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Tracheal rupture and the creation of a false passage after emergency intubation
AIRWAY/CASE REPORT
Tracheal Rupture and the Creation of a False Passage After Emergency Intubation
David Sternfeld, MD Stewart Wright, MD From the Department of Emergency Medicine, University Hospital, Cincinnati, OH.
Endotracheal intubation is a common emergency department procedure with rare but potentially life-threatening complications. A systematic review of the literature demonstrated that all patients with traumatic tracheal rupture after endotracheal intubation could be adequately ventilated despite tracheal perforation. We report an unusual case of tracheal perforation in which the patient could not be effectively ventilated because of the creation of a false passage caused by the endotracheal tube adjacent to the posterior wall of the trachea. [Ann Emerg Med. 2003;42:88-92.]
Copyright © 2003 by the American College of Emergency Physicians. 0196-0644/2003/$30.00 + 0 doi:10.1067/mem.2003.278
8 8
ANNALS OF EMERGENCY MEDICINE
42:1
JULY 2003
TRACHEAL RUPTURE Sternfeld & Wright
INTRODUCTION
Emergency endotracheal intubation is a common procedure performed by emergency physicians. We report an unusual complication of endotracheal intubation that contributed to patient mortality. Although numerous reports of tracheal perforation after endotracheal intubation have been previously described, the creation of a false passage and the inability to ventilate the patient have not been reported in the literature.1-4 CASE REPORT
A 69-year-old woman presented to the emergency department (ED) complaining of palpitations and mild dyspnea for 1 day. The ED is a Level I trauma center in an urban setting with an annual census of more than 80,000 patients per year. The patient denied chest pain, cough, and fever but did complain of vague abdominal pain for the past several months. Her past medical history was significant for hypertension. She denied any tobacco or alcohol use. Her medications included nifedipine. She had no known drug allergies. Her vital signs were a blood pressure of 133/93 mm Hg, a pulse rate of 190 beats/min, an irregular respiratory rate of 32 breaths/min, and a temperature of 36.1°C (97.1°F). Her hemoglobin oxygen saturation was 99% on room air. She was morbidly obese (body mass index=42), 5 ft tall, comfortable, alert and oriented, and in no respiratory distress. Examination of the neck revealed no jugular venous distention. Auscultation of the lungs demonstrated clear breath sounds. Auscultation of the heart revealed an irregular rhythm with no murmurs. The abdomen did not appear distended and was not tender to palpation. An ECG revealed atrial fibrillation at a rate of 190 beats/min. The chest radiograph revealed mild cardiomegaly and clear lung fields. The patient was treated with 20 mg of diltiazem intravenous push and started on a diltiazem drip at 10 mg/h. Her heart rate decreased to 120 beats/min after this treatment, and her dyspnea improved. The diagnostic strategy was to obtain a ventilation-perfusion scan to evaluate pulmonary embolism
JULY 2003
42:1
ANNALS OF EMERGENCY MEDICINE
as a cause for her new-onset atrial fibrillation and dyspnea. Approximately 45 minutes later, the patient experienced the sudden onset of severe respiratory distress that rapidly progressed to respiratory arrest, requiring emergency endotracheal intubation. The first intubation was successfully performed on the first attempt by a second-year emergency medicine resident using direct laryngoscopy and a 7.5-mm endotracheal tube (Lo-Pro Tracheal Tube, Mallinckrodt, St. Louis, MO) with a stylet (Satin-Slip Intubating Stylet, Mallinckrodt). Auscultation of the lungs after intubation revealed distant breath sounds but an absence of air movement over the epigastrium. End-tidal carbon dioxide could not be detected with a colorimetric detector (Easy Cap II CO2 Detector, Nellcor Puritan Bennett Inc., Pleasanton, CA). Repeat laryngoscopy by an emergency attending physician revealed that the endotracheal tube passed through the vocal cords. The patient’s clinical condition continued to deteriorate as she became more bradycardic, presumably