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Inadvertent intubation of the left mainstem bronchus
Brief Reports
Inadvertent Intubation of the Left Mainstem Bronchus BRIAN J. RIBEIRO, MD This is a case report of a previously healthy Bl-year-old white male who was emergently intubated in the field by paramedical personnel and transported to the emergency department. Physical examination revealed minimal-to-absent breath sounds over the right hemithorax associated with cyanosis of the head, face, and upper extremities. Emergency needle decompression of the right lung was accomplished without improvement. A postmortem chest radiograph revealed a lefl mainstem bronchus intubation. Use of the physical examination, the endotracheal tube depth, and an awareness of the possible-but rare-complication of left mainstem bronchus intubation may lead to accurate diagnosis and treatment and avoid unnecessary procedures. (Am J Emerg Med 1993;11:33-34.Copy-
right 0 1993 by W.6. Saunders Company) Intubation of the right mainstem bronchus is a known and common complication of endotracheal intubationlm6 and may be more prevalent when accomplished under emergent situations. Left mainstem bronchus intubation is a rare complication of endotracheal intubation and has only been reported twice in the medical literature.lS4 The following case report describes the presentation of a patient with a left mainstem bronchus intubation resulting from emergent endotracheal intubation for sudden cardiac arrest.
CASE REPORT A 61-year-old white male with a remote history of myocardial infarction and atherosclerotic vascular disease had complained of epigastric and lower chest pain and discomfort for approximately 6 hours’ duration. He had used sublingual nitroglycerin for the discomfort. He was found at home slumped on the bathroom floor by a family member. A paramedical team arrived 5 minutes later and found the patient to be pulseless but with electrical activity on the portable electrocardiogram monitor. Cardiopulmonary resuscitation was immediately initiated and endotracheal intubation was accomplished on the first attempt without difficulty. Intravenous peripheral access was not obtained despite multiple attempts, and advanced cardiac life support protocol for electromechanical dissoci-
From the Department of Medicine, Martin Army Hospital, Fort Benning, GA. Manuscript received June 1, 1992; accepted June 3, 1992. Address reprint requests to Dr Ribeiro, Department of Medicine, Martin Army Hospital, Fort Benning, GA 31905. The opinions and assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense. Key Words: Endobronchial intubation, endotracheal intubation, left mainstem bronchus intubation, emergency intubation. Copyright 0 1993 by W.B. Saunders Company 0735-6757/93/l l Ol -0006$5.00/O
ation was initiated. On arrival to the emergency department the patient was noted to have adequate breath sounds with ambubagging over the left lung fields, but breath sounds were minimal to absent over the right lung fields. The patient had a short, thick neck, making evaluation for possible tracheal shift difficult. Intravenous access was obtained by percutaneous cannulation of the right subclavian vein, while simultaneous attempts to obtain an arterial specimen for blood gas analysis were unsuccessful. Cyanosis of the face, neck, and upper extremities were noted. Because of the concern of a possible right-sided tension pneumothorax, emergency percutaneous decompression of the right hemithorax with a no. 14 gauge angiocatheter was attempted. Only minimal air return was obtained on its introduction into the chest cavity. The angiocatheter was left in place and clamped with a stopcock. Advanced cardiac life support protocol was continued for electromechanical dissociation and asystole. Continued efforts were unsuccessful and the patient died approximately 40 minutes after initiation of advanced cardiac life support. A postmortem chest radiograph was obtained and was remarkable in that the tip of the endotracheal tube was positioned in the left mainstem bronchus (Figure 1). A postmortem examination was obtained and the immediate cause of death was reported as cardiac arrest resulting from exsanguination due to the rupture of an atherosclerotic abdominal aortic aneurysm.
DISCUSSION Endobronchial intubation is a common complication of emergency endotracheal intubation. Intubation of the right mainstem bronchus may occur in as many as 28% of all emergency endotracheal intubations’.’ and is not usually recognized until a postintubation radiograph is obtained.* Intubation of the left mainstem bronchus is a rarer complication, having only been reported twice in the medical literature . ’ -4 This may be due to the narrower and less direct path of the left mainstem bronchus as compared with the right.4 Although current teaching about the absence of breath sounds on the right side of the chest after emergency endotracheal intubation may include a differential diagnosis of pneumothorax, hemothorax, pleural effusion, bronchus obstruction by a foreign body, or previous pneumonectomy,4 left mainstem bronchus intubation may not be emphasized and may in fact initiate an unnecessary procedure (eg, needle decompression or tube thoracostomy of a chest cavity). This is especially important since the repositioning of the endotracheal tube is an easily and quickly accomplished procedure that will return ventilation to both lung fields. As this case illustrates, left mainstem bronchus intubation does occur. Although methods to determine endobronchial intubation may be unreliable, such as auscultation of breath sounds and the presence of hypoxia,’ when present they can
33
34
AMERICAN
JOURNAL
OF EMERGENCY
MEDICINE
bation, especially right hemithorax. The author thanks cal assistance.
