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Ann Thorac Surg 1995;60:1367-1371
© 1995 The Society of Thoracic Surgeons

Original Articles: General Thoracic

Membranous Tracheal Rupture After Endotracheal Intubation

Charles-Henri Marty-Ané, MD, Eric Picard, Md, Olivier Jonquet, MD, Henri Mary, MD

Service de Chirurgie Thoracique,, Hôpital Arnaud de Villeneuve, Centre Hospitalier Universitaire, Montpellier, France

Accepted for publication June 5, 1995.


   Abstract
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 Footnotes
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 References
 
Background.Tracheobronchial rupture after tracheal intubation has been infrequently reported. We report 6 cases of membranous tracheal rupture after endotracheal intubation treated at our institution over 7 years.

Methods. Overinflation of the tracheal cuff was speculated to be a frequent cause of the tracheal damage because the lesion was always a linear laceration of the posterior membranous wall. The diagnosis was suspected on the basis of common signs such as subcutaneous emphysema, respiratory distress, pneumomediastnum and pneumothorax. Fiberoptic bronchoscopy was the best means of confirming the diagnosis and determining the location and extent of the lesion. In 5 patients, extensive laceration with severe respiratory disorders required emergent repair through a right posterolateral thoracotomy.

Results. There were two postoperative deaths unrelated to the tracheal lesion. A patient with a small tracheal defect and favorable clinical presentation showed a rapid positive outcome after conservative treatment.

Conclusions. Tracheal intubation–related airways ruptures are rare but probably underestimated. Early recognition and emergent repair are essential because failure to do so could result in potentially lethal events.


   Introduction
Top
 Footnotes
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 References
 
Tracheabronchial rupture is considered to be a life-threatening condition, most commonly occurring after blunt trauma to the neck and chest, but rarely after tracheal intubation. However, single- and double- lumen endotracheal tubes can cause serious airway injury [1–6]. Recognition of this complication and the possible contributing factors is critical because failure to do so could result in potentially lethal events. The following is a report on 6 cases of tracheal rupture related to tracheal intubation treated at our institution. We discuss the causes, diagnosis, and treatment of these lesions.


   Material and Methods
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 Abstract
 Introduction
 Material and Methods
Results
 Comment
 References
 
From 1986 to 1993, 17 patients were admitted to our institution for tracheobronchial disruptions. Among them, 6 patients had tracheal rupture after endotracheal intubation. All 6 were women with age ranging from 32 to 87 years (mean age, 51 years). In 3 patients, preoperative endotracheal intubation had been done for an elective operation (total hip joint replacement, operation for auricular osteoma, and appendectomy). In 1 case intubation was described as difficult; it was uneventful in the 2 other cases. In the 3 other patients, emergent endotracheal intubation was required for respiratory distress related to intoxication, craniocerebral trauma (without chest trauma), and tetanus. In all patients, the tracheal rupture was confirmed by fiberoptic bronchoscopy,in 5 at the time of operation. All data concerning age, sex, presenting symptoms, radiologic and endoscopic findings, treatment, and outcome were reviewed in detail and reported in Table 1.Go Clinical follow-up was available for all patients, and distant bronchoscopic control was done in all surviving patients every year for 3 years.


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  		Table 1. . Data on 6 Patients With Tracheal Membranous Tear
 

   Results
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 Abstract
 Introduction
 Material and Methods
 Results
Comment
 References
 
Etiology
In 2 patients, overinflation of the tracheal cuff was suspected as the initial cause of the tracheal injury because of the distended appearance of the cuff was evident on the previous chest roentgenogram. In 1 patient, intubation was described as difficult and required the use of a stylet. In the three other cases, the tracheal cuff was inflated using the minimal leak technique. Muscle relaxants were used to facilitate intubation in 4 patients. Anesthesia with nitrous oxide was used in 2 patients. In all patients, the endotracheal tubes used were high-volume/low pressure cuffs, and the tube size was adapted to the patient size. No patient presented a history of diabetes, corticosteroid treatment, or other factors that could predispose to weakness of the tracheal tissue, except for the first patient who had chronic obstructive airway disease.