as a result of hypoxia. Pulse oximetry could not be used during the intubation attempts because the probe did not detect a signal because of inadequate perfusion. The patient was extubated after deflation of the cuff of the endotracheal tube and immediately reintubated by a third-year emergency medicine resident using direct laryngoscopy and a different endotracheal tube and stylet. After this intubation, the patient had massive subcutaneous emphysema of the head, neck, and thorax. The patient could not be effectively ventilated, and she died after bilateral needle thoracostomies and chest tube insertion. In both attempts at intubation, the stylet was manually inserted into the endotracheal tube without difficulty, and the endotracheal tube was manually shaped with the distal tip angled upward. Both intubations were easily performed with one laryngoscopy attempt, and the vocal cords were easily visualized. The stylet was removed once the endotracheal tube was permanently seated at 21 cm, and 10 mL of air was inflated into the balloon cuff. No medications were administered to the patient before the intubation attempts because the patient precipitously had
8 9
TRACHEAL RUPTURE Sternfeld & Wright
respiratory arrest. There were no abrupt patient movements or excessive coughing during or after the intubation attempts. Autopsy findings included 2 perforations of the membranous trachea just proximal to the carina, an occlusive pulmonary embolus of the right pulmonary artery, and peritoneal carcinomatosis, with primary tumor most likely ovarian adenocarcinoma. The tip of the endotracheal tube was not located in the tracheobronchial tree but rather in a false passage adjacent to the posterior wall of the trachea (Figure).
DISCUSSION
Tracheal rupture is a rare complication of intubation. Most of the literature regarding iatrogenic tracheal injuries involves case reports with very few patients. Furthermore, most of the reported injuries involve postsurgical patients whose intubation was electively performed. A literature review through 2002 revealed that the creation of a false passage by an endotracheal tube and failure to adequately ventilate a patient has never been reported.
Figure.
Autopsy photographs showing puncture of the posterior (membranous) wall of the trachea by the endotracheal tube just proximal to the carina. Figures A and B clearly show the dissected trachea with the endotracheal tube lying in a false passage outside of the tracheal wall. The top arrow represents the membranous wall of the trachea. The center arrow represents the tip of the endotracheal tube. The bottom arrow is the carina of the trachea.
A
9 0
B
ANNALS OF EMERGENCY MEDICINE
42:1
JULY 2003
TRACHEAL RUPTURE Sternfeld & Wright
In the case described in this article, the patient could not be ventilated because the endotracheal tube created a false passage just proximal to the carina. Massive subcutaneous emphysema resulted from the insufflation of air into the false passage. The patient did not have a surgical airway performed. It is theoretically possible that the patient could have been ventilated after a cricothyroidotomy if the endotracheal tube was positioned proximal to the false passage, thus allowing some oxygen to enter the pulmonary circuit. Also, fiberoptic intubation could have been performed to facilitate placing the endotracheal tube distal to the endotracheal tear. However, the patient had been in a nonperfusing rhythm for approximately 10 minutes when either of these airway adjuncts was considered, and therefore, a decision was made not to perform them. It is unclear why this patient’s tracheal wall was perforated in 2 different locations on subsequent intubations. The length of the stylet used was slightly shorter than the endotracheal tube; therefore, perforation with the stylet alone is not a plausible explanation. However, the use of a stylet might have indirectly contributed to the tracheal perforation because the stylet could have made the endotracheal tube less pliable and more apt to puncture the tracheal wall. Possibly, the patient had a preexisting anatomic defect in her trachea that predisposed her to rupture. However, at autopsy, the patient’s trachea