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LETTER TO EDITOR
Year : 2014  |  Volume : 58  |  Issue : 3  |  Page : 357-358  

Posterior tracheal wall rupture following uneventful general endotracheal anaesthesia


Department of Anaesthesiology, North Bengal Medical College, Darjeeling, West Bengal, India

Date of Web Publication23-Jun-2014

Correspondence Address:
Dr. Tirtha Sahoo
Department of Anaesthesiology, North Bengal Medical College, Sushrutanagar, Darjeeling - 734 012, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5049.135092

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How to cite this article:
Mishra N, Sahoo T, Mandal BK, Das S. Posterior tracheal wall rupture following uneventful general endotracheal anaesthesia. Indian J Anaesth 2014;58:357-8

How to cite this URL:
Mishra N, Sahoo T, Mandal BK, Das S. Posterior tracheal wall rupture following uneventful general endotracheal anaesthesia. Indian J Anaesth [serial online] 2014 [cited 2019 Dec 9];58:357-8. Available from: http://www.ijaweb.org/text.asp?2014/58/3/357/135092

Sir,

Posterior tracheal wall rupture is a rare, but serious iatrogenic complication of tracheal intubation. [1],[2] The laceration usually occurs in the lower third of the trachea longitudinally at the posterior membranous wall or at the junction between the membranous wall and the cartilaginous ring. Over inflation of the cuff and sudden movement of the tube are the two most common reasons, and direct tear caused by the tube itself is rare. [3] Potential factors contributing to intubation-related injury are vigorous coughing over tube, female sex, short stature, old age, inappropriate tube size, malposition of tube, oesophageal surgery and steroid therapy. [1],[2],[3] In most cases, the initial presentation is cervicothoracic subcutaneous emphysema and dyspnoea. [1],[4] Diagnosis is usually made by bronchoscopy or high-resolution computed tomography. Although superficial tears may heal spontaneously, deeper and longer lacerations with increasing symptoms require prompt surgical repair. [1],[3] We came across a case of tracheal rupture following uneventful endotracheal intubation.

A 60-year-old lady with height of 145 cm and body weight of 62 kg (body mass index 29.49 kg/m 2 ) was scheduled to undergo intercondylar fixation of right humerus. She had no comorbidity. After induction, endotracheal intubation was effected with 7.5 mm internal diameter (I.D.) cuffed tracheal tube through oral route. Standard anaesthesia techniques were followed with proper monitoring. The operative period was uneventful. Patient was extubated in the operating room after adequate reversal and shifted to the recovery ward.

In the recovery room patient developed respiratory distress with surgical emphysema. Computed tomography scan showed a rent in the posterior tracheal wall. Bronchoscopy followed by surgical intervention was planned. Fibre optic bronchoscope (with preloaded endotracheal tube of 6.5 mm I.D.) was inserted through nasal route and a 4 cm longitudinal tear on the posterior tracheal wall ending 3 cm above carina was found. Patient was intubated over the bronchoscope and guided into the left main bronchus and one lung ventilation was initiated. The anterior wall of trachea was incised longitudinally, the tracheal tube was withdrawn after deflating the cuff and kept above this rent. Another tracheal tube of 5.5 mm I.D. was inserted through the incision and placed in the left main bronchus and one lung ventilation maintained. Posterior wall tear was repaired. Incision of the anterior wall was sutured starting from above. When it was near completion, second tracheal tube was taken out, and the first tracheal tube was advanced to position it just above the carina. Ventilation was adequate throughout the procedure.

The patient was extubated on the next day. Post-operative period was uneventful. A chest radiograph performed on day 7 showed complete resolution of the subcutaneous and mediastinal emphysema. The patient was discharged on day 8. A follow-up bronchoscopy after 5 weeks revealed complete healing without stenosis.

Post-intubation tracheal rupture may present more frequently in women. Weaker pars membranosa and smaller tracheal diameters predispose women more vulnerable to cuff overinflation. Short stature and use of nitrous oxide could be other contributing factors [3] in our case.

Consideration of post-intubation tracheal rupture as a potential complication and increased awareness among the anaesthesiologists may lead to early diagnosis and prompt treatment. Intra-operative manipulation of the airway and maintenance of adequate ventilation are also very critical.

 
   References Top

1.Miñambres E, Burón J, Ballesteros MA, Llorca J, Muñoz P, González-Castro A. Tracheal rupture after endotracheal intubation: A literature systematic review. Eur J Cardiothorac Surg 2009;35:1056-62.  Back to cited text no. 1
    
2.Joshi M, Mardakh S, Yarmush J, Kamath H, Schianodicola J, Mendoza E. Intraoperatively diagnosed tracheal tear after using an NIM EMG ETT with previously undiagnosed tracheomalacia. Case Rep Anesthesiol 2013;2013:568373.  Back to cited text no. 2
    
3.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 Anesthesiol 2012;62:277-80.  Back to cited text no. 3
    
4.Kim KH, Kim MH, Choi JB, Kuh JH, Jo JK, Park HK. Postintubation tracheal ruptures: A case report. Korean J Thorac Cardiovasc Surg 2011;44:260-5.  Back to cited text no. 4
    




 

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