8/16/2019 Br. j. Anaesth. 1994 Van Klarenbosch 550 1

1/2

British Journal of naesthesia 1994; 73 : 550-551

racheal rupture after tracheal intubation

J. VAN KLAREN BOSCH , J. M EYER AND J. J. DE L A N G E

S u m m a r y

Tracheal rupture is a rare complication of trachealintubation. We present a case of tracheal rupturewhich was diagnosed 20 h after a smooth intubation sequence and uncomplicated anaesthesia.Possible causes are discussed wi th reference tocases described previously. Br. J Anaesth. 1994;7 3 : 550-551

Key wordsIntubation tracheal Airway, complications.

Case report

A 54-yr-old m an was scheduled for extirpation of thesuperficial part of the left pa rotid g land. R outineindirect laryngoscopy had shown a cyst on the leftside of the vallecula but no additional abnormalitieswere noticed in the larynx. He smoked 25 cigaretteseach day and had a chronic non -productive cough.Medical history, physical examination and labora-tory investigation showed no further abnorm alities.No preoperative chest x-ray was performed.

After induction of anaesthesia with fentanyl,thiopentone and suxamethon ium, oral intubationwas performed using a lo -p ro tube, size 9.0(Mallinckrodt Laboratories, Ireland), as the vocalcords were easily visible. A few minutes later, at therequest of the surgeon, the trachea was reintubatedwith a preformed oral tube of the same size with anintermediate volume cuff (RAE Mallinckrodt). An-aesthesia was maintained with 70 % nitrous oxide inoxygen, fentanyl, vecuro nium and 0.3 % isoflurane.Cuff pressure was m onitored and maintained at20 cm H 2 O using a cuff pressure gauge(Mallinckrodt). During operation no unexpectedevents occurred and after its conclusion the tracheawas extubated and the patient taken to the recoveryroom . No adverse events were noticed in the recoveryroom and the patient had no com plaints.

The night after operation he started coughing andproduced bloody mucus. He complained of chestpain and body temp erature increased to 39.1 °C.Indir ect laryngoscopy showed an intact vallecula cystand superficial erosions of the mucous mem braneof the larynx. Because of clinical suspicion of anairway infection, antibiotics were prescribed. Thenext morning the patient's head and neck wereswollen. Chest x-ray showed subcutaneous emphy-sema of the head, neck and upper thorax, and alsomediastinal emphysema. Bronchoscopy revealed tra-cheal rupture extending from 3 cm below the vocalcords proximal to the right main bronchus. The

tracheal rupture was repaired via a right-sidedthoracotomy. He was treated w ith antibiotics afteroperation and with m echanical ventilation for 7 days.He mad e a full recovery and left the hosp ital 1 weeklater.

iscussion

Rupture of the trachea as a com plication of trachealintubation is rare. The literature on this subjectconsists only of case histories. In almost all casespublished to date, the cause was obvious; cuff-induced tracheal rupture by means of acute over-distension and rupture of the cuff [1], and the cuffacting as a distending force [2,3]. Also, circum-stances affecting tracheal anatomy and rigidity [2]such as oesophageal resection in which the oesoph-agus is separated from the membranous portion ofthe trachea, and the presence of metastatic lymphnodes in the mediastinum, can make the tracheamore vulnerable. The use of a stiff red rubber tube,especially with an asymmetric cuff can cause injury

[4]. At least two cases have been reported in whichdifficult intuba tion was considered to be the cause oftracheal rupture [5, 6].

In contrast with bronchial intubation using adouble-lumen tube [7], tracheal ruptu re has neverbeen reported after tracheal intubation using a styletinside the tube. Tw o cases of oesophageal rup turehas been described after intubation with a styletinside the tube [8 9] and recently a case ofhaemopneumothorax after bougie-assisted intuba-tion was reported [10]. In our patient, the reason forthe tracheal rup ture is not clear. Cuff-induced injuryto the trachea can be avoided by monitoring cuffpressure or by filling the cuff with a mixture ofoxygen and nitrous oxide to prevent diffusion ofnitrous oxide into the cuff [11]. We maintained cuffpressure at 20 cm H2O; tracheal injury can occur atpressures greater than 27 cm H2O [11] and thereforeit is unlikely th at cuff injury occ urred in our patien t.