appeared grossly normal. Histology of the trachea was not performed. Previously reported causes for tracheal perforation include overinflation of the endotracheal tube cuff, damage caused by use of a stylet, excessive coughing at the time of intubation, and multiple attempts at intubation.1-5 Predisposing risk factors include congenital tracheal abnormalities, chronic steroid use, chronic obstructive pulmonary disease, older age, and female sex. A recent review of 56 patients with tracheal injury after intubation showed that 86% were female and 66% were older than 50 years.6 Another case series of 13 patients demonstrated that 77% of injuries occurred just proximal to the carina and involved the membranous portion of the trachea in 92% of cases.7
JULY 2003
42:1
ANNALS OF EMERGENCY MEDICINE
Unfortunately, this patient did not survive after respiratory arrest. Most patients who survive an acute tracheobronchial disruption after intubation will invariably have signs suggesting the injury. These include subcutaneous emphysema, tracheal bleeding, pneumothorax or pneumomediastinum on chest radiograph, and difficulty with mechanical ventilation. The time of onset until manifestation of symptoms varies widely, from immediate to several days.8 The treatment of tracheal lacerations is usually surgical, although conservative measures have also been shown to be effective.9-11 We present an unfortunate case of tracheal perforation and the creation of a false passage after emergency endotracheal intubation. Although the exact cause for the tracheal tear is unclear, it is most likely related to the use of a stiffened endotracheal tube in a patient predisposed to such an injury. The patient described in this report was an older woman with short stature and morbid obesity. All of these characteristics have been associated with tracheal injury during endotracheal intubation. Clinicians should consider using smaller endotracheal tubes without a stylet when initially performing endotracheal intubation on any patients with any of the predisposing risk factors for tracheal injury listed previously. Furthermore, if a stylet is used, it should be removed as soon as the endotracheal tube has passed through the vocal cords before advancing the tube to its final resting position. Received for publication April 12, 2002. Revisions received November 4, 2002, and January 16, 2003. Accepted for publication February 10, 2003. The authors report this study did not receive any outside funding or support. Address for reprints: David Sternfeld, MD, Department of Emergency Medicine, University Hospital, 231 Bethesda Avenue, Cincinnati, OH 45267; 513-558-8114, fax 513-558-5791; E-mail [email protected].
REFERENCES 1. Harris R, Joseph A. Acute tracheal rupture related to endotracheal intubation: case report. J Emerg Med. 1999;18:35-39. 2. Wagner A, Roeggla M, Hirschl M, et al. Tracheal rupture after emergency intubation during cardiopulmonary resuscitation. Resuscitation. 1995;30:263-266.
9 1
TRACHEAL RUPTURE Sternfeld & Wright
3. Tornvall SS, Jackson KH, Oyandel E. Tracheal rupture, complication of cuffed endobronchial tree. Chest. 1971;59:237-239. 4. Regragui IA, Fagan AM, Natrajan KM. Tracheal rupture after tracheal intubation. Br J Anaesth. 1994;72:705-706. 5. Kumar SM, Pandit SK, Cohen PJ. Tracheal laceration associated with endotracheal anaesthesia. Anaesthesiology. 1977;47:298-299. 6. Chen EH, Logman ZM, Glass PS, et al. A case of tracheal injury after emergent endotracheal intubation: a review of the literature and causalities. Anesth Analg. 2001;93:1270-1271. 7. Meyer M. Iatrogenic tracheobronchial lesions—a report on 13 cases. Thorac Cardiovasc Surg. 2001;49:115-119. 8. Kaloud H, Smolle-Juettner FM, Prause G, et al. Iatrogenic ruptures of the tracheobronchial tree. Chest. 1997;112:774-778. 9. Klarenbosch J, Meyer J, De Lange JJ. Tracheal rupture after tracheal intubation. Br J Anaesth. 1994;73:550-551. 10. Marquette C, Bocquillon N, Roumilhad D, et al. Conservative treatment of tracheal rupture. J Thorac Cardiovasc Surg. 1999;117:399-401. 11. Borasio P, Ardissone F, Chiampo G. Post-intubation tracheal rupture. a report on ten cases. Eur J Cardiothorac Surg. 1997;12:98-100.
