CASE CONFERENCE
CASE 9–2014 Supracarinal Tracheal Tear After Atraumatic Endotracheal Intubation: Anesthetic Considerations for Surgical Repair Mary E. Arthur, MD,* Nadine Odo, BA,* William Parker, MD,† Paul M. Weinberger, MD,‡ and Vijay S. Patel, MD§
I
ATROGENIC TRACHEAL TEARS are rare but very serious complications of tracheal intubation. Because an unknown fraction of postintubation tracheal injuries are undiagnosed, misdiagnosed, or underreported, the actual incidence and outcomes of such injuries are unknown. The incidence of reported cases is approximately 1 in every 20,000 intubation attempts,1 but postmortem studies suggest the actual incidence may be as high as 15% of emergency intubations.2 When discovered, tracheal tears typically are managed conservatively, although larger tracheal tears generally require surgical intervention after diagnosis by fiberoptic bronchoscopy. The authors report on the anesthetic and surgical management of a large tracheal tear close to the carina in a young female patient and discuss airway management recommendations for such injuries. CASE PRESENTATION* A 27-year-old Caucasian female with a history of migraines and intractable seizure disorder presented for a left craniotomy and an implantation of subdural grid and depth electrodes to localize the site of her seizures. She and her husband had expressed a desire to have children, and this procedure was meant to facilitate weaning her off of potentially fetotoxic seizure medications. An uneventful anesthesia induction with 150 mg of propofol, 50 mg of lidocaine, and 50 µg fentanyl was followed by a single atraumatic attempt at direct laryngoscopy with a grade-1 view. The patient was intubated with a 7.0 endotracheal tube (ETT) that was taped at 22 cm at the lips before the surgeon attached the Mayfield frame to the head in the magnetic resonance imaging suite. After the required images were obtained, the intubated patient was transported to the operating room (OR) and sedated with propofol (100 µg/kg/min) for the second part of the procedure, a left craniotomy, implantation of subdural grid with the use of stealth navigation, and stereotactic implantation of right and left depth electrodes, to localize the epileptogenic focus. The patient was extubated and transported to the postanesthesia care unit after the uneventful procedure. On postoperative day 2, she was rushed to the OR for an emergency craniotomy to evacuate an epidural hematoma. Her reintubation with a styletted 7.0 ETT was atraumatic with a grade-1 view on laryngoscopy. Shortly after the procedure started, the patient spontaneously desaturated into the low 80s and was ventilated manually back to an SpO2 of 100%. A second episode of desaturation occurred an hour and 25 minutes into the case, prompting an arterial blood gas (ABG) analysis, which revealed a PaO2 of 49.3 mmHg. A repeat ABG 30 minutes after the desaturation episode was normal (PaO2 of 370 mmHg). Thirty-two minutes after the second set of ABG results was obtained, a third episode of spontaneous desaturation (89%)
*M. E. Arthur and N. Odo
reverted to 100% with little intervention. The authors observed that the ETT had migrated down into the right main bronchus and left breath sounds were diminished. The tube was readjusted and pulled back from 24 cm and retaped at 22 cm at the lip. Because of the unexplained desaturations in the OR, the anesthesia and surgical teams agreed that the patient should remain intubated. Axial and coronal views on computed tomography angiography, which were obtained to rule out a pulmonary embolus, instead revealed a small pneumomediastinum (Figs 1 and 2), prompting an urgent cardiothoracic consult and return to the OR for exploration. PaO2 was 54.7 mmHg on arrival in the OR. Standard monitors were attached and adequate anesthesia was ensured. The surgeon then evaluated the entire trachea under fiberoptic guidance through the existing ETT and discovered a 6-cm tear that was 2 cm from the carina (Figs 3 and 4). The surgeon decided to approach the repair through a right thoracotomy. Because of the airway trauma and proximity of the injury to the carina, the authors isolated the left lung by advancing the ETT into the left main bronchus under bronchoscopic guidance. The patient was placed on ventilator support with a tidal volume of 400 mL. Peak and plateau airway pressures were 22 and 21 cmH2O, respectively, and SpO2 was 100%. A desaturation episode (SpO2 of 65%) an hour into the case could not be explained by the tube position because it was distal to the lesion. Fiberoptic bronchoscopy revealed further migration of the ETT past the left bronchial bifurcation. The ETT was, therefore, repositioned distal to the carina but proximal to the left bronchial bifurcation, also under fiberoptic guidance. Oxygenation improved significantly, and the patient was placed in a left lateral decubitus position for a 6-hour right open thoracotomy. The tracheal defect was found to be just beneath the ETT cuff (Fig 5), with only a thin membrane separating the cuff from the tracheal lumen. Once the defect was opened, the ETT and deflated cuff clearly could be seen just entering the left mainstem bronchus (Fig 6). The tube was advanced further to repair the site. Intraoperative management included intermittent manual ventilation for adequate oxygenation.
