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Cardillo G, Ricciardi S, Forcione AR, Carbone L, Carleo F, Di Martino M, Jaus MO, Perdichizzi S, Scarci M, Ricci A, Dello Iacono R, Lucantoni G, Galluccio G. Post-intubation tracheal lacerations: Risk-stratification and treatment protocol according to morphological classification. Front Surg 2022; 9:1049126. [PMID: 36504581 PMCID: PMC9727090 DOI: 10.3389/fsurg.2022.1049126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 10/31/2022] [Indexed: 11/24/2022] Open
Abstract
Background Post-intubation tracheal laceration (PITL) is a rare condition (0.005% of intubations). The treatment of choice has traditionally been surgical repair. Following our first report in 2010 of treatment protocol tailored to a risk-stratified morphological classification there is now clear evidence that conservative therapy represents the gold standard in the majority of patients. In this paper we aim to validate our risk-stratified treatment protocol through the largest ever reported series of patients. Methods This retrospective analysis is based on a prospectively collected series (2003-2020) of 62 patients with PITL, staged and treated according to our revised morphological classification. Results Fifty-five patients with Level I (#8), II (#36) and IIIA (#11) PITL were successfully treated conservatively. Six patients with Level IIIB injury and 1 patient with Level IV underwent a surgical repair of the trachea. No mortality was reported. Bronchoscopy confirmed complete healing in all patients by day 30. Statistical analysis showed age only to be a risk factor for PITL severity. Conclusions Our previously proposed risk-stratified morphological classification has been validated as the major tool for defining the type of treatment in PITL.
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Affiliation(s)
- Giuseppe Cardillo
- Unit of Thoracic Surgery, Azienda Ospedaliera San Camillo-Forlanini, Carlo Forlanini Hospital, Rome, Italy,Unicamillus–Saint Camillus University of Health Sciences, Rome, Italy
| | - Sara Ricciardi
- Unit of Thoracic Surgery, Azienda Ospedaliera San Camillo-Forlanini, Carlo Forlanini Hospital, Rome, Italy,PhD Program, Alma Mater Studiorum, University of Bologna, Bologna, Italy,Correspondence: Sara Ricciardi
| | - Anna Rita Forcione
- Unit of Thoracic Surgery, Azienda Ospedaliera San Camillo-Forlanini, Carlo Forlanini Hospital, Rome, Italy
| | - Luigi Carbone
- Unit of Thoracic Surgery, Azienda Ospedaliera San Camillo-Forlanini, Carlo Forlanini Hospital, Rome, Italy
| | - Francesco Carleo
- Unit of Thoracic Surgery, Azienda Ospedaliera San Camillo-Forlanini, Carlo Forlanini Hospital, Rome, Italy
| | - Marco Di Martino
- Unit of Thoracic Surgery, Azienda Ospedaliera San Camillo-Forlanini, Carlo Forlanini Hospital, Rome, Italy
| | - Massimo O. Jaus
- Unit of Thoracic Surgery, Azienda Ospedaliera San Camillo-Forlanini, Carlo Forlanini Hospital, Rome, Italy
| | | | - Marco Scarci
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Alberto Ricci
- Unit of Pulmonology, Sapienza University of Rome, San Andrea Hospital, Rome, Italy
| | - Raffaele Dello Iacono
- Unit of Pulmonology and Thoracic Endoscopy, Azienda Ospedaliera San Camillo-Forlanini,
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Martínez Juste JF. Laceración traqueal tras realizar una intubación con videolaringoscopio C-MAC ®. Reporte de caso. REVISTA DE LA FACULTAD DE MEDICINA 2022. [DOI: 10.15446/revfacmed.v71n2.96868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Introducción. La laceración traqueal post-intubación es una complicación con una baja incidencia, pero que, debido a su relevancia clínica y alto riesgo de mortalidad, debe ser sospechada en casos de intubación endotraqueal.