Diagnosis
The diagnosis was suspected at extubation in two cases and 2 hours after extubation in the third postoperative case. In the 3 cases of emergent intubation for respiratory distress, the delay in diagnosis was longer and varied from 6 to 12 hours after intubation. In all cases, cervicothoracic subcutaneous emphysema revealed the tracheal rupture. Radiologic findings included pneumomediastinum in all patients, with right pneumothorax in 3. In 2 patients, the acutely distended appearance of the cuff was visible on the chest roentgenogram.

Endoscopy
Endoscopic findings are reported in Table 1.GoIn all patients, fiberoptic bronchoscopy results demonstrated a linear, right-sided membranous tear at the junction of the cartilage and the membranous wall. In two cases, the tear also involved the end of the cervical part of the trachea.

Treatment
In 5 patients surgical repair was performed through a right posterolateral thoracotomy with 4/0 Vicryl interrupted sutures associated with application of biologic glue (Tissucol). In 1 patient with a cervicothoracic tracheal tear, the cervical part of the laceration was inaccessible through a right posterolateral thoracotomy; it was not repaired but healed spontaneously. The last patient of this series had a small laceration of the membranous wall (less than 2 cm) with a favorable clinical presentation. This was managed medically with antibiotic therapy (amoxicillin 2 g/d; metronidazole, 1.5 g/d) without tracheotomy.

Outcome
There were two deaths unrelated to the tracheal lesion. An 87-year-old patient died on postoperative day 15 of cardiac failure; control fiberoptic bronchoscopy performed on day 8, had shown total closure of the tracheal laceration. Another patient with severe tetanus experienced neurovegetative disorders with cardiac complications and died on postoperative day 4 of cardiac arrhythmias. In the other 4 patients, the outcome was favorable and bronchoscopy done before discharge showed complete healing of the trachea. In the follow-up of these patients, distant bronchoscopic control revealed no evidence of tracheal stenosis.


   Comment
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 Abstract
 Introduction
 Material and Methods
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Airway disruptions are associated with thoracic operations, bronchoscopy, or deceleration trauma, but are rarely a direct complication of tracheal intubation. In many cases, the specific cause of this unusual injury remains unclear. Previously reported factors contributing to tracheal rupture with endotracheal tubes are as follows:

Overinflation of the tracheal or bronchial cuff is a possible contributing factor [9–12]. In most instances, the posterior membranous wall ruptures longitudinally at the junction with the cartilage (Fig 1Go) and the length of the rupture generally corresponds to the length of the cuff (4 to 6 cam), but extensive tearing can be explained by further dissection under positive ventilation [5, 10]. This mechanism was probably a constant factor in this series because the tears were always linear lacerations of the membranous wall near the cartilage on the right side. In 2 patients, the acutely distended appearance of the cuff on roentgenogram had been seen previously (Fig 2Go) However, all cuffs are permeable to nitrous oxide (used for anesthesia), leading to increased volume, and accidental overinflation can result from its diffusion in the cuff [1, 2, 9, 16]. Body temperature can contribute to this expansion. Increases in cuff pressure and size are time dependent and cuff pressures can increase by up to 90%, even during relatively short procedures [2].



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  		Fig 1. . Overinflation of the tracheal cuff resulting in right-sided linear membranous tracheal rupture.

 


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  		Fig 2. . Chest roentgenogram showing acutely distended appearance of tracheal cuff (single arrow) associated with pneumomediastinum (double arrows).

 
Tracheal laceration was reported to occur in association with vigorous attempts at difficult or emergent intubation. In this series, intubation was performed as an emergency in 2 cases and was described as difficult in 1 case. There is often concern about the tip of the tube or the tip of the stylets protruding from the tracheal tubes, resulting in mucosal erosion or perforation of the anterior cartilaginous tracheal wall [5, 7, 8]. It is difficult to explain right posterolateral tracheal lacerations when the tip has been inserted through the cords anteriorly. An acute increase in airway pressure during anesthesia caused by vigorous coughing with a closed expiratory valve may severely overdistend the trachea and could cause airway rupture [13]. Rupture of the trachea can also occur when these intubated patients are moved abruptly [15] or when harsh maneuvers are attempted during bucking and coughing. The membranous part of the trachea is very friable and susceptible to tearing in the elderly and in women (all patients in our series). Patients undergoing esophagectomy are at greater risk of rupture of the membranous trachea because of weakness caused by surgical dissection [3]. Chronic obstructive airway disease has been suggested as a possible risk factor in tracheal trauma [2, 5]. Emphysema leading to opening of the cartilage rings and enlargement of the trachea results in an increase in surface of the membranous portion of the tracheal wall, which could explain the propensity for damage of this already vulnerable area.