9 2
ANNALS OF EMERGENCY MEDICINE
42:1
JULY 2003
Tracheal Rupture and the Creation of a False Passage After Emergency Intubation
David Sternfeld, MD Stewart Wright, MD From the Department of Emergency Medicine, University Hospital, Cincinnati, OH.
Endotracheal intubation is a common emergency department procedure with rare but potentially life-threatening complications. A systematic review of the literature demonstrated that all patients with traumatic tracheal rupture after endotracheal intubation could be adequately ventilated despite tracheal perforation. We report an unusual case of tracheal perforation in which the patient could not be effectively ventilated because of the creation of a false passage caused by the endotracheal tube adjacent to the posterior wall of the trachea. [Ann Emerg Med. 2003;42:88-92.]
Copyright © 2003 by the American College of Emergency Physicians. 0196-0644/2003/$30.00 + 0 doi:10.1067/mem.2003.278
8 8
ANNALS OF EMERGENCY MEDICINE
42:1
JULY 2003
TRACHEAL RUPTURE Sternfeld & Wright
INTRODUCTION
Emergency endotracheal intubation is a common procedure performed by emergency physicians. We report an unusual complication of endotracheal intubation that contributed to patient mortality. Although numerous reports of tracheal perforation after endotracheal intubation have been previously described, the creation of a false passage and the inability to ventilate the patient have not been reported in the literature.1-4 CASE REPORT
A 69-year-old woman presented to the emergency department (ED) complaining of palpitations and mild dyspnea for 1 day. The ED is a Level I trauma center in an urban setting with an annual census of more than 80,000 patients per year. The patient denied chest pain, cough, and fever but did complain of vague abdominal pain for the past several months. Her past medical history was significant for hypertension. She denied any tobacco or alcohol use. Her medications included nifedipine. She had no known drug allergies. Her vital signs were a blood pressure of 133/93 mm Hg, a pulse rate of 190 beats/min, an irregular respiratory rate of 32 breaths/min, and a temperature of 36.1°C (97.1°F). Her hemoglobin oxygen saturation was 99% on room air. She was morbidly obese (body mass index=42), 5 ft tall, comfortable, alert and oriented, and in no respiratory distress. Examination of the neck revealed no jugular venous distention. Auscultation of the lungs demonstrated clear breath sounds. Auscultation of the heart revealed an irregular rhythm with no murmurs. The abdomen did not appear distended and was not tender to palpation. An ECG revealed atrial fibrillation at a rate of 190 beats/min. The chest radiograph revealed mild cardiomegaly and clear lung fields. The patient was treated with 20 mg of diltiazem intravenous push and started on a diltiazem drip at 10 mg/h. Her heart rate decreased to 120 beats/min after this treatment, and her dyspnea improved. The diagnostic strategy was to obtain a ventilation-perfusion scan to evaluate pulmonary embolism
JULY 2003
42:1
ANNALS OF EMERGENCY MEDICINE
as a cause for her new-onset atrial fibrillation and dyspnea. Approximately 45 minutes later, the patient experienced the sudden onset of severe respiratory distress that rapidly progressed to respiratory arrest, requiring emergency endotracheal intubation. The first intubation was successfully performed on the first attempt by a second-year emergency medicine resident using direct laryngoscopy and a 7.5-mm endotracheal tube (Lo-Pro Tracheal Tube, Mallinckrodt, St. Louis, MO) with a stylet (Satin-Slip Intubating Stylet, Mallinckrodt). Auscultation of the lungs after intubation revealed distant breath sounds but an absence of air movement over the epigastrium. End-tidal carbon dioxide could not be detected with a colorimetric detector (Easy Cap II CO2 Detector, Nellcor Puritan Bennett Inc., Pleasanton, CA). Repeat laryngoscopy by an emergency attending physician revealed that the endotracheal tube passed through the vocal cords. The patient’s clinical condition continued to deteriorate as she became more bradycardic, presumably as a result of hypoxia. Pulse oximetry could not be used during the intubation