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Ann Thorac Surg 1997;63:227-228
© 1997 The Society of Thoracic Surgeons

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Case Report

Danger of False Intubation After Traumatic Tracheal Transection

Division of Cardiothoracic Surgery, Harbor-UCLA Medical Center, Torrance, California

Accepted for publication July 1, 1996.

	Abstract

Top Footnotes Abstract Introduction Comment Reference

 
Blunt tracheobronchial injuries may be difficult to diagnosis at presentation but can pose major airway difficulties. We present a patient with a tracheal transection who underwent intubation with the tip of the endotracheal tube exiting the trachea and terminating in the mediastinum adjacent to the distal trachea. He underwent surgical repair of the injury with end-to-end anastomosis. Although intubation over a flexible fiberoptic bronchoscope is desirable in cases of suspected tracheobronchial injury, it may not be feasible. In cases of suspected tracheobronchial injuries with blind endotracheal intubation, the possibility of false intubation should always be entertained.

	Introduction

Top Footnotes Abstract Introduction Comment Reference

 
In 1990, we reported a series of 9 patients with blunt tracheobronchial injuries and emphasized the importance of early flexible fiberoptic bronchoscopy in patients suspected of having such an injury [1]. The presence of a tracheal disruption makes this recommendation even more compelling, because blind intubation from above could lead to further distal tracheal displacement. As a follow-up, we report a patient undergoing false extratracheal intubation from above after sustaining a complete tracheal transection.

A 31-year-old man presented to Harbor-UCLA Medical Center after a motor vehicle accident in which he was the unrestrained passenger. The patient had a flail left chest and pulmonary contusion but no pneumothorax or subcutaneous emphysema. He was agitated and in respiratory distress with labored breathing and urgently intubated orotracheally. The breath sounds on auscultation were present but blunted. The patient had high peak ventilator pressures but saturated well. Massive subcutaneous emphysema was present on examination and radiographically, and this developed only after intubation. Nonetheless, a chest film showed the endotracheal tube to be in an apparent correct position.

Because of concern for suspected tracheobronchial injury, we performed flexible fiberoptic bronchoscopy in the emergency room. This showed the presence of tissue at the tip of the endotracheal tube without the normal expected tracheal lumen. Because the patient was well saturated, we did not want to risk adjusting the tube, but instead brought the patient to the computed tomographic scanner for delineation of the injury anatomy. The scan revealed an area of tracheal separation of approximately 6 cm, and although the tube was within the proximal trachea, it was outside and parallel to the distal trachea (Fig 1).

View larger version (70K): [in this window] [in a new window]   Fig 1. . (A) Computed tomographic scan depicting the endotracheal tube within the proximal trachea. (B) Endotracheal tube in ventilated mediastinal space (arrow) without evidence of trachea at this level. (C) Endotracheal tube (arrow) in mediastinum outside the distal trachea.

Postoperatively, the patient had a prolonged ventilator course secondary to his pulmonary contusion and required a tracheostomy. He subsequently was extubated and has done well.

	Comment

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This patient was in respiratory distress and underwent urgent intubation. Despite having a false extraluminal intubation, our patient was fortunate enough to be ventilated because the mediastinal pleura remained intact. If pleural disruption had resulted from endotracheal tube placement, the outcome would have been fatal long before the patient reached the operating room. The case illustrates the theoretical importance of intubating patients with suspected tracheal injuries over a flexible fiberoptic scope, if possible. The flexible scope acts as a stent to guide the endotracheal tube from proximal to distal trachea to prevent deviation of the tube into a false passage. This recommendation does not imply that all patients with suspected tracheal injuries be intubated over a fiberoptic scope, because many of these patients are in respiratory distress and the delay may result more in delaying life-saving care than preventing injury. However, flexible fiberoptic airway evaluation should then be done after the airway is secured. If blind intubation is necessary for respiratory distress, as in our patient, and massive subcutaneous emphysema results, thought should be given to the possibility of false intubation.

	Footnotes

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Address reprint requests to Dr Baumgartner, Division of Cardiothoracic Surgery, Harbor-UCLA Medical Center, 1000 West Carson St, Bin 423, Torrance, CA 90509.

	Reference

Top Footnotes Abstract Introduction Comment Reference

 

1. Baumgartner F, Sheppard B, de Virgilio C, et al. Tracheal and main bronchial disruptions after blunt chest trauma: presentation and management. Ann Thorac Surg 1990;50:569–74.

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Fritz J. Baumgartner Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Baumgartner, F. J. Articles by Theuer, C. Search for Related Content PubMed PubMed Citation Articles by Baumgartner, F. J. Articles by Theuer, C.