From the Departments of *Anesthesiology and Perioperative Medicine, †Diagnostic, Therapeutic and Interventional Radiology, ‡Otolaryngology, and §Surgery, Medical College of Georgia, Georgia Regents University, Augusta, GA. Presented at the American Society of Anesthesiologists Annual Meeting, October 15-19, 2011, Chicago, IL as a medically challenging case. Address reprint requests to Mary E. Arthur, MD, 1120 15th Street, BIW-2144, Georgia Regents University, Augusta, GA 30912. E-mail:
[email protected] Published by Elsevier Inc. 1053-0770/2602-0033$36.00/0 http://dx.doi.org/10.1053/j.jvca.2013.08.014 Key words: trachea, tracheal tear, endotracheal intubation, complications, tracheal injury, anesthesia, otolaryngology, surgery
Journal of Cardiothoracic and Vascular Anesthesia, Vol 28, No 4 (August), 2014: pp 1149–1157
1149
1150
ARTHUR ET AL
Fig 1. Axial view of chest computed tomography. A pneumomediastinum from the tracheal tear (red arrow), endotracheal tube in right mainstem bronchus (blue arrow), and enteric tube in esophagus (green arrow) can be seen. (Color version of figure is available online.)
After the repair, the ETT was pulled back under fiberoptic guidance to a site proximal to the repair to avoid ETT balloon compression of the repair. When the defect was tested with Valsalva of up to 30 cmH2O, no leak was visible. The patient then was placed on pressure control ventilation with a peak pressure of 25 cm H2O, respiratory rate of 16 breaths/minute, and FIO2 of 100%. At the end of the procedure, the patient was extubated awake in the OR and transferred to the intensive care unit in stable condition. The defect was intact on postoperative day 19 (Fig 7).
DISCUSSION
Iatrogenic tracheal injuries are rare but potentially life threatening. The incidence of reported cases is approximately 1 in every 20,000 intubation attempts,1 or 0.005%, although certain postmortem studies suggest an incidence as high as 15% in cases involving emergency intubation.2 In an analysis of American Society of Anesthesiologists (ASA) closed claims data (1961-1996), 6% of claims were due to airway injury. Factors associated with claims for pharyngoesophageal perforation included difficult intubation, age older than 60 years, and female gender. Nevertheless, 9 of 13 claims for tracheal perforation involved routine (nondifficult) tracheal intubation.3
Fig 2. Coronal view of chest computed tomography. The tip of the endotracheal tube is in the right main bronchus (blue arrow) and air is in the mediastinum (red arrows). (Color version of figure is available online.)
Fig 3. Virtual 3-D bronchoscopic image. The endotracheal tube is entering the right main bronchus, and the tear is in the posterior wall of the trachea. (Color version of figure is available online.)
The trachea is susceptible to injury whenever an ETT is placed. It is a cartilaginous (anterior two-thirds) and membranous (posterior third) tube extending from the lower part of the larynx at the level of the sixth cervical vertebra to the upper border of the fifth thoracic vertebra, where it divides into the two main bronchi. Made up of fibrous tissue and muscular fibers, the posterior third is the weakest part of the trachea and the location of most reported injuries.4 ETIOLOGY AND RISK FACTORS
The mechanism of tracheal injury remains unclear, but the most probable explanation is a direct laceration from the tip of an ETT when it is caught in a fold of a flaccid posterior tracheal membrane as the tube is being advanced. The vast majority of cases have been reported in shorter female patients.5 The smaller airway of female patients is an injury risk factor. The upper limits of coronal and sagittal tracheal dimensions are 25 and 27 mm, respectively, in men, and about 4 mm smaller in both dimensions in women. The lower limit of normal for both dimensions is 13 mm in men and 10 mm in women. The tracheal diameter from side to side is 2 to 2.5 mm, always greater in males than females.6 Other important risk factors for tracheal injury include pathologic conditions such as tracheomalacia or stenosis, size and mobility of the ETT, and the skill level of the provider placing the ETT. Emergency intubations, unanticipated difficult airways resulting in repeated intubations,7 duration of intubation, inappropriate use of a stylet, ETT cuff pressure, and surgeries involving the head and neck region are also predisposing factors. A prospective study reported a 4% incidence of tracheal stenosis for intubations lasting 5 to 10 days and up to 12% for intubations lasting 11 to 24 days.8 Repeated intubations and prolonged contact of the tracheal mucosa with the ETT cuff are associated with inflammatory changes that make the trachea susceptible to injury. In an animal study, anesthetized neonatal piglets were randomized to 1 of 4 groups: Injured (reintubated every 0.5 hours), intratracheal pretreated (given intratracheal pretreatment of 1 mg of nebulized budesonide), intravenous
1151
CASE 9–2014
Fig 4.
