Tracheal rupture complicating emergent endotracheal intubation

doi:10.1016/j.ajem.2004.04.012

The American Journal of Emergency Medicine

Volume 22, Issue 4, July 2004, Pages 289-293

https://doi.org/10.1016/j.ajem.2004.04.012 Get rights and content

Abstract

Tracheal rupture is rare in clinical practice. We present 2 female patients with tracheal rupture after emergent endotracheal intubation from different injury mechanisms; penetrating injury of using stylet during intubation in one case and overinflation of cuff of the endotracheal tube under rapid sequence intubation in another. The lesions of rupture could be detected by bronchoscopy and reconstructive 3-dimensional computed tomography. Both cases received surgical repair without complication. In our report, reconstructive 3-dimensional computed tomography scrupulously detected the rupture sites and provided the noninvasive modality for diagnosis. We review the literature of tracheal rupture after emergent endotracheal intubation in respects of the diagnosis, the possible mechanisms of the injury, and suggest strategies of management.

Section snippets

Case 1

A 69-year-old female patient with renal failure presented progressive dyspnea and disturbed consciousness in the emergency department (ED). Respiratory distress with 26 breathes per minute and shallow effort of breathing was noted. The oxygen saturation was 80% of pulse oxymetry under room air. Physical examination revealed crackles over bilateral lung field and chest radiography revealed acute pulmonary congestion. She was intubated without sedation using a size 7.5mm endotracheal tube for

Discussion

Endotracheal intubation-related airway ruptures are rare.1, 2, 4, 5 Several mechanical and anatomic factors have been proposed (Table 1). 2, 8 Overinflation of cuff or sudden moves of the tube are the most two reasons and direct tear caused by the tube itself remained rare.5

Woman are more frequently reported with iatrogenic tracheal rupture because of anatomic factors including weakness of the membranous portion of trachea and smaller body size which increases the risk of placing the tube too

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Cited by (80)

