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Tracheal perforation as a complication of nasotracheal intubation in a neonate
April 1976 The Journal o f P E D I A T R I C S
631
Tracheal perforation as a complication of nasotracheal intubation in a neonate Juerg P. Schild, M.D., Andr6 Wuilloud, M.D., Heinrich Kollberg, M.D., and E m i l i o B o s s i , M . D . , * Berne, S w i t z e r l a n d
TRACHEAL PERFORATION during i n t u b a t i o n o f the n e w b o r n infant is a rare event?, 2 K n o w l e d g e o f this complication and o f its clinical manifestations could be life saving.
CASE REPORT Patient E. F. was born at term to a 24-year-old primigravida after an uneventful pregnancy. Because of secondary uterine inertia, vacuum extraction was performed. The infant weighed 3,970 gm. Because of neonatal asphyxia, the infant was intubated orotracheally with an uncuffed rubber tube, without stylet, internal diameter 3.0 mm (Rtisch Co., Rommelshausen, Federal Republic of Germany), after mask ventilation and administration of bicarbonate and glucose intravenously. Because of inability to breathe spontaneously, the infant was referred to our hospital, and nasotracheal intubation was attempted for transportation. The uncuffed, siliconized polyvinylchloride tube without styler, with an internal diameter of 3.0 mm (Portex Ltd., Hythe, Kent, England) could not be pushed further than a few millimeters below the vocal cords, even though Magill forceps were used. Immediately after onset of ventilation through this tube, rapidly increasing subcutaneous emphysema, cyanosis, and shock were noted. The tube was removed and orotracheal reintubation performed without complication. A roentgenogram of the chest showed bilateral pneumothoraces, pneumomediastinum, and subcutaneous emphysema. The pneumothorax was drained with Bard I-Caths, Needle size 17 G x 2" (Bard International Ltd., Sunderland, England). The infant's condition improved. Transportation to our hospital was then carried out. Upon arrival at the intensive care unit, the decision was made to ventilate the child mechanically. For this purpose, nasotracheal intubation was performed, using the same kind of Portex tube, but with an internal diameter of 3.5 mm. The tube was seen
From the Division of Neonatology, University Children's Hospital, Berne, HOpital Cantonal, Fribourg. *Reprint address: Universitaets-Kinderklinik, Inselspital, 3010 Berne, Switzerland.
Fig. 1. Perforation of the anterior wall of the trachea, 1 cm below the thyroid cartilage (arrow), as found at necropsy. (Autopsy performed by the Institute of Pathology of the University of Berne.) passing the vocal cords and could easily be pushed 2 cm fnrther. Immediately after the onset of bag ventilation, however, the thorax was noted not to expand as usual, and subcutaneous emphysema of the upper half of the chest, of the neck, and of the
Vol. 88, No. 4, part 1, pp. 631-632
632
SchiM et al.
The Journal of Pediatrics April 1976
lower part of the face appeared and increased rapidly. Unfortunately, at this time the exact sequence of events at the referring hospital with the history of successful orotracheal reintubation wasnot yet known. Cardiac arrest occurred and the infant died 15 minutes after the nasotracheal intubation. Postmortem examination showed a perforation of the anterior tracheal wall with a diameter of 8 mm, 1 cm below the thyroid cartilage (Figs. 1 and 2). The microscopic findings revealed a perforation of an otherwise normal trachea with normal epithelial lining. DISCUSSION It is a s s u m e d that p e r f o r a t i o n resulted f r o m a too vigorous attempt at the first n a s o t r a c h e a l i n t u b a t i o n . I n a s m u c h as orotracheal i n t u b a t i o n h a d b e e n successful the first time, it is suggested t h a t this p r o c e d u r e m i g h t b e the emergency t r e a t m e n t o f choice in t r a c h e a l p e r f o r a t i o n occurring after nasotracheal i n t u b a t i o n . REFERENCES
1. Serlin SP, and Daily WJR: Tracheal perforation in the neonate: A complication of endotracheal intubation, J PEDIATR 86:596, 1975. 2. Bretscher J: Die Gefahren der Schaedigung bei der Reanimation Neugeborener, Z Geburtsh Gynaek 169:44, 1968.