n Volume
11, Number
1 n January
1993
when breath sounds are absent over the Marie J. Trenga,
MD for editorial
and techni-
REFERENCES
FIGURE 1. Inadvertent intubation of the left mainstem bronchus. help lead to accurate diagnosis and treatment. Observance of the endotracheal tube depth3 in conjunction with the above physical findings’ may heighten the suspicion for and may serve as an adjunct in the diagnosis of endobronchial intu-
1. Stauffer JL, Olson DE, Petty TL: Complications and consequences of endotracheal intubation and tracheotomy: A prospective study of 150 critically ill adult patients. Am J Med 1981; 70:85-78 2. Bissinger U, Lenz G, Kuhn T: Unrecognized endobronchial intubation of emergency patients. Ann Emerg Med 1989;18:853855 3. Brunel W, Coleman DL, Schwartz DE, et al: Assessment of routine chest roentgenograms and the physical examination to confirm endotracheal tube position. Chest 1989;98:1043-1045 4. Saunders CE, Sedman AJ: Left mainstem bronchus intubation. Am J Emerg Med 1984;2:408-407 5. Dronen S, Chadwick 0, Nowak R, et al: Endotracheal tip position in the arrested patient. Ann Emerg Med 1982;11:118117 6. Taryle DA, Chandler JE, Good JT Jr: Emergency room intubations-Complications and survival. Chest 1979;75:541-543 7. Owen RL, Cheney FW: Endobronchial intubation: A preventable complication. Anesthesiology 1987;67:255-257 8. Andersen KH, Hald A: Assessing the position of the tracheal tube. The reliability of different methods. Anaesthesia 1989;44: 984-985
Inadvertent Intubation of the Left Mainstem Bronchus BRIAN J. RIBEIRO, MD This is a case report of a previously healthy Bl-year-old white male who was emergently intubated in the field by paramedical personnel and transported to the emergency department. Physical examination revealed minimal-to-absent breath sounds over the right hemithorax associated with cyanosis of the head, face, and upper extremities. Emergency needle decompression of the right lung was accomplished without improvement. A postmortem chest radiograph revealed a lefl mainstem bronchus intubation. Use of the physical examination, the endotracheal tube depth, and an awareness of the possible-but rare-complication of left mainstem bronchus intubation may lead to accurate diagnosis and treatment and avoid unnecessary procedures. (Am J Emerg Med 1993;11:33-34.Copy-
right 0 1993 by W.6. Saunders Company) Intubation of the right mainstem bronchus is a known and common complication of endotracheal intubationlm6 and may be more prevalent when accomplished under emergent situations. Left mainstem bronchus intubation is a rare complication of endotracheal intubation and has only been reported twice in the medical literature.lS4 The following case report describes the presentation of a patient with a left mainstem bronchus intubation resulting from emergent endotracheal intubation for sudden cardiac arrest.