attempts because the probe did not detect a signal because of inadequate perfusion. The patient was extubated after deflation of the cuff of the endotracheal tube and immediately reintubated by a third-year emergency medicine resident using direct laryngoscopy and a different endotracheal tube and stylet. After this intubation, the patient had massive subcutaneous emphysema of the head, neck, and thorax. The patient could not be effectively ventilated, and she died after bilateral needle thoracostomies and chest tube insertion. In both attempts at intubation, the stylet was manually inserted into the endotracheal tube without difficulty, and the endotracheal tube was manually shaped with the distal tip angled upward. Both intubations were easily performed with one laryngoscopy attempt, and the vocal cords were easily visualized. The stylet was removed once the endotracheal tube was permanently seated at 21 cm, and 10 mL of air was inflated into the balloon cuff. No medications were administered to the patient before the intubation attempts because the patient precipitously had
8 9
TRACHEAL RUPTURE Sternfeld & Wright
respiratory arrest. There were no abrupt patient movements or excessive coughing during or after the intubation attempts. Autopsy findings included 2 perforations of the membranous trachea just proximal to the carina, an occlusive pulmonary embolus of the right pulmonary artery, and peritoneal carcinomatosis, with primary tumor most likely ovarian adenocarcinoma. The tip of the endotracheal tube was not located in the tracheobronchial tree but rather in a false passage adjacent to the posterior wall of the trachea (Figure).
DISCUSSION
Tracheal rupture is a rare complication of intubation. Most of the literature regarding iatrogenic tracheal injuries involves case reports with very few patients. Furthermore, most of the reported injuries involve postsurgical patients whose intubation was electively performed. A literature review through 2002 revealed that the creation of a false passage by an endotracheal tube and failure to adequately ventilate a patient has never been reported.
Figure.
Autopsy photographs showing puncture of the posterior (membranous) wall of the trachea by the endotracheal tube just proximal to the carina. Figures A and B clearly show the dissected trachea with the endotracheal tube lying in a false passage outside of the tracheal wall. The top arrow represents the membranous wall of the trachea. The center arrow represents the tip of the endotracheal tube. The bottom arrow is the carina of the trachea.
A
9 0
B
ANNALS OF EMERGENCY MEDICINE
42:1
JULY 2003
TRACHEAL RUPTURE Sternfeld & Wright
In the case described in this article, the patient could not be ventilated because the endotracheal tube created a false passage just proximal to the carina. Massive subcutaneous emphysema resulted from the insufflation of air into the false passage. The patient did not have a surgical airway performed. It is theoretically possible that the patient could have been ventilated after a cricothyroidotomy if the endotracheal tube was positioned proximal to the false passage, thus allowing some oxygen to enter the pulmonary circuit. Also, fiberoptic intubation could have been performed to facilitate placing the endotracheal tube distal to the endotracheal tear. However, the patient had been in a nonperfusing rhythm for approximately 10 minutes when either of these airway adjuncts was considered, and therefore, a decision was made not to perform them. It is unclear why this patient’s tracheal wall was perforated in 2 different locations on subsequent intubations. The length of the stylet used was slightly shorter than the endotracheal tube; therefore, perforation with the stylet alone is not a plausible explanation. However, the use of a stylet might have indirectly contributed to the tracheal perforation because the stylet could have made the endotracheal tube less pliable and more apt to puncture the tracheal wall. Possibly, the patient had a preexisting anatomic defect in her trachea that predisposed her to rupture. However, at autopsy, the patient’s trachea appeared grossly normal. Histology of the trachea was not