Fiberoptic bronchoscopy of a 6 cm full thickness tracheal tear very close to the carina. (Color version of figure is available online.)
pretreated (given intravenous pretreatment of 0.3 mg/kg of dexamethasone), or control (not intubated). Both expression levels of interleukin-6, an inflammatory cytokine, and degree of tracheal injury were significantly higher among “injured” and “intratracheal pretreated” subjects than controls. Systemic steroids offered some protection against inflammation.9 Tracheal injury usually occurs at the tube cuff site.10 Hyperinflation of the ETT cuff is the most frequent risk factor for tracheal ischemia and subsequent complications. In fact, just a few hours after intubation, the ETT cuff can cause tracheal mucosal lesions, which may result in tracheal stenosis and rupture. Further, several reports described postoperative hoarseness and sore throat after general anesthesia, which were attributed to high ETT cuff pressure.11,12 The prevalence of postintubation and post-tracheotomy stenosis varies from 10% to 19% in intensive care unit patients using a low-volume highpressure endotracheal cuff.13 High-volume, low-pressure cuffs greatly reduce the occurrence of cuff injury. An animal study that compared manual with continuous control of endotracheal cuff pressure in a setting mimicking that of intubated critically ill patients noted that all animals had hyperemia and hemorrhage at the cuff contact area.14 The recommended mucosal pressure exerted by the cuff should, therefore, be below the capillary mucosal pressure of approximately 26 mmHg. Although double-lumen endotracheal tubes (DLT) are currently the most widely used tubes to achieve lung isolation, they
are stiff, bulky, and notorious for causing severe tracheal damage. Risk factors for DLT-related tracheal injury include direct trauma, cuff overinflation and pre-existing airway pathology.15 It is more likely that a tracheobronchial injury will be caused by a singlelumen tube than a DLT, but this is because more patients are intubated with single-lumen tubes. DLTs account for less than 1% of all tracheal ruptures.16 Nevertheless, an inappropriately sized DLT can cause airway trauma, interfere with oxygenation, and hinder lung separation during one-lung ventilation.17,18 Selecting the appropriate size is problematic, because the tracheal internal diameter does not closely correlate with sex, age, height, or weight. Suggested criteria for sizing left-sided DLT have included measuring tracheal diameter by chest radiograph,19 left main bronchus diameter by CT scan,20 or left main bronchus by direct measurement using a posterior-anterior chest x-ray and estimating the bronchial diameter to be 10% smaller than measured.17,18 The authors combined a meta-analysis of articles published from 1966 to 2007 with a more recent single-center observational study (2003-2008) and found that being female and older appeared to be risk factors for injury, as did emergency intubation, difficult intubation, and use of a DLT. Shorter stature and overweight may also be factors (Table 1). SYMPTOMS
Because the signs and symptoms can be nonspecific, diagnosis of tracheobronchial injury requires a high index of
Fig 5. Tracheal defect just beneath the endotracheal tube cuff. A thin membrane separates the defect from the cuff. (Color version of figure is available online.)
1152
ARTHUR ET AL
Fig 6. Repaired site immediately after surgery. There was no visible leak when the repaired defect was tested with valsalva to 30 cmH2O. (Color version of figure is available online.)
suspicion and should be considered in patients who develop subcutaneous emphysema after intubation, with or without respiratory symptoms. Tracheobronchial injury also could present with pneumothorax, hemoptysis, respiratory insufficiency, tracheal shift, cyanosis, airway obstruction, and pneumomediastinum. Some patients may be asymptomatic.18 If there have been repeated intubations, the differential diagnosis for hypoxemia should include tracheal injury. The recurrent hypoxemic episodes in this patient mandated a chest x-ray and CT scan. The pneumomediastinum noted on CT prompted an immediate cardiothoracic consult and fiberoptic bronchoscopy, which led to a definitive diagnosis.
Three-dimensional surface shaded display (3-DSSD) recognizes tissue either by its density (similar to CT) or manually by drawing the contour of the organ and showing the surface of the organs as an opaque object. When the cursor is placed within the airway of an image, the contours of the airway will be indicated. MinIP and 3-DSSD were used to reconstruct the tracheal perforation in this case (Fig 3). Fiberoptic bronchoscopy is the gold standard for diagnosis confirmation and revealing the size and extent of a lesion.21 Because this patient arrived in the OR already intubated, it was important to pull the ETT back to ensure that the whole length of the trachea was evaluated.
DIAGNOSIS
Depending on the presenting signs and symptoms, as well as the extent of the injury, treatment may consist of either conservative management or urgent surgical repair. A postoperative mortality as high as 40% has been reported after iatrogenic rupture of the tracheobronchial tree.22 A study comparing conservatively managed and surgical groups reported a mortality rate of 29% and 2.8%, respectively. There is little consensus on management of postintubation tracheal tears. Factors to consider include size, location, and depth of tear; associated esophageal injury; mediastinitis; and need for ventilator support.23 Recent evidence suggests that
OVERALL MANAGEMENT
The severity and urgency of airway compromise often dictate the modality used for diagnosis. A chest x-ray and CT scan of the thorax are warranted in a patient with suspected postintubation tracheobronchial injury. The diagnostic sensitivity of CT is 85% in tracheobronchial injury. CT angiography images can be processed by maximum intensity projection and minimum intensity projection (MinIP), which are volume rendering techniques that define the volume of interest. Either the entire image data set or the region of interest may be used. Organs filled with air, eg, airways and sinuses, are shown using MinIP.