At first we assumed that puncture of the mucousmembrane of the trachea by the tip of the tub e wasthe primary cause and that postoperative coughingenlarged the lesion into a large tracheal tear. Thishypothesis implies that during smooth intubationthe posterior wall of the trachea may be punctured.To test this hypothesis, while performing orotracheal

J. VAN KLARENBOSCH, MD, J. MEYER, MD, J. J. DE LANGE, MD, PHD,Department of Anaesthesiology, Academic Hospital Vrije Uni-veniteit, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands.Accepted for publication: April 7, 1994.

b y g u e s t onM

a y1 8 ,2 0 1 6

h t t p : / / b j a . oxf or d j o ur n a l s . or g /

D o wnl o a d e d f r om

http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/

8/16/2019 Br. j. Anaesth. 1994 Van Klarenbosch 550 1

2/2

Tracheal rupture after intubation 551

intuba tion in several patien ts, we used a fibrescope nthe tube to watch the tip entering the trachea. Weobserved that when the tube was positioned in thetrachea, the tip pointed at the anterior or lateraltracheal wall but not at the posterior wall, sopuncture of this part of the trachea seems veryunlikely. A more probable explanation for thetracheal rupture described here is that superficialinjury of the larynx or trachea by intubation, whichis not uncom mo n [12, 13], caused irritation andcoughing in the postoperative period. Our patientwas a heavy smoker at risk of postoperative cough ingand possibly had low grade chronic tracheo-bronchial inflammation making the trachea morevulnerable. Severe coughing may lead to trachealrupture, as has been described previously afterexpulsive efforts to remove a foreign body in thetrachea [14]. As far as we know, this is the firstdescription of postoperative tracheal rupture inwhich severe coughing was probably the main cause.

References1. De Lange JJ, Booij LHDJ. Tracheal rupture. naesthesia

1985; 40: 211-212.2. Smith BAC , Hopkinson R B. Tracheal rupture during

anesthesia. naesthesia 1984; 39: 894-898.

3. Orta DA, Cousar JE, Yergin BM, Olsen GN. Trachea]laceration with massive subcutaneous emphysema: a rarecomplication of endotracheal intubation. Thorax 1979; 34:665-669.

4. Eaton JM. Tracheal rupture. naesthesia 1985; 40: 212.5. Bein T, Lenhart F P, Berger H, Schilling V, Briegel J. Haller

M, Forst H. Ruptur der Trachea bei erschwener Intubation. naesthetist 1991; 40: 456-^57.

6. d'Odemont J P, Pringot J, Goncette L, Goenen M, RodenseinDO . Spontaneous favorable outcome of tracheal laceration.Chest 1991; 99: 1290-1292.

7. Wagner DL , Gammage GW , Marshall LW. Tracheal rupturefollowing the insertion of a disposable double-lumen endo-tracheal rube. nesthesiology 1985; 63 : 698-700.

8. O'Neill JE, Giffin JP, Cotrell JE. Pharyngeal and esophagealperforation following endotracheal intubation. nesthesiology1984; 60 : 487^88.

9. Johnson KG, Hood DD. Esophageal perforation associatedwith endotracheal intubation. nesthesiology 1986; 64:281-283.

10. Smith BL. Haemopneumothorax following bougie-assistedtracheal intubation. naesthesia 1994; 49: 91.

11. Raeder JC, Borchgrevink PC, Sellevold OM. Tracheal tubecuff pressures. naesthesia 1985; 40: 444-447.

12. Kambic V, Radsel Z. Intubation lesions of the larynx. BritishJournal of naesthesia 1978; 50: 587-590.

13. Stout DM, Bishop MJ , Dwersteg JF , Cullen BF . Correlationof endotracheal tube size with sore throat and hoarsenessfollowing general anesthesia. nesthesiology 1987; 67:419-421.

14. Nach RL, Rothman M. Injuries to the larynx and trachea.Surgery, Gynecology an d Obstetrics 1943; 76: 614-622.

b y g u e s t onM

a y1 8 ,2 0 1 6

h t t p : / / b j a . oxf or d j o ur n a l s . or g /

D o wnl o a d e d f r om

http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/