CASE REPORT A 61-year-old white male with a remote history of myocardial infarction and atherosclerotic vascular disease had complained of epigastric and lower chest pain and discomfort for approximately 6 hours’ duration. He had used sublingual nitroglycerin for the discomfort. He was found at home slumped on the bathroom floor by a family member. A paramedical team arrived 5 minutes later and found the patient to be pulseless but with electrical activity on the portable electrocardiogram monitor. Cardiopulmonary resuscitation was immediately initiated and endotracheal intubation was accomplished on the first attempt without difficulty. Intravenous peripheral access was not obtained despite multiple attempts, and advanced cardiac life support protocol for electromechanical dissoci-
From the Department of Medicine, Martin Army Hospital, Fort Benning, GA. Manuscript received June 1, 1992; accepted June 3, 1992. Address reprint requests to Dr Ribeiro, Department of Medicine, Martin Army Hospital, Fort Benning, GA 31905. The opinions and assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense. Key Words: Endobronchial intubation, endotracheal intubation, left mainstem bronchus intubation, emergency intubation. Copyright 0 1993 by W.B. Saunders Company 0735-6757/93/l l Ol -0006$5.00/O
ation was initiated. On arrival to the emergency department the patient was noted to have adequate breath sounds with ambubagging over the left lung fields, but breath sounds were minimal to absent over the right lung fields. The patient had a short, thick neck, making evaluation for possible tracheal shift difficult. Intravenous access was obtained by percutaneous cannulation of the right subclavian vein, while simultaneous attempts to obtain an arterial specimen for blood gas analysis were unsuccessful. Cyanosis of the face, neck, and upper extremities were noted. Because of the concern of a possible right-sided tension pneumothorax, emergency percutaneous decompression of the right hemithorax with a no. 14 gauge angiocatheter was attempted. Only minimal air return was obtained on its introduction into the chest cavity. The angiocatheter was left in place and clamped with a stopcock. Advanced cardiac life support protocol was continued for electromechanical dissociation and asystole. Continued efforts were unsuccessful and the patient died approximately 40 minutes after initiation of advanced cardiac life support. A postmortem chest radiograph was obtained and was remarkable in that the tip of the endotracheal tube was positioned in the left mainstem bronchus (Figure 1). A postmortem examination was obtained and the immediate cause of death was reported as cardiac arrest resulting from exsanguination due to the rupture of an atherosclerotic abdominal aortic aneurysm.
DISCUSSION Endobronchial intubation is a common complication of emergency endotracheal intubation. Intubation of the right mainstem bronchus may occur in as many as 28% of all emergency endotracheal intubations’.’ and is not usually recognized until a postintubation radiograph is obtained.* Intubation of the left mainstem bronchus is a rarer complication, having only been reported twice in the medical literature . ’ -4 This may be due to the narrower and less direct path of the left mainstem bronchus as compared with the right.4 Although current teaching about the absence of breath sounds on the right side of the chest after emergency endotracheal intubation may include a differential diagnosis of pneumothorax, hemothorax, pleural effusion, bronchus obstruction by a foreign body, or previous pneumonectomy,4 left mainstem bronchus intubation may not be emphasized and may in fact initiate an unnecessary procedure (eg, needle decompression or tube thoracostomy of a chest cavity). This is especially important since the repositioning of the endotracheal tube is an easily and quickly accomplished procedure that will return ventilation to both lung fields. As this case illustrates, left mainstem bronchus intubation does occur. Although methods to determine endobronchial intubation may be unreliable, such as auscultation of breath sounds and the presence of hypoxia,’ when present they can
33
34
AMERICAN
JOURNAL
OF EMERGENCY
MEDICINE
bation, especially right hemithorax. The author thanks cal assistance.
n Volume
11, Number
1 n January
1993
when breath sounds are absent over the Marie J. Trenga,
MD for editorial
and techni-
REFERENCES
FIGURE 1. Inadvertent intubation of the left mainstem bronchus. help lead to accurate diagnosis and treatment. Observance of the endotracheal tube depth3 in conjunction with the above physical findings’ may heighten the suspicion for and may serve as an adjunct in the diagnosis of endobronchial intu-
1. Stauffer JL, Olson DE, Petty TL: Complications and consequences of endotracheal intubation and tracheotomy: A prospective study of 150 critically ill adult patients. Am J Med 1981; 70:85-78 2. Bissinger U, Lenz G, Kuhn T: Unrecognized endobronchial intubation of emergency patients. Ann Emerg Med 1989;18:853855 3. Brunel W, Coleman DL, Schwartz DE, et al: Assessment of routine chest roentgenograms and the physical examination to confirm endotracheal tube position. Chest 1989;98:1043-1045 4. Saunders CE, Sedman AJ: Left mainstem bronchus intubation. Am J Emerg Med 1984;2:408-407 5. Dronen S, Chadwick 0, Nowak R, et al: Endotracheal tip position in the arrested patient. Ann Emerg Med 1982;11:118117 6. Taryle DA, Chandler JE, Good JT Jr: Emergency room intubations-Complications and survival. Chest 1979;75:541-543 7. Owen RL, Cheney FW: Endobronchial intubation: A preventable complication. Anesthesiology 1987;67:255-257 8. Andersen KH, Hald A: Assessing the position of the tracheal tube. The reliability of different methods. Anaesthesia 1989;44: 984-985