Fig 7.
Intact defect on postoperative day 19. (Color version of figure is available online.)
1153
CASE 9–2014
Table 1. Risk Factors for Tracheal Injury Based on Minambres and Cardillo
Risk Factor
Female gender Short stature (o165 cm)* Age 450 years* BMI Z25* Use of doublelumen tube Emergency intubation Difficult intubation
Minambres 1966–
Cardillo 2003–
Percent with
2007 (n ¼ 182)
2008 (n ¼ 30)
Risk Factor
156
28 22
87% 73%
85
16 16 4
53% 53% 42%
50†
8
27%
26
‡
14%
Abbreviation: BMI, body mass index. *Analyzable data not available from Minambres study; mean age was 61 years. †Information not available for 12 patients in Minambres study. ‡Data not available from Cardillo study.
conservative management produces more favorable outcomes for small lesions once the patient is clinically stable.21,24–27 On the other hand, immediate surgical repair is required when a lesion is large enough to be life-threatening. Cardillo et al staged tracheal lesions based on the tracheal wall involvement, from level I (mucosal or submucosal tracheal involvement without mediastinal emphysema and without esophageal involvement) to level IIIB (any laceration of the tracheal wall with esophageal injury or mediatinitis).23 Primary signs of mediastinitis, such as localized mediastinal fluid or pneumomediastinum or both, can be used to identify patients with mediastinitis. The site of the lesion determines the surgical approach as well as the surgical service to be called upon to repair it. High and mid-tracheal injuries usually are repaired by an otolaryngologist, and low tracheal and bronchial injuries, by a thoracic surgeon. A right-sided approach is recommended to avoid the large thoracic vessels. The authors propose an algorithm to help guide diagnosis and treatment of suspected tracheal injuries based on experience at this institution and Cardillo’s classification of tracheal injury (Fig 8). ANESTHETIC MANAGEMENT
The fact that the surgeon and anesthesiologist share the airway presents a challenge in tracheal surgery. The surgeon needs airway access and a surgical field unobstructed by the ETT, and the anesthesiologist must provide adequate ventilation and oxygenation in the presence of an open airway. Ventilation can be achieved by manual oxygen jet ventilation, highfrequency jet ventilation, distal tracheal intubation, or lung isolation using a bronchial blocker. In some instances, cardiopulmonary bypass may be needed. Surgical repair of tracheal injuries requires general anesthesia with endotracheal intubation. In this case, the surgeon approached the repair through a right thoracotomy to avoid the large vessels on the left side. A right radial arterial catheter was inserted before induction of anesthesia. Stable hemodynamics and adequate cerebral perfusion pressure were maintained. An intracranial pressure (ICP) monitor was placed soon after induction and opioids and beta-
blockers were given to prevent increases in ICP and worsening of the tracheal injury. Lidocaine was administered to prevent pain, hypertension, tachycardia, and “bucking” on the tube. Because the surgery was planned for the region of the great vessels, two 16-G intravenous catheters were placed to ensure adequate intravenous access in the event of a catastrophic bleed. The lung isolation technique depends on the proximity of the lesion to the carina. The authors chose a left mainstem intubation with a single-lumen tube as the lesion was very close to the carina. Left-sided DLT routinely are used for lung isolation but are bulky and cannot be used in an airway with pre-existing trauma. Bronchial blockers are another option. In a similar case,28 the inner lumen of a 7F Arndt endobronchial blocker was used to ventilate the right lung with manual jet ventilation at a jet frequency of 1 Hz, aiming for an inspirationto-expiration ratio of 1:2. Although oxygenation was adequate, the patient retained CO2. If the authors had used this technique in this patient, there would have been a massive air leak from the injury site. Further, CO2 retention in a patient with preexisting brain injury would have led to an increase in ICP and a worse neurologic outcome. Dreyfuss et al recommended highfrequency ventilation for management of tracheobronchial trauma, because it allows good ventilation without increased positive airway pressures even in the presence of pulmonary contusion and avoids the need for a cuffed ETT, which could damage the tracheal suture line.29 Iwasaki reported that a Univent tube, an ETT with a movable blocker capable of excluding one lung, facilitated perioperative and intraoperative respiratory management by preventing aspiration of blood into the healthy lung while maintaining adequate ventilation.30 The authors chose ventilator settings that ensured adequate ventilation while at the same time avoiding airway pressure increases, which could further worsen the injury or compromise the repair after the case. It is advisable to maintain a peak airway pressure of 25 cmH2O or below. In this patient, ventilatory support and oxygenation were facilitated by endobronchial intubation by advancing the single-lumen ETT into the left main bronchus but making sure the authors did not block the bifurcation of the left lung. Mechanical ventilation via the ETT was supplemented by intermittent manual ventilation throughout the case. Clearly, the patient with a possible tracheal injury should not be intubated orally in a “blind” manner, even with direct visualization of the cords, to avoid distal tracheal injury. Most thoracic surgeons and cardiothoracic anesthesiologists recommend endotracheal intubation under direct fiberoptic visualization to confirm positioning distal to the damaged area. Both surgeon and anesthesiologist must be familiar with airway anatomy to ensure correct placement of the ETT; otherwise, a false passage could be created into soft tissue through the tracheal defect. There also must be excellent communication and coordination between the providers to ensure patient safety with well-planned and executed airway management strategies. Inotropic or vasopressor support may be necessary, especially in patients with depressed ventricular function, to maintain cerebral and coronary perfusion pressures. In the absence of depressed ventricular function, a pure alphaagonist such as phenylephrine infusion can be used to maintain cerebral perfusion pressure without elevating
1154
ARTHUR ET AL
Fig 8. Proposed algorithm to help guide diagnosis and treatment of suspected tracheal injuries based on experience at this institution and classification of tracheal injury by Cardillo et al.
