life - threatening condition. It may occur following external or internal chest injury with trachea being the most common place of the rupture. We present the case of a 61 yr-old woman, scheduled for the right lobectomy, who had undergone chemoterapy supplemented by steroids. During thoracotomy, a surgeon noticed free air in the madiastinum and found the ruptured trachea, whitch had been subsequently reconstructed. Further surgery and anaesthesia went smoothly and patient recovered completely.
Tracheal rupture is a rare complication of tracheal intubation [1, 2, 3, 4, 5, 6, 7, 8, 10], mechanical ventilation  or resuscitation , being frequently of an iatrogenic character [13, 14, 15]. The majority of publications describe single cases (case reports) [4, 5, 6, 7, 9, 12], single centre's' series of patients being much more rare [1, 13, 14].
The largest clinical material, including 12 patients with iatrogenic tracheal rupture, was published by Koloud et al. . In Polish medical literature 4 cases of such tracheal lesions caused by the endotracheal tube cuff have been described .
The tear is almost always localised in the membranous part and is parallel to the longitudinal axis of the trachea. It may involve the cervical and/or thoracic part of the organ and extend sometimes to one of the main bronchi. The longest tear reported was 13 cm long .
The suspicion of tracheal rupture is made on the basis of the presence of air in the soft tissues of the neck, pneumomediastinum and/or pneumothorax. The treatment consists of immediate surgical repair of the lesion. Delay in diagnosis and treatment makes the prognosis worse: several cases of deaths following pulmonary complications or mediastinitis have been described in the literature [13, 14, 16, 17]. Many authors express the opinion that the scale of the problem of iatrogenic tracheal rupture is underestimated and the real frequency of this complication is much higher, than generally admitted.
This paper presents the case of a female patient in whom the tracheal rupture occurred during anaesthesia for right upper lobectomy.
The patient, a 61-year old female, was admitted for surgical treatment of a macrocellular, partially planoepithelial cancer of the right lung. Before surgery, the patient was scheduled to receive 3 courses of chemotherapy, consisting of gemcitabine 1400 mg (days 1, 8 and 15 of the cycle) and cisplatine 140 mg (day 2 and every 28 days). Chemotherapy had to be stopped during the second cycle, because of untoward effects of the drugs. Thrombocytopaenia was treated by dexamethasone (4 mg t.i.d. for 10 days) which was withdrawn after normalisation of laboratory test values 14 days before the scheduled operation.
Induction of anaesthesia was performed with thiopentone and suxamethonium. In order to assure selective ventilation of lungs, a double lumen endobronchial tube (Bronchocath, Mallinckrodt, Great Britain) was introduced. Anaesthesia was maintained with N2O/O2 mixture (2:1), halothane (0.2-0.4 vol%) and fractionated doses of fentanyl and pancuronium. During the procedure the patient was ventilated with an anaesthetic machine using IPPV technique.
The course of anaesthesia during thoracotomy and isolation of the right lung bronchi and vessels was uneventful. After the resection of the 3rdright lung segment, during preparations to stop ventilation of the right lung a sudden, transient drop in saturation (to 90%) was noted. A moment later the surgeon reported the presence of air in the mediastinum, floating in a space limited by superior vena cava anteriorly, vertebral column posteriorly and azygos vein caudally. Decrease in peak inspiratory pressure value and saturation (to 85%) were also observed. After incision of mediastinal pleura, a tear in the membranous part of the trachea, 7 cm long, was found (figure 1). The protruding cuff of the endobronchial tube could be seen in the defect. The double - lumen tube was changed for a standard endotracheal one with its cuff inflated distally to the lesion to assure proper ventilation of the lungs. The tracheal tear was repaired with a running suture. Subsequent course of the operation (lobectomy, pleural drainage and closure of the operative wound) was uneventful. The patient was extubated and transferred to the postoperative ward in a stable condition.
Fig. 1. Scheme of the operative field.
Endoscopy of the upper airways, performed 7 days after the operation, demonstrated normal healing of the tracheal wound without narrowing of the tracheal lumen. Air leak from the pleural drain was observed till the 10th postoperative day, it's cause most probably being the bronchial stump.
The patient was discharged 17 days after surgery and remains in observation at the outpatient department.
The exact mechanism of tracheal rupture is not completely elucidated. In cases when the lesion is provoked by endotracheal intubation, the most probable cause is excessive pressure in the cuff of the tube. This pressure, exerted by the cuff on the tracheal wall, may lead to a tear in its most vulnerable i.e. membranous part. It has been proved that the pressure inside the cuff may be as high as 120 cm H2O (12kPa) and result in traumatization of the surrounding tissue . These observations led to the introduction into clinical practice of new types of endotracheal tubes, characterised by high-volume low-pressure cuffs. Some centres advocate also monitoring of the cuff pressure during anaesthesia.
Data available from the current literature suggest that tracheal rupture occurs more frequently in small women with a short neck [16, 17]. Our patient, described in this paper, corresponded with these characteristics. Additionally, she underwent chemotherapy and subsequent corticosteroid treatment. Both groups of drugs are well known for their deleterious effects on tissues and can cause severe complications [18,19,20]. We are far from stating that preoperative treatment was the main factor of tracheal rupture in our patient, as the intracuff pressure was not monitored.
There is common consent on the mode of treatment of tracheal rupture. It must be immediately closed from the cervical or right thoracic approach or both,if necessary. The prognosis worsens with delay in diagnosis and treatment. In small tears, in patients with a high operative risk, an attempt to conservative treatment may be undertaken (antibiotics, parenteral nutrition, appropriate physio-therapy). Some authors recommend tracheostomy , although it seems, that with an immediate lesion repair it is not necessary and may increase the risk of infection.
Early diagnosis and immediate surgical repair of a tracheal rupture are primary factors influencing the outcome of this dangerous complication.
Originally published in Anestezjologia Intensywna Terapia 31; (1), 21-23, 1999.
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