Fig. 2. Same preparation as in Fig. I, with tube introduced through the perforation site.
631
Tracheal perforation as a complication of nasotracheal intubation in a neonate Juerg P. Schild, M.D., Andr6 Wuilloud, M.D., Heinrich Kollberg, M.D., and E m i l i o B o s s i , M . D . , * Berne, S w i t z e r l a n d
TRACHEAL PERFORATION during i n t u b a t i o n o f the n e w b o r n infant is a rare event?, 2 K n o w l e d g e o f this complication and o f its clinical manifestations could be life saving.
CASE REPORT Patient E. F. was born at term to a 24-year-old primigravida after an uneventful pregnancy. Because of secondary uterine inertia, vacuum extraction was performed. The infant weighed 3,970 gm. Because of neonatal asphyxia, the infant was intubated orotracheally with an uncuffed rubber tube, without stylet, internal diameter 3.0 mm (Rtisch Co., Rommelshausen, Federal Republic of Germany), after mask ventilation and administration of bicarbonate and glucose intravenously. Because of inability to breathe spontaneously, the infant was referred to our hospital, and nasotracheal intubation was attempted for transportation. The uncuffed, siliconized polyvinylchloride tube without styler, with an internal diameter of 3.0 mm (Portex Ltd., Hythe, Kent, England) could not be pushed further than a few millimeters below the vocal cords, even though Magill forceps were used. Immediately after onset of ventilation through this tube, rapidly increasing subcutaneous emphysema, cyanosis, and shock were noted. The tube was removed and orotracheal reintubation performed without complication. A roentgenogram of the chest showed bilateral pneumothoraces, pneumomediastinum, and subcutaneous emphysema. The pneumothorax was drained with Bard I-Caths, Needle size 17 G x 2" (Bard International Ltd., Sunderland, England). The infant's condition improved. Transportation to our hospital was then carried out. Upon arrival at the intensive care unit, the decision was made to ventilate the child mechanically. For this purpose, nasotracheal intubation was performed, using the same kind of Portex tube, but with an internal diameter of 3.5 mm. The tube was seen
From the Division of Neonatology, University Children's Hospital, Berne, HOpital Cantonal, Fribourg. *Reprint address: Universitaets-Kinderklinik, Inselspital, 3010 Berne, Switzerland.
Fig. 1. Perforation of the anterior wall of the trachea, 1 cm below the thyroid cartilage (arrow), as found at necropsy. (Autopsy performed by the Institute of Pathology of the University of Berne.) passing the vocal cords and could easily be pushed 2 cm fnrther. Immediately after the onset of bag ventilation, however, the thorax was noted not to expand as usual, and subcutaneous emphysema of the upper half of the chest, of the neck, and of the
Vol. 88, No. 4, part 1, pp. 631-632
632
SchiM et al.
The Journal of Pediatrics April 1976
lower part of the face appeared and increased rapidly. Unfortunately, at this time the exact sequence of events at the referring hospital with the history of successful orotracheal reintubation wasnot yet known. Cardiac arrest occurred and the infant died 15 minutes after the nasotracheal intubation. Postmortem examination showed a perforation of the anterior tracheal wall with a diameter of 8 mm, 1 cm below the thyroid cartilage (Figs. 1 and 2). The microscopic findings revealed a perforation of an otherwise normal trachea with normal epithelial lining. DISCUSSION It is a s s u m e d that p e r f o r a t i o n resulted f r o m a too vigorous attempt at the first n a s o t r a c h e a l i n t u b a t i o n . I n a s m u c h as orotracheal i n t u b a t i o n h a d b e e n successful the first time, it is suggested t h a t this p r o c e d u r e m i g h t b e the emergency t r e a t m e n t o f choice in t r a c h e a l p e r f o r a t i o n occurring after nasotracheal i n t u b a t i o n . REFERENCES
1. Serlin SP, and Daily WJR: Tracheal perforation in the neonate: A complication of endotracheal intubation, J PEDIATR 86:596, 1975. 2. Bretscher J: Die Gefahren der Schaedigung bei der Reanimation Neugeborener, Z Geburtsh Gynaek 169:44, 1968.
Fig. 2. Same preparation as in Fig. I, with tube introduced through the perforation site.