intracranial pressure. After the repair is completed, the tube should be repositioned proximal to the repair site and the position should be confirmed by fiberoptic bronchoscopy to prevent disruption of the suture line. The integrity of the repair can be tested with Valsava up to 30 cmH2O. On
resumption of mechanical ventilation, the peak pressure should be no greater than 25 cmH2O. Because prolonged intubation with endotracheal cuff pressure causes mucosal ischemia, it is best to extubate the patient immediately after surgical repair. Deep extubation prevents
1155
CASE 9–2014
coughing and bucking on the tube, which could disrupt the suture lines. In patients with marginal respiratory status, the patient should remain intubated and adequate sedation provided to prevent coughing and bucking. In a hemodynamically stable patient, dexmedetomidine, an alpha-2 centrally acting agent, is a good choice for sedation because it allows for smooth extubation; the patient remains calm and comfortable yet is easily arousable and able to follow commands. In a hemodynamically vulnerable patient, continued intubation with mechanical ventilation may be needed until the patient is ready for extubation. Midazolam and fentanyl infusion are useful agents in such cases. Administration of systemic steroid injections may decrease the severity of the inflammatory response and should be considered in patients who are reintubated or intubated for prolonged periods to decrease the incidence of tracheal damage.9,31 PROGNOSIS
Better diagnostic techniques and clinical judgment have led to much earlier recognition and intervention. Tracheal injury always should be considered after endotracheal intubation is compromised by hypoxemia, pneumomediastinum or pneumothorax, or subcutaneous emphysema without a known cause. Despite its rarity, tracheobronchial rupture always should be considered after blunt chest and neck trauma, and traumatic and emergent intubations, and should be recognized and treated early to restore lung function and prevent associated complications. SUMMARY
Tracheal tears are rare and potentially life-threatening injuries that require a high index of suspicion to diagnose. Animal studies have shown that atraumatic intubations, multiple intubations, and prolonged contact with the cuff can increase the likelihood for injury and that steroids may decrease the inflammatory cascade, providing a protective effect. Because differences in tracheal anatomy also can affect incidence of injury, it is advisable to use a much smaller ETT when intubating female or shorter patients. Selection criteria for conservative or surgical management of postintubation tracheal lacerations are a matter of debate. If there are life-threatening symptoms, however, surgical closure is the obvious answer to restore effective ventilation and prevent short- and long-term complications such as mediastinitis and tracheal stenosis. COMMENTARY: CARDIOTHORACIC SURGEON’S PERSPECTIVE†
Although rare, iatrogenic tracheobronchial injuries are caused most commonly by endotracheal intubation, particularly under emergency or other stressful conditions. Similar injuries also have been associated with percutaneous tracheostomy insertion.32 A high degree of suspicion is important for prompt diagnosis and management. The most common clinical findings after these injuries is subcutaneous emphysema involving the upper chest and neck,
†V. S. Patel
mediastinal emphysema, hemoptysis, and pneumothorax. The initial evaluation often involves radiographic imaging, including a chest CT scan;33 however, the study of choice is a diagnostic fiberoptic bronchoscopy.34,35 The latter provides direct visualization of the entire tracheobronchial anatomy to confirm and define the lesion, including its location, length, and depth. This information directs subsequent management of the injury. In addition, fiberoptic bronchoscopy can facilitate airway management in nonoperative patients who require continued mechanical ventilation. In surgical patients, intraoperative fiberoptic bronchoscopy is indispensable in facilitating controlled endotracheal intubation and endotracheal tube exchange, preventing worsening of the tracheal injury, and positioning of the ETT. The preferred treatment traditionally has been early surgical intervention; however, the role for nonoperative management has grown.36,37 Despite the lack of universally accepted management guidelines, conservative management is favored in patients with spontaneous ventilation with small lacerations measuring less than 2 to 4 cm; the clinically stable with minimal and nonprogressive manifestations of subcutaneous and mediastinal emphysema, drained pneumothorax, absence of mediastinitis and esophageal injury; and the critically ill who are poor surgical candidates.23,38,39 Surgical intervention is favored in patients with progressively worsening clinical manifestations, ventilator support instability, pneumothorax with large air leak and persistently collapsed lung, and large tears. Early surgical intervention provides reliable healing and avoids immediate and long-term complications including abnormal scarring and stenosis, particularly in patients with distal injuries involving the carina and subcarinal lacerations.40,41 Regardless of the treatment strategy selected, all patients diagnosed with a tracheal laceration, including those managed nonoperatively, should receive a broad spectrum antibiotic for at least 7 days.38 The surgical approach is based on the location of the injury.41 Lacerations in the proximal two-thirds of the posterior membranous wall can be repaired safely through a transcervical-transtracheal approach.40 The surgical procedure involves a cervical low-collar incision exposing the midline trachea. An anterior longitudinal tracheotomy allows access to the posterior membranous injury. The field should be prepared for a possible partial or full sternotomy. A previously positioned small single-lumen ETT ensures adequate space for repair of the injury. If necessary, the orotracheal tube can be withdrawn and a new distal tracheal tube positioned through the tracheotomy to facilitate unhindered exposure and repair of the full extent of the injury. The latter would require intraoperative planning and preparation, including coordination with the anesthesia team for successful airway management. This approach preserves the vascular supply to the trachea and avoids injury to the recurrent laryngeal nerve during excessive tracheal dissection. Injuries involving the distal trachea and subcarinal bronchus generally are approached through a right posterolateral thoracotomy through the fourth or fifth intercostal space to provide excellent exposure of the distal trachea, the bifurcation, and both mainstem bronchi.42 In rare cases of distal left bronchial injuries, the left thoracotomy approach is preferable. Single-
