American Journal of Emergency Medicine 33 (2015) 128.e1-128.e3

Contents lists available at ScienceDirect

American Journal of Emergency Medicine

journal homepage: locate/ ajem

Case Report

Tracheal laceration as a complication of out-of-hospital emergency tracheal intubation in a patient with COPD

Abstract

Tracheobronchial injuries related to emergency endotracheal intubations are reported to be associated with an increased risk of mortality. Many mechanical risk factors may become more frequent in an emergency setting leading to such injuries. Aside from these factors that may complicate endotracheal intubation, this procedure is not recommended a priori for ventilation due to the resulting interrup- tions in external chest compressions, by 2010 cardiopulmonary resuscitation (CPR) and external chest compression guidelines. We present a 78-year-old woman with known chronic obstructive pulmonary disease who had a tracheal laceration after emergency endotracheal intubation during CPR. Thorax computed tomography revealed an overinflated tube cuff. The trachea was repaired surgically; however, our patient died on the fourth postoperative day due to multiple-organ failure. Prehospital providers must remain especially vigilant to priorities in airway management during CPR and aware of the dangers associated with field tracheal intubation under less than ideal conditions.

Tracheobronchial injuries related to Endotracheal intubation are not very uncommon. These injuries may occur in a nature that can be treated conservatively or may occur as a fatal complication to be treated with Surgical repair. The type of these injuries itself, the etiology, the clinical status of the patient, and the time that passes until recognition of such an injury are the main determinants of the outcome [1-3].

These iatrogenic injuries related to ETI are longitudinal, low- impact lacerations, as it has been clearly distincted by Lampl, from ruptures that occur secondary to trauma [2]. In a study addressing the prevelance of tracheobronchial injuries including both ruptures and lacerations, the injuries related to emergency ETIs were reported to be 27.4% of all tracheobronchial injuries. In the same study, these lacerations related to emergency ETIs were reported to be associated with increased mortality [3].

In an emergency situation such as resuscitation, many mechanical risk factors leading to such injuries may become more prone to occur. These risk factors include multiple attempts, use of stylet protruding beyond the endotracheal tube tip, overinflation of the ETT cuff, inappropriate ETT size, inadequate medication during laryngoscopy, and ETI leading to coughing, gagging and/or movement, and misplacement [1,3,4]. In addition, the duration of transport is a major concern for the victims because ETT displacement may occur with its cuff inflated, and there may occur undesirable head and neck movements, which may become the other possible risk factors for the occurance of tracheobronchial injuries [4].

Aside from the factors that may complicate laryngoscopy and ETI in an emergency setting, there arises another major problem. In inexperienced hands, these procedures may result in unacceptable interruption of external chest compressions during resuscitation. The 2010 European Resuscitation Council and the American Heart Association/American Cardiology College guidelines strictly recom- mend bag mask or supraglottic airway devices a priori for ventilation instead of ETI for both preventing the complications and minimizing the interruptions in external chest compressions [5,6].

Our aim is to remind the priorities in airway management of an adult patient in emergency setting and the preventable causes of the tracheobronchial injuries related to ETI, by presenting a patient who was diagnosed to have full thickness tracheal laceration on arrival to our hospital for postresuscitative care.

A 78-year-old woman, with known chronic obstructive pulmonary disease (COPD), was brought to the emergency department (ED) of our hospital by emergency medical services (EMS) for post- resuscitative care.

The EMS was called at 2:00 PM for deterioration of the general clinical status of the patient. When the EMS arrived, they detected agonal breathing and no pulse, then started cardiopulmonary resuscitation (CPR). During CPR the trachea was intubated. After 2 cycles of CPR, the sinus rythym and spontaneous circulation returned. The patient arrived at the ED within 1 hour after the first contact with the patient. ThoracoAbdominal computed tomography (CT) revealed pneumothorax and generalized pneumomediastinum. In the CT scan, there was an asymmetrical irregular widening at the level of proximal trachea due to ETT cuff, leading to a diameter of 33 mm. Trachea did not seem to have clear and definitive wall, and disruption was detected (Figs. 1 and 2). These findings were considered in favor of a full-thickness tracheal laceration. Meanwhile, in 2 houRS time after the first contact with the patient, subcutaneous emphysema became apparent. Emergency surgery for tracheal repair was planned. On arrival to the operating room, the patient was mechanically ventilated via ETT and the patient’s hemodynamic parameters were within normal ranges. The ETT placement was confirmed. Arterial blood gas analysis revealed respiratory acidosis and hypoxemia. Anesthesia was induced by thiopental and midazolam and maintained by sevoflurane supplemented with remifentanil infusion. On normo- thermic cardiopulmonary bypass (CPB), a tube exchanger was advanced through the ETT, and the tube was gently pulled out, railroaded over the tube exchanger. Tracheal resection and repair were performed with the tube exchanger inside (Fig. 3). As the repair was completed, 6.5-mm internal diameter flexible armored ETT was placed, led by the exchanger. The exchanger was pulled out gently. Location was confirmed by fiberoptic bronchoscope (FOB). Tube cuff

