Tracheal rupture after adult endotracheal intubation : a case report with analysis of aetiological and management issues

Abstract

Introduction: Tracheal rupture is a rare but potentially life threatening complication of endotracheal intubation. The usual site in adults is the membranous portion of the trachea. The mechanism of injury is still unclear. Patient risk factors include age, short stature, obesity, chronic steroid use and chronic illness. Anaesthetic risk factors include tube size, stylet use and balloon inflation volume. There is also no clear consensus on the management of such a complication. The past literature favoured direct surgical repair which carries a relatively high morbidity and mortality. Recently, conservative management is gaining support.

Aim: A case report of a 68 year old woman with a tracheal rupture after ophthalmic surgery under general anaesthesia is being presented. Conservative management was used together with a tracheostomy. Our experience with this patient was compared to a literature review.

Methodology: A preformed endotracheal tube, size 7.5mm, was used to secure the airway for cataract surgery. On extubation, subcutaneous emphysema of the face and neck was noted. No pneumothorax was identified on chest radiographs. High resolution computed tomography of the neck and thorax confirmed extensive pneumomediastinum and a 5cm tracheal rupture starting 1cm above the carina in the right membranous trachea. Patient risk factors identified included short stature, obesity, asthma and chronic steroid inhaler use. Conservative management included intravenous piperacillin and tazobactam but the emphysema was noted to be deteriorating due to chronic cough. The patient was deemed not ideal for open thoracic surgery repair and an open tracheostomy was done to decompress the airway pressures produced by coughing and vocalisation. Flexible tracheoscopy confirmed the location and size of the perforation.

Results: Subcutaneous emphysema resolved rapidly after the tracheostomy was performed. The patient was discharged home without need for major surgery.

Conclusion: Prevention of such injuries should be advocated by identifying high risk patients and using smaller size endotracheal tubes and lower cuff pressures, or even avoiding unnecessary intubation. High resolution computed tomography of the neck and thorax is as effective as flexible tracheoscopy to detect gross tracheobronchial perforations. Conservative management should be taken into consideration as first line treatment of such iatrogenic tracheal perforations irrespective of the size of the perforation provided that the patient is haemodynamically stable and the complication is recognized early. A tracheostomy is a useful, much less invasive adjunct to conservative measures that can be used irrespective of the site of the perforation in relation to the carina.