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Ann Thorac Surg 1997;63:240-242
© 1997 The Society of Thoracic Surgeons

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Case Report

Nonoperative Management of Tracheal Laceration During Endotracheal Intubation

Departments of Surgery (Thoracic Service) and Anesthesiology and Critical Care Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York

Accepted for publication July 31, 1996.

	Abstract

Top Footnotes Abstract Introduction Comment References

 
Tracheal laceration is a rare but potentially devastating complication of endotracheal intubation. Traditional management of intubation-related tracheal laceration is operative. Nonoperative management of a woman noted to have a tracheal laceration during intubation is described. Criteria by which nonoperative treatment can be considered are outlined.

	Introduction

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An 80-year-old woman (Karnofsky performance status 90%) presented 2 years after resection of pulmonary and hepatic colorectal metastases with a new left upper lobe lesion. Resection of this lesion was scheduled. The patient was brought to the operating room and intubated with an 8-mm internal diameter single-lumen endotracheal tube without difficulty under general anesthesia. Fiberoptic bronchoscopy was performed. The trachea and bilateral bronchi were found to be of normal diameter and without endobronchial lesions. The single-lumen endotracheal tube was removed and a 39F double-lumen endotracheal tube was placed with moderate difficulty.

Bronchoscopic examination revealed a small amount of blood at the distal end of the endotracheal tube with no trachea or bronchi visible. The 39F tube was therefore removed. Attempts to place a smaller 37F double-lumen endotracheal tube were unsuccessful. A single-lumen endotracheal tube was therefore placed. Bronchoscopy revealed a linear tear 3 cm in length and 1 cm wide in the posterior distal trachea extending down to the carina (Fig 1). This tear appeared to be full thickness.

View larger version (135K): [in this window] [in a new window]   Fig 1. . Bronchoscopic photograph of the posterior distal tracheal laceration. The linear laceration can be seen to extend to the carina.

View larger version (110K): [in this window] [in a new window]   Fig 2. . Thoracic computed tomogram with oral barium contrast. No extravasation of contrast from the esophagus is evident. Minimal pneumomediastinum is seen.

Fourteen days after the patient's tracheal laceration, fiberoptic bronchoscopy revealed the lesion to be completely healed. Fifteen days after tracheal laceration the patient underwent wedge resection of her left lung lesion through a left posterolateral thoracotomy without difficulty or incident. Airway management was achieved using a 7-mm inner diameter single-lumen endotracheal tube and an 8/14F Fogarty venous occlusion catheter as a bronchial blocker.

	Comment

Top Footnotes Abstract Introduction Comment References

 
Tracheal laceration is a rare complication of endotracheal intubation. The literature describing this injury has focused largely on its cause and early identification [1–4]. The tracheal lacerations in these reports were discovered either intraoperatively or within 24 hours postoperatively. Most were repaired surgically. Few reports in the English-language literature describe nonoperative management of intubation-related tracheal lacerations [5–7].

D'Odemont and associates [5] described a 57-year-old woman who underwent cholecystectomy in whom subcutaneous emphysema of the face and neck developed 30 minutes after extubation. Initial intubation of this patient with a single-lumen 8-mm cuffed Argyle endotracheal tube was described as difficult. During the operation and postoperatively the patient's vital signs were stable. Fiberoptic bronchoscopy revealed a 5 x 2-cm wide posterior wall laceration extending from the midtrachea to the carina. Thoracic computed tomography confirmed subcutaneous emphysema, pneumomediastinum, and a floating posterior tracheal flap 6 cm in height extending up to the carina. Amikacin, penicillin, and metronidazole were administered, and the patient was observed. Bronchoscopy 10 days later revealed closure of the tracheal laceration.

Marty-Ané and colleagues [6] described 1 patient who was managed nonoperatively. This patient had undergone an appendectomy and was discovered to have a tracheal laceration after development of cervicothoracic subcutaneous emphysema. Radiologic workup revealed pneumomediastinum, and bronchoscopy demonstrated a 2-cm-long laceration of the membranous trachea 3 cm below the vocal chords. Antibiotic therapy with amoxicillin and metronidazole was instituted. The patient was discharged on the tenth postoperative day.