performed. Previously reported causes for tracheal perforation include overinflation of the endotracheal tube cuff, damage caused by use of a stylet, excessive coughing at the time of intubation, and multiple attempts at intubation.1-5 Predisposing risk factors include congenital tracheal abnormalities, chronic steroid use, chronic obstructive pulmonary disease, older age, and female sex. A recent review of 56 patients with tracheal injury after intubation showed that 86% were female and 66% were older than 50 years.6 Another case series of 13 patients demonstrated that 77% of injuries occurred just proximal to the carina and involved the membranous portion of the trachea in 92% of cases.7
JULY 2003
42:1
ANNALS OF EMERGENCY MEDICINE
Unfortunately, this patient did not survive after respiratory arrest. Most patients who survive an acute tracheobronchial disruption after intubation will invariably have signs suggesting the injury. These include subcutaneous emphysema, tracheal bleeding, pneumothorax or pneumomediastinum on chest radiograph, and difficulty with mechanical ventilation. The time of onset until manifestation of symptoms varies widely, from immediate to several days.8 The treatment of tracheal lacerations is usually surgical, although conservative measures have also been shown to be effective.9-11 We present an unfortunate case of tracheal perforation and the creation of a false passage after emergency endotracheal intubation. Although the exact cause for the tracheal tear is unclear, it is most likely related to the use of a stiffened endotracheal tube in a patient predisposed to such an injury. The patient described in this report was an older woman with short stature and morbid obesity. All of these characteristics have been associated with tracheal injury during endotracheal intubation. Clinicians should consider using smaller endotracheal tubes without a stylet when initially performing endotracheal intubation on any patients with any of the predisposing risk factors for tracheal injury listed previously. Furthermore, if a stylet is used, it should be removed as soon as the endotracheal tube has passed through the vocal cords before advancing the tube to its final resting position. Received for publication April 12, 2002. Revisions received November 4, 2002, and January 16, 2003. Accepted for publication February 10, 2003. The authors report this study did not receive any outside funding or support. Address for reprints: David Sternfeld, MD, Department of Emergency Medicine, University Hospital, 231 Bethesda Avenue, Cincinnati, OH 45267; 513-558-8114, fax 513-558-5791; E-mail [email protected].
REFERENCES 1. Harris R, Joseph A. Acute tracheal rupture related to endotracheal intubation: case report. J Emerg Med. 1999;18:35-39. 2. Wagner A, Roeggla M, Hirschl M, et al. Tracheal rupture after emergency intubation during cardiopulmonary resuscitation. Resuscitation. 1995;30:263-266.
9 1
TRACHEAL RUPTURE Sternfeld & Wright
3. Tornvall SS, Jackson KH, Oyandel E. Tracheal rupture, complication of cuffed endobronchial tree. Chest. 1971;59:237-239. 4. Regragui IA, Fagan AM, Natrajan KM. Tracheal rupture after tracheal intubation. Br J Anaesth. 1994;72:705-706. 5. Kumar SM, Pandit SK, Cohen PJ. Tracheal laceration associated with endotracheal anaesthesia. Anaesthesiology. 1977;47:298-299. 6. Chen EH, Logman ZM, Glass PS, et al. A case of tracheal injury after emergent endotracheal intubation: a review of the literature and causalities. Anesth Analg. 2001;93:1270-1271. 7. Meyer M. Iatrogenic tracheobronchial lesions—a report on 13 cases. Thorac Cardiovasc Surg. 2001;49:115-119. 8. Kaloud H, Smolle-Juettner FM, Prause G, et al. Iatrogenic ruptures of the tracheobronchial tree. Chest. 1997;112:774-778. 9. Klarenbosch J, Meyer J, De Lange JJ. Tracheal rupture after tracheal intubation. Br J Anaesth. 1994;73:550-551. 10. Marquette C, Bocquillon N, Roumilhad D, et al. Conservative treatment of tracheal rupture. J Thorac Cardiovasc Surg. 1999;117:399-401. 11. Borasio P, Ardissone F, Chiampo G. Post-intubation tracheal rupture. a report on ten cases. Eur J Cardiothorac Surg. 1997;12:98-100.
9 2
ANNALS OF EMERGENCY MEDICINE
42:1
JULY 2003