1156
ARTHUR ET AL
lung isolation and stable airway management are vital and accomplished using fiberoptic bronchoscopy and active engagement of the anesthesia team. The importance of planning the intraoperative airway management with the anesthesia team cannot be overemphasized for a successful outcome. The repaired injury typically is buttressed with an intercostal muscle or pleural flap.43 Surgical intervention provides a definitive and relatively safe treatment for these complex injuries.41,44 The postoperative prognosis generally is dictated by preoperative risk factors, including patient age, emergency intubation, male gender, underlying medical comorbidities that necessitate mechanical ventilation, delayed diagnosis, and mediastinitis.21,45 Recent reports of endoscopic repair techniques include applications of glue, suture repair, and placement of stent to cover the injury. Their role in future management of these injuries is yet to be defined.46,47 COMMENTARY: OTOLARYNGOLOGIST’S PERSPECTIVE‡
The trachea extends proximally from the larynx through the neck to enter the mediastinum and intrathoracic segment distally. Thus, surgical evaluation and intervention for serious tracheal airway issues such as stenosis, cancer, or trauma often involve both otolaryngology and cardiothoracic surgery. Because this particular injury was confined to the distal trachea at the level of the carina, surgical intervention was appropriately led by the cardiothoracic surgery team. It should be noted that in an emergency situation involving a suspected airway injury, the anesthesiologist (or intensivist) should consider consulting both services if they are available. Otolaryngologists often are well versed in emergency airway management and positioned to provide a rapid initial endoscopic evaluation of the trachea. In centers with a focus on airway reconstruction, it is common for the two services to share cases and complement each other’s expertise. Proximal injuries are better managed through a cervical approach by the otolaryngology team, whereas distal lesions usually require a thoracotomy or sternotomy approach. Often a joint approach is indicated, and even cervical tracheal repair can necessitate thoracic maneuvers to release tension on the trachea.48 In nonoperative situations, such as when the patient is in the intensive care unit with a suspected tracheal injury, a highresolution CT greatly can impact surgical planning if the patient’s condition allows.49 The surgical approach will be dictated by the nature of the injury and the patient’s clinical presentation. Often if the injury is proximal (as opposed to near the carina), less than 3 cm in size, and one that does not involve the esophagus, conservative
management can be successful.50 The disrupted tracheal mucosa is allowed to repair without surgical closure by either clinical observation alone or by advancing the ETT cuff distal to the injury. Placement of the ETT without further expanding the injury is critical. This is best accomplished by passing an endoscope distal to the injury and advancing the ETT over the endoscope (a modified Seldinger technique using the endoscope as the guidewire). The patient is left on mechanical ventilation for several days to a week, and the area of injury examined endoscopically, usually in the OR. If this approach fails or if the injury is large or involves the esophagus, an open approach is necessary.48 Occasionally, the site of injury can be accessed via an anterior tracheostomy, with endoscopic visualization from above (transglottic) although suturing can be quite problematic through this limited access. For patients with suspected esophageal disruption, an esophagoscopy at the time of repair is mandated. The cervical operative site is flooded with saline, and air is insufflated into the esophagus while observing the operative site for air bubbles. If an injury are noted, it should be repaired directly and a muscle flap or acellular skin graft interposed between the tracheal repair and the esophageal repair. Most often a circumferential tracheal transection and reanastomosis are required to obtain adequate access to the esophageal injury in these cases.48 The otolaryngologist is uniquely equipped to evaluate vocal fold motion after the repair. Injury to the recurrent laryngeal nerve during tracheal surgery, although uncommon, is certainly within the realm of possibility and should be ruled out. Additionally, multiple and emergency intubations increase the likelihood of arytenoid dislocation, which usually can be corrected if identified early. It has been suggested that clinical monitoring for hoarseness or stridor is inadequate for detecting vocal fold immobility, so endoscopic evaluation of vocal fold motion is recommended.49 The prognosis varies according to the degree of injury. Patients with proximal tracheal injuries without esophageal involvement have an excellent prognosis barring other factors.50 For patients with distal injuries (such as the present case) or esophageal involvement, outcomes tend to be less favorable but can still be quite good if managed appropriately.