The experience with our patient coupled with the patient outcomes in the previously noted case reports suggests the practicality of conservative management in select cases [5–7], but criteria to assess the potential for nonoperative management of intubation-related tracheal injury are needed. A stable patient is mandatory. Prompt evaluation of the extent of injury is critical. Fiberoptic bronchoscopy allows investigation of the injury and permits antibiotic irrigation and confirmation of tube placement. Bronchoscopy is recommended by many authors for routine placement of double-lumen endotracheal tubes and is a practice with which we concur [4, 8]. Smith and associates [8] found that when double-lumen endotracheal tubes were inserted without the aid of fiberoptic bronchoscopy 48% were found to be malpositioned. Tracheal lacerations have occurred after the placement of both double-lumen and single-lumen endotracheal tubes. To prevent tracheal injury, fiberoptic bronchoscopy should be used to aid intubation in all cases where intubation is difficult.

Evaluation of associated esophageal injury is important and consists of flexible esophagoscopy and thoracic computed tomography with oral contrast. Computed tomography allows assessment of esophageal leak and pneumomediastinum. In addition, computed tomography permits analysis of the volume of mediastinal fluid collection. A large collection suggests hemorrhage and has the possibility of becoming infected.

Antibiotic prophylaxis toward common endobronchial flora is prudent. The length of antibiotic administration should be tailored to the patient.

In summary, we propose the following criteria to be used as guidelines in deciding on nonoperative management of intubation-related tracheal lacerations:

1. Stable vital signs in the patient
   
2. No difficulty ventilating the patient while intubated or respiratory distress while extubated
   
3. No evidence of esophageal injury
   
4. Minimal mediastinal fluid collection
   
5. Nonprogressive pneumomediastinum or subcutaneous emphysema
   
6. No signs of sepsis
   

A low threshold for returning to the operating room for definitive treatment of the injury is warranted should complications develop.

	Footnotes

Top Footnotes Abstract Introduction Comment References

 
Address reprint requests to Dr Burt, Division of Thoracic Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021.

	References

Top Footnotes Abstract Introduction Comment References

 

1. Kumar SM, Pandit SK, Cohen PJ. Tracheal laceration associated with endotracheal anesthesia. Anesthesiology 1977;47:298–9.[Medline]
2. Guernelli N, Bragaglia RB, Briccoli A, Mastrorilli M, Vecchi R. Tracheobronchial ruptures due to cuffed Carlens tubes. Ann Thorac Surg 1979;28:66–8.
3. Wagner DL, Gammage GW, Wong ML. Tracheal rupture following the insertion of a disposable double-lumen endotracheal tube. Anesthesiology 1985;63:698–700.[Medline]
4. Massard G, Rouge C, Dabbagh A, et al. Tracheobronchial lacerations after intubation and tracheostomy. Ann Thorac Surg 1996;61:1483–7.[Abstract/Free Full Text]
5. D'Odemont JP, Pringot J, Goncette L, Goenen M, Rodenstein DO. Spontaneous favorable outcome of tracheal laceration. Chest 1991;99:1290–2.[Abstract/Free Full Text]
6. Marty-Ané C, Picard E, Jonquet O, Mary H. Membranous tracheal rupture after endotracheal intubation. Ann Thorac Surg 1995;60:1367–71.[Abstract/Free Full Text]
7. Eaton JM. Tracheal rupture. Anaesthesia 1985;40:212.
8. Smith GB, Hirsch NP, Ehrenwerth J. Placement of double-lumen endobronchial tubes. Br J Anaesth 1986;58:1317–20.[Abstract/Free Full Text]

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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): Michael E. Burt Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Ross, H. M. Articles by Burt, M. E. Search for Related Content PubMed PubMed Citation Articles by Ross, H. M. Articles by Burt, M. E.