0735-6757/(C) 2014

128.e2 F. Uzumcugil et al. / American Journal of Emergency Medicine 33 (2015) 128.e1–128.e3

B

A

Fig. 3. Trachea resection and repair on normothermic cardiopulmonary bypass.

Fig. 1. Thoracoabdominal CT. Pneumomediastinum; posterolateral (A) and anterior (A, B) Mediastinal emphysema.

was not inflated to prevent possible necrosis in the site of anastomosis due to cuff pressure. Cuff leak and ventilation of both lungs were confirmed before discontinuing CPB. The patient was transferred to the intensive care unit on vasopressor support. On the fourth postoperative day, the patient died due to multiple-organ failure.

Tracheobronchial injuries were strictly discriminated as ruptures and lacerations previously, according to the etiology [2]. The injuries caused by trauma were defined as ruptures, whereas the iatrogenic injuries were defined as lacerations [2]. Our patient did not have a history of trauma, but, on the other hand, had a history of resuscitation with an emergency ETI. This led us to consider this full-thickness laceration as an Iatrogenic injury caused by ETI. There are also spontaneous Tracheal ruptures reported in the literature [7,8]. Because our patient’s trachea was intubated by EMS on the scene, we can not actually know whether any Spontaneous ruptures had occurred leading to the primary deterioration of the patient. Furthermore, the laceration was localized and longitudinal full-thickness tear on the

posterolateral wall, which we thought this injury was a laceration due to intubation. Unfortunately, the condition of intubation (e.g., difficulty in airway management) and the technique used (e.g., use of a stylet) were not reported in the EMS records.

The tracheobronchial CT revealed an irregular widening and disruption in the wall at the level of the tube cuff resulting in a diameter of 33 mm. The anterior-posterior (AP) and transverse diameter of trachea in women were reported to be 19.2 +- 2.6 and

22.9 +- 2.6 mm, respectively [9]. It is clear that the cuff was overinflated. An 8.0-mm internal diameter ETT cuff requires a volume of at least 20 mL of air to reach a diameter of 33 mm. This volume may have caused an injury in the tracheal wall, and the laceration may have become worse with positive pressure ventilation, as these were also reported previously as the contributing factors to tracheobronchial injuries [4,10]. It should be highlighted that these kind of mechanical factors are preventable. The ETT cuff should be inflated to the minimum volume possible, preventing leakage, which is described as “just-seal volume.” The most common complication that may occur with overinflation of a tube cuff, especially in patients on long-term follow-up with ETT in place, is tissue ischemia on the tracheal wall. To prevent ischemia caused by the pressure exerted on the wall by the tube cuff, this pressure has been recommended to be monitored in both operating room and intensive care unit. The pressure should be maintained within a range of 25 to 30 cm H₂O [11]. However, to the best of our knowledge, there is no recommendation for monitoring the ETT cuff pressure during resuscitation. We cannot make any suggestion on the reliability of such monitoring during CPR, as well.

ETT cuff

Irregular tracheal wall

Fig. 2. Thoracoabdominal CT. The tracheal wall irregularity with asymmetric ETT cuff.

F. Uzumcugil et al. / American Journal of Emergency Medicine 33 (2015) 128.e1–128.e3 128.e3

We can only recommend to ensure that the cuff is inflated to the minimum volume possible required just to make a seal with the tracheal wall inside.

In addition to the mechanical factors that may have contributed to the tracheal injury of our patient, there were also some anatomical factors that may also have contributed. Our patient had COPD, which may result in functional and anatomical disruption in airway. The change in airway morphology described as the widening in anteropos- terior diameter and narrowing in trasverse diameter, defined as “saber- sheat trachea” is considered specific for COPD [12]. That kind of change in structure leads to a smaller-than-normal trachea. Its prevelance has been reported to be 25.4% [13]. We cannot obtain any prior chest X-ray or thorax CT of our patient to suggest any morphological change associated with the disease. Thus, we cannot suggest any contribution of such a change in morphology to our patient’s tracheal injury. However, there are reports describing such morphological changes developing even in the very early stages of the disease that we thought our patient may have developed such morphological changes making the airway vulnerable to intubation [12].