ACKNOWLEDGMENTS The authors thank William Bates, MD at the Medical College of Georgia at Georgia Regents University for his help in the 3D reconstruction of the trachea showing the tear.
REFERENCES 1. Lampl L: Tracheobronchial injuries. Conservative treatment. Interact Cardiovasc Thorac Surg 3:401-405, 2004 2. Maxeiner H: Weichteilverletzungen am Kehlkopf bei notfallmäßiger Intubation. Anästh Intensivmed 29:42-49, 1988 3. Domino KB, Posner KL, Caplan RA, et al: Airway injury during anesthesia: A closed claims analysis. Anesthesiology 91:1703-1711, 1999
‡P. M. Weinberger
4. Marty-Ane CH, Picard E, Jonquet O, et al: Membranous tracheal rupture after endotracheal intubation. Ann Thorac Surg 60: 1367-1371, 1995 5. Kaloud H, Smolle-Juettner FM, Prause G, et al: Iatrogenic ruptures of the tracheobronchial tree. Chest 112:774-778, 1997 6. Tewfik TL: Trachea anatomy. Medscape Reference Web site. http://emedicine.medscape.com/article/1949391-overview#showall. Updated June 19, 2013. Accessed November 5, 2013. 7. Borasio P, Ardissone F, Chiampo G: Post-intubation tracheal rupture. A report on ten cases. Eur J Cardiothorac Surg 12:98-100, 1997
CASE 9–2014
8. Jaeger K, Ruschulte H, Osthaus A, et al: Tracheal injury as a sequence of multiple attempts of endotracheal intubation in the course of a preclinical cardiopulmonary resuscitation. Resuscitation 43: 147-150, 2000 9. Oshodi A, Dysart K, Cook A, et al: Airway injury resulting from repeated endotracheal intubation: Possible prevention strategies. Pediatr Crit Care Med 12:e34-e39, 2011 10. Sarper A, et al: Tracheal stenosis after tracheostomy or intubation: review with special regard to cause and management. Tex Heart Inst J 32:154-158, 2005 11. Liu J, Zhang X, Gong W, et al: Correlations between controlled endotracheal tube cuff pressure and postprocedural complications: A multicenter study. Anesth Analg 111:1133-1137, 2010 12. Joe HB, Kim DH, Chae YJ, et al: The effect of cuff pressure on postoperative sore throat after Cobra perilaryngeal airway. J Anesth 26: 225-229, 2012 13. Kastanos N, Estopá Miró R, Marín Perez A, et al: Laryngotracheal injury due to endotracheal intubation: Incidence, evolution, and predisposing factors. A prospective long-term study. Crit Care Med 11: 362-367, 1983 14. Nseir S, Duguet A, Copin MC, et al: Continuous control of endotracheal cuff pressure and tracheal wall damage: A randomized controlled animal study. Crit Care 11:R109, 2007 15. Fitzmaurice BG, Brodsky JB: Airway rupture from double-lumen tubes. J Cardiothorac Vasc Anesth 13:322-329, 1999 16. Liu H, Jahr JS, Sullivan E, et al: Tracheobronchial rupture after double-lumen endotracheal intubation. J Cardiothorac Vasc Anesth 18: 228-233, 2004 17. Hannallah MS, Benumof JL, Ruttimann UE: The relationship between left mainstem bronchial diameter and patient size. J Cardiothorac Vasc Anesth 9:119-121, 1995 18. Russell WJ, Strong TS: Dimensions of double-lumen tracheobronchial tubes. Anaesth Intensive Care 31:50-53, 2003 19. Brodsky JB, Lemmens HJ: Tracheal width and left double-lumen tube size: A formula to estimate left-bronchial width. J Clin Anesth 17: 267-270, 2005 20. Chow MY, Liam BL, Thng CH, et al: Predicting the size of a double-lumen endobronchial tube using computed tomographic scan measurements of the left main bronchus diameter. Anesth Analg 88: 302-305, 1999 21. Minambres E, Burón J, Ballesteros MA, et al: Tracheal rupture after endotracheal intubation: A literature systematic review. Eur J Cardiothorac Surg 35:1056-1062, 2009 22. Hofmann HS, Rettig G, Radke J, et al: Iatrogenic ruptures of the tracheobronchial tree. Eur J Cardiothroac Surg 21:649-652, 2002 23. Cardillo G, Carbone L, Carleo F, et al: Tracheal lacerations after endotracheal intubation: A proposed morphological classification to guide non-surgical treatment. Eur J Cardiothorac Surg 37:581-587, 2010 24. Beiderlinden M, Adamzik M, Peters J: Conservative treatment of tracheal injuries. Anesth Analg 100:210-214, 2005 25. 