Several authors reported airway rupture after insertion of a double-lumen endotracheal tube [1–6] due to inadequate tube size, malpositioning of the tip of the tube, failure to deflate the tracheal and bronchial cuff when repositioning the patient or the tube, or overinflation or insufflation of the bronchial balloon too rapidly. Moreover, Carlens, White, and Robertshaw tubes have low-volume and high-pressure cuffs that sometimes inflate asymmetrically, leading to deviation of their tips toward the bronchial wall [3]. With this type of tube, isolated tracheal injury is rare, and most serious airway injuries involve the intubated main stem bronchus. Some reports [5, 13] have pointed out that tracheal lacerations may occur with any type of``atraumatically'' placed endotracheal tube, as in case 3 case 6 of this series.

Signs of tracheal rupture usually appear immediately or soon after the initial intubation, and the diagnosis is suspected from the common signs of subcutaneous emphysema and respiratory distress. However, Hood and Sloan [18] reported that in 66% of 98 patients with tracheobronchial injury, more than 24 hours elapsed between the injury and diagnosis. This delay is explained by partial-thickness wall lacerations and dissection by air into adventitia, expanding it and producing aneursymal dilatation with further rupture in the mediastinum or pleural space [5]. Early radiographic findings include pneumomediastinum, subcutaneous emphysema, and pneumothorax, but emergent fiberoptic bronchoscopy is the best means of confirming the diagnosis and determining the exact location and extent of the lesion. This should be done immediately after observing unexplained subcutaneous emphysema or inexhaustible pneumothorax, which could indicate tracheal laceration. Tracheal rupture is a life-threatening condition requiring aggressive management through operation. Its acute complications include tension pneumothorax or anoxia when most of the tidal volume is leaking through the tracheal tear. Subacute complications include potentially lethal mediastinitis and tracheal stricture.

Tracheal intubation distal to the lesion or bronchial intubation with a double-lumen tube and pleural drainage (if pneumothorax is present) are of prime importance for effective control of respiratory distress. Conservative treatment may be appropriate for small lacerations of the membranous trachea or when less than one third of the circumference of the trachea or bronchus is disrupted [19–21]. The last patient of this series presented with a small linear membranous laceration, which was managed medically with spontaneous healing and uneventful recovery, However, for more serious injuries, most investigators recommend early surgical repair through a cervical or thoracic incision. Petterson and co-workers [22] recommended imperative surgical repair in the event of respiratory or circulatory failure. Lesions of the lower half of the trachea, particularly of the membranous posterior wall, are most easily approached through a high right thoracotomy incision. Lesions in the upper and mid-trachea are best approached cervically, with partial division of the sternum if necessary for further exposure. The repair procedure involves end-to-end anastomosis for disruptions and simple suture for cases of laceration. Autogenous free pericardial graft [14, 23, 24] and intercostal muscle flap [25] have been used to reinforce primary closures and bridge small defects. As in any case of tracheal repair, positive pressure ventilation should be avoided, and extubation of the trachea should be performed as soon as possible.

Airway injuries after the use of double-lumen tubes emphasize the need for routine inspection of the mediastinum with both lungs ventilated after every thoracic procedure. Tracheal intubation–related airway ruptures are rare but probably underestimated. It is possible that some postoperative subcutaneous emphysema or pneumothorax assigned to bleb or bullous disease of the lung could be related to unrecognized tracheal laceration after endotracheal intubation.


   Footnotes
Top
 Footnotes
Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 
Address reprint requests to Dr Marty-Ané, Service de Chirurgie Thoracique, Hopital Arnaud de Villeneuve, Centre Hospitalier Universitaire, 34295 Montpellier Cedex 5, France.


   References
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 Footnotes
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 

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