Whatever the etiology of a tracheobronchial injury is, the symptoms and signs are similar. However, these symptoms and signs may be apparent or discrete depending on the severity of injury, and so the time that passes until recognition mostly depends on the severity, as well. Respiratory distress, subcutaneous emphysema, pneumothorax, and pneumomediastinum are the main features [3]. In ED, cranial and thoracoabdominal CTs were obtained in advance for the differential diagnosis, that the tracheal injury of our patient was recognized early, before the development of any symptoms. Respira- tory distress or subcutaneous emphysema were not apparent on arrival. However, with the recognition of the injury on CT, simulta- neously the subcutaneous emphysema become apparent. Although early recognition of such injuries were reported to improve outcome in these patients, we presume that the primary cause of cardiopul- monary arrest may have led to the postoperative multiple-organ failure and death of our patient.

Overinflation of the ETT cuff has been recognized well as a risk factor for tracheobronchial injuries. The mechanical risk factors of tracheobronchial injuries are mostly preventable, as well as the overinflation of the cuff. To prevent the occurance of such injuries and to recognize such injuries early, experience, practice, and mainte- nance of the skill are vital. In emergency setting such as resuscitation, the inexperienced providers are strictly recommended to prefer the use of bag mask or Supraglottic airway devices a priori for ventilation instead of ETI.

In addition, it may be better to keep in mind that COPD patients may be more prone to develop tracheobronchial injuries due to the

morphological changes in the structure of airway. Inappropriate ETT size and/or overinflation of an ETT cuff may easily result in injuries in varying degrees of severity. A smaller than normal ETT may be preferred in these patients with considering the least possible cuff inflation volume.

Filiz Uzumcugil, MD, DESA? Gulcin Babaoglu, MD Ezgi Denizci, MD Fatma Saricaoglu, MD Meral Kanbak, MD

Hacettepe University School of Medicine Department of Anesthesiology and Reanimation

?Corresponding author. Hacettepe University School of Medicine Department of Anesthesiology and Reanimation, 06230, Altindag

Ankara, Turkey

http://dx.doi.org/10.1016/j.ajem.2014.06.021

References

1. Sahin M, Anglade D, Buchberger M, Jankowski A, Albaladejo P, Ferretti GR. Case reports: iatrogenic bronchial rupture following the use of endotracheal tube introducers. Can J Anaesth 2012;59:963-7.
2. Lampl L. Tracheobronchial injuries. Conservative treatment. Interact Cardiovasc Thorac Surg 2004;3(2):401-5.
3. Minambres E, Buron J, Ballesteros MA, Llorca J, Munoz P, Gonzales-Castro A. Tracheal rupture after endotracheal intubation: a literature systematic review. Eur J Cardiothorac Surg 2009;35(6):1056-62.
4. Lim H, Kim JH, Kim D, Lee J, Son JS, Kim DC, et al. Tracheal rupture after endotracheal intubation–a report of three cases. Korean J Anaesth 2012;62 (3):277-80.
5. European Resuscitation Council. Guidelines for resuscitation; 2010 [www.erc.edu].
6. American Heart Association. Guidelines for CPR and ECC; 2010 [www.heart.org].
7. Rousie C, Van Damme H, Radermecker MA, Reginster P, Tecqmenne C, Limet R. Spontaneous tracheal rupture: a case report. Acta Chir Belg 2004;104(2):204-8.
8. Stevens MS, Mullis TC, Carran JD. Spontaneous tracheal rupture caused by vomiting. Am J Otolaryngol 2010;31(4):276-8.
9. Kamel KS, Lau G, Stringer MD. In vivo and in vitro morphometry of the human trachea. Clin Anat 2009;22:571-9.
10. Austin RD. Thoracotomy for tracheal disruption after traumatic intubation: a case report. AANA J 2010;78(5):400-4.
11. Chapter 50Henderson J. Airway management in the adult. In: Miller Ronald D, editor. Miller’s Anesthesia. 7th ed. Churchill Livingstone Elsevier; 2010.

    p. 1573-610.

    EOM JS, Lee G, Lee HY, Oh JY, Woo SY, Jeon K, et al. The relationships between tracheal index and lung volumeparameters in mild-to-moderate COPD. Eur J Radiol 2013;82(12):e867-72.

12. Ciccarese F, Poerio A, Stagni S, Attina D, Fasano L, Carbonara P, et al. Saber-sheat trachea as a marker of severe airflow obstruction in chronic obstructive pulmonary disease. Radiol Med 2014;119:90-6.