Endotracheal Tube Intracuff Pressure Changes in Patients Transported by a Helicopter Emergency Medical Service: A Prospective Observational Study
2021, Air Medical Journal
The pressure within an endotracheal tube cuff is of particular importance in helicopter emergency medical services (HEMS) transport because the unpressurized cabin is subjected to decreases in atmospheric pressure. This can cause the cuff to overinflate and may be associated with clinical complications. We sought to evaluate endotracheal tube cuff pressure changes among intubated patients during HEMS transport.
A prospective observational study was performed including adult patients who were intubated and transported by helicopter between April 2017 and October 2018. Cuff pressures were measured before, during, and after HEMS transport with a commercial manometer.
A total of 208 patients were included. The median maximum flight altitude was 3,000 (interquartile range [IQR], 2,000-5,000) ft. The median initial cuff pressure before takeoff was 35 (IQR, 24-50) cm H₂O, which increased to 50 (IQR, 35-70) cm H₂O at maximum altitude. A total of 169 (81.3%) patients had a cuff pressure > 30 cm H₂O at maximum altitude. There was a moderate correlation between altitude and cuff pressure (r = 0.532, P < .001).
Cuff pressure increased during HEMS transport, demonstrating the need for routine cuff pressure monitoring during flight. Further research is required to determine if exposure to transient increases in cuff pressure for short durations is clinically significant.
Pediatric tracheal trauma
2021, Seminars in Pediatric Surgery
Citation Excerpt :
Low pressure cuffs are now advocated to reduce pressure injury, nonetheless, given the frequency of intubations and capability of prolonged intubation, injuries still occur.16 In contrast to chronic pressure necrosis, acute post-intubation injury, such as tracheal wall laceration17–19 and rupture20–26 can occur as well. Of these, known and presumed direct causes include extruded endotracheal tube stylets, overinflated cuff, multiple attempts at intubation, and incorrect endotracheal tube size.17–26 (
Tracheal trauma is an uncommon but potentially serious cause of airway injury in children. Presentation may be acute in cases of blunt or penetrating trauma, or delayed in cases of chronic irritation or indwelling endotracheal tubes. Symptoms include dyspnea, progressive respiratory distress, neck and chest swelling and ecchymosis, and dysphonia. Workup is pursued as allowed by the patient's clinical status and may include plain radiography, computed tomography, and endoscopy. Accuracy and efficiency of diagnosis is paramount for those at risk of rapid decompensation. Treatment may include observation, elective and strategic intubation, or primary surgical repair.
Postintubation Tracheal Perforation While on Long-Term Steroid Therapy: A Case Report
2021, Journal of Emergency Medicine
Citation Excerpt :
Of the few cases noted previously, most did not report any anticipated difficulties for intubation (4,7). The patient was on long-term steroid use for 16 years, which is noted as one of the possible risk factors for perforation (4,8). This complication can present immediately or be delayed (9).
Endotracheal intubation is an essential basic skill for emergency physicians. The procedure can cause complications that should be recognized. Awareness and early identification of complications are needed to allow early intervention to optimize outcomes. The risk factors for tracheal perforation during intubation are typically related to the physician skill and experience and to the patient's comorbidities, including body habitus and chronic use of certain medications.
We report a case of a 45-year-old man with renal transplant on tacrolimus and prednisolone for 16 years. He presented with decreased level of consciousness due to an acute intracranial hemorrhage and was intubated for airway protection. Post intubation, a significant subcutaneous emphysema was noted on the patient's neck and chest, which was subsequently determined to be caused by a tracheal perforation. The management of tracheal injury depends on the size and location of the tear, as well as the patient's clinical status and comorbidities. In this case, the tracheal perforation was treated conservatively and was successful.
This case has been reported to increase awareness about this rare and potentially life-threatening event. The prevention of this rare injury can be difficult but use of a slightly smaller endotracheal tube in a high-risk patient can be of benefit. In addition, early consideration of this complication when there is an acute change in physiologic status will allow for rapid facilitated management.
Novel expandable architected breathing tube for improving airway securement in emergency care
2021, Journal of the Mechanical Behavior of Biomedical Materials
Citation Excerpt :
The cuff is composed of a thin film that, when inflated, exerts a radial pressure against the inner wall of the trachea (Fig. 1-b). Traditional ETT design features, including the inflatable cuff, have been recognized as risk factors (Fan et al., 2004; Bhatti et al., 2010; Gaynor and Greenberg, 1985; Bangaari et al., 2012; Stauffer et al., 1981). Since the film can inflate freely, the cuff behaves like a donut-shaped balloon.
Life-saving interventions utilize endotracheal intubation to secure a patient's airway, but performance of the clinical standard of care endotracheal tube (ETT) is inadequate. For instance, in the current COVID-19 crisis, patients can expect prolonged intubation. This protracted intubation may produce health complications such as tracheal stenosis, pneumonia, and necrosis of tracheal tissue, as current ETTs are not designed for extended use. In this work, we propose an improved ETT design that seeks to overcome these limitations by utilizing unique geometries which enable a novel expanding cylinder. The mechanism provides a better distribution of the contact forces between the ETT and the trachea, which should enhance patient tolerability. Results show that at full expansion, our new ETT exerts pressures in a silicone tracheal phantom well within the recommended standard of care. Also, preliminary manikin tests demonstrated that the new ETT can deliver similar performance in terms of air pressure and air volume when compared with the current gold standard ETT. The potential benefits of this new architected ETT are threefold, by limiting exposure of healthcare providers to patient pathogens through streamlining the intubation process, reducing downstream complications, and eliminating the need of multiple size ETT as one architected ETT fits all.
Endotracheal Cuff Pressure Changes During Helicopter Transport: A Systematic Review
2017, Air Medical Journal
Citation Excerpt :
This is despite ETT intracuff pressures being known to be very high in both the prehospital and emergency department settings, and the harm caused by excessive pressures is well-documented.1,6-9 Overinflation of tracheal cuffs can cause various complications ranging from minor issues such as hoarseness, a sore throat, and mild mucosal damage22,23 to more complex problems such as tracheal stenosis, tracheoesophageal fistula, and tracheal rupture.24-26 The time span for injuries caused by increased ETT intracuff pressure is yet to be fully understood.
Cuff pressures are important in ventilated patients undergoing helicopter transport. An altitude-related increase in endotracheal tube (ETT) intracuff pressure has been shown in simulated hypobaric environments, model tracheas, and animal studies and may not accurately reflect in vivo pressures. The aim of this study was to determine if ETT intracuff pressure increases above the critical perfusion pressure of the trachea in ventilated patients during helicopter transport.
Ovid Medline, CINAHL, Embase, Scopus, and the Cochrane Library were searched from their commencement to January 29, 2016. Google Scholar was searched, and reference lists of relevant articles were examined to identify additional studies. Articles were included if they reported on ETT intracuff pressure in ventilated patients during helicopter emergency medical service transport.
A total of 330 articles were identified; only 2 prospective observational studies met the inclusion criteria. The studies reported a mean cuff pressure increase of 23 cm H₂O and 33.9 cm H₂O. Both studies reported ETT intracuff pressure to frequently exceed the critical perfusion pressure of the tracheal mucosa during helicopter transport.
Further research with longitudinal follow-up is required to confirm these findings to determine if the effects of transient increased ETT intracuff pressure are clinically significant.
Iatrogenic tracheal laceration in the setting of chronic steroids
2017, Journal of Clinical Anesthesia
Citation Excerpt :
Although the true incidence of iatrogenic tracheal injury as a complication of emergent or nonelective endotracheal intubation remains unknown, several risk factors have been identified. They include emergency and multiple intubation attempts, improper use of stylets, improper use of the laryngoscope, inappropriate endotracheal tube size, overinflation of the cuff, improper suctioning of the endotracheal tube, malposition of the tip of the tube, tube reposition without deflating the cuff, and abrupt head and neck movements [1,3-7]. Patients who are female, older, have a history of corticosteroid use, and have COPD have been identified to be predisposed to tracheal injury during intubation [1,3,4,6-9].
We report the case of a 71-year-old woman with end-stage chronic obstructive pulmonary disease who presented with a 10-cm tracheal laceration from a presumed traumatic intubation in the setting of respiratory distress and chronic obstructive pulmonary disease exacerbation and subsequently developed significant subcutaneous emphysema along her neck and mediastinum in addition to her peritoneum and mesentery. We were successfully able to treat this patient conservatively up until the time that tracheostomy was warranted. We discuss and review tracheobronchial injuries with respect to etiology, risk factors, and management and hope to benefit health care providers managing airways in patients at risk for tracheal injury.

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Brief reportTracheal rupture complicating emergent endotracheal intubation

Abstract

Section snippets

Case 1

Discussion

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Chest

J Emerg Med

Brief report
Tracheal rupture complicating emergent endotracheal intubation