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 93:1270-1271, table of contents, 2001 26. Mullan GP, Georgalas C, Arora A, et al: Conservative management of a major post-intubation tracheal injury and review of current management. Eur Arch Otorhinolaryngol 264:685-688, 2007 27. Prunet B, Lacroix G, Asencio Y, et al: Iatrogenic post-intubation tracheal rupture treated conservatively without intubation: A case report. Cases J 1:259, 2008 28. Luyet C, Boudah R, McCartney CJ, et al: Low-frequency jet ventilation through a bronchial blocker for tracheal repair after a rare complication of percutaneous dilatational tracheostomy. J Cardiothorac Vasc Anesth 27:108-110, 2013
1157
29. Dreyfuss D, Jackson RS, Coffin LH, et al: High-frequency ventilation in the management of tracheal trauma. J Trauma 26:287-289, 1986 30. Iwasaki M, Kaga K, Ogawa J, et al: Bronchoscopy findings and early treatment of patients with blunt tracheo-bronchial trauma. J Cardiovasc Surg 35:269-271, 1994 31. Othersen HB Jr: Intubation injuries of the trachea in children. Management and prevention. Ann Surg 189:601-606, 1979 32. Walz MK, Peitgen K, Thürauf N, et al: Percutaneous dilatational tracheostomy–Early results and long-term outcome of 326 critically ill patients. Intensive Care Med 24:685-690, 1998 33. Scaglione M, Romano S, Pinto A, et al: Acute tracheobronchial injuries: Impact of imaging on diagnosis and management implications. Eur J Radiol 59:336-343, 2006 34. Baumgartner FJ, Ayres B, Theuer C: Danger of false intubation after traumatic tracheal transection. Ann Thorac Surg 63:227-228, 1997 35. Rossbach MM, Johnson SB, Gomez MA, et al: Management of major tracheobronchial injuries: A 28-year experience. Ann Thorac Surg 65:182-186, 1998 36. Conti M, Pougeoise M, Wurtz A, et al: Management of postintubation tracheobronchial ruptures. Chest 130:412-418, 2006 37. Schneider T, Storz K, Dienemann H, et al: Management of iatrogenic tracheobronchial injuries: A retrospective analysis of 29 cases. Ann Thorac Surg 83:1960-1964, 2007 38. Jougon J, Ballester M, Choukroun E, et al: Conservative treatment for postintubation tracheobronchial rupture. Ann Thorac Surg 69: 216-220, 2000 39. Gomez-Caro Andres A, Moradiellos Díez FJ, Ausín Herrero P, et al: Successful conservative management in iatrogenic tracheobronchial injury. Ann Thorac Surg 79:1872-1878, 2005 40. Angelillo-Mackinlay T: Transcervical repair of distal membranous tracheal laceration. Ann Thorac Surg 59:531-532, 1995 41. Mussi A, Ambrogi MC, Menconi G, et al: Surgical approaches to membranous tracheal wall lacerations. J Thorac Cardiovasc Surg 120: 115-118, 2000 42. Gabor S, Renner H, Pinter H, et al: Indications for surgery in tracheobronchial ruptures. Eur J Cardiothorac Surg 20:399-404, 2001 43. Anderson TM, Miller JI Jr: Use of pleura, azygos vein, pericardium, and muscle flaps in tracheobronchial surgery. Ann Thorac Surg 60:729-733, 1995 44. Carbognani P, Bobbio A, Cattelani L, et al: Management of postintubation membranous tracheal rupture. Ann Thorac Surg 77: 406-409, 2004 45. Leinung S, Möbius C, Hofmann HS, et al: Iatrogenic tracheobronchial ruptures - treatment and outcomes. Interact Cardiovasc Thorac Surg 5:303-306, 2006 46. Marchese R, Mercadante S, Paglino G, et al: Tracheal stent to repair tracheal laceration after a double-lumen intubation. Ann Thorac Surg 94:1001-1003, 2012 47. Welter S, Jacobs J, Krbek T, et al: A new endoscopic technique for intraluminal repair of posterior tracheal laceration. Ann Thorac Surg 90:686-688, 2010 48. Grillo HC: Reconstruction of the trachea. Experience in 100 consecutive cases. Thorax 28:667-679, 1973 49. Sulica L: Hoarseness misattributed to reflux: sources and patterns of error. Transactions of the 2010 Meeting of the American Laryngologic Association, Las Vegas, Nevada, April 2010, p. 42. Available at http://www.alahns.org/i4a/pages/index.cfm?pageid=3502. Accessed November 4, 2013. 50. Carretta A, Melloni G, Bandiera A, et al: Conservative and surgical treatment of acute posttraumatic tracheobronchial injuries. World J Surg 35:2568-2574, 2011