Presentación del caso. Mujer de 74 años con antecedentes médicos de hipertensión arterial e insuficiencias mitral y tricuspídea que fue sometida a colecistectomía laparoscópica bajo anestesia general en un hospital de tercer nivel de Zaragoza, España, donde se utilizó un videolaringoscopio C-MAC® para realizar la intubación. La paciente, 20 minutos después de la extubación, presentó hemoptisis, disnea y disminución de la saturación de oxígeno, por lo que se realizó una fibrobroncoscopia, en la cual se evidenció una laceración traqueal sangrante de 1.5 cm. Se inició tratamiento antibiótico endovenoso y mediante radiografía de tórax y tomografía axial computarizada se descartaron complicaciones graves como neumotórax, neumomediastino o rotura traqueal. Durante el período de observación, la paciente tuvo un nivel normal de oxígeno en la sangre, su condición hemodinámica permaneció estable, y recibió el alta hospitalaria a las 72 horas.
Conclusiones. Debido a la alta mortalidad asociada a las laceraciones traqueales, se requiere un alto índice de sospecha clínica, en particular en pacientes con factores de riesgo para este tipo de lesiones y en casos de intubación difícil, para no demorar el inicio de medidas diagnósticas y terapéuticas oportunas, disminuyendo así las posibles complicaciones y mejorando el pronóstico. Además, estas lesiones requieren un manejo individualizado por parte de un equipo multidisciplinario.
riesgo de mortalidad, debe ser sospechada en casos de intubaciónendotraqueal.
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Mohd Esa NY, Faisal M, Vengadesa Pilla S, Abdul Rahaman JA. Silicone Y-stent insertion under extracorporeal membrane oxygenation (ECMO) in a patient with tracheal tear. BMJ Case Rep 2020; 13:13/12/e236414. [PMID: 33370965 PMCID: PMC7757493 DOI: 10.1136/bcr-2020-236414] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Tracheal tear after endotracheal intubation is extremely rare. The role of silicone Y-stent in the management of tracheal injury has been documented in the previous studies. However, none of the studies have mentioned the deployment of silicone Y-stent via rigid bronchoscope with the patient solely supported by extracorporeal membrane oxygenation (ECMO) without general anaesthesia delivered via the side port of the rigid bronchoscope. We report a patient who had a tracheal tear due to endotracheal tube migration following a routine video-assisted thoracoscopic surgery sympathectomy, which was successfully managed with silicone Y-stent insertion. Procedure was done while she was undergoing ECMO; hence, no ventilator connection to the side port of the rigid scope was required. This was our first experience in performing Y-stent insertion fully under ECMO, and the patient had a successful recovery.
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Affiliation(s)
| | - Mohamed Faisal
- Respiratory, National University of Malaysia Faculty of Medicine, Kuala Lumpur, Malaysia
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Postintubation Tracheal Perforation While on Long-Term Steroid Therapy: A Case Report. J Emerg Med 2020; 60:380-383. [PMID: 33308913 DOI: 10.1016/j.jemermed.2020.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 10/04/2020] [Accepted: 11/01/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endotracheal intubation is an essential basic skill for emergency physicians. The procedure can cause complications that should be recognized. Awareness and early identification of complications are needed to allow early intervention to optimize outcomes. The risk factors for tracheal perforation during intubation are typically related to the physician skill and experience and to the patient's comorbidities, including body habitus and chronic use of certain medications. CASE REPORT We report a case of a 45-year-old man with renal transplant on tacrolimus and prednisolone for 16 years. He presented with decreased level of consciousness due to an acute intracranial hemorrhage and was intubated for airway protection. Post intubation, a significant subcutaneous emphysema was noted on the patient's neck and chest, which was subsequently determined to be caused by a tracheal perforation. The management of tracheal injury depends on the size and location of the tear, as well as the patient's clinical status and comorbidities. In this case, the tracheal perforation was treated conservatively and was successful. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case has been reported to increase awareness about this rare and potentially life-threatening event. The prevention of this rare injury can be difficult but use of a slightly smaller endotracheal tube in a high-risk patient can be of benefit. In addition, early consideration of this complication when there is an acute change in physiologic status will allow for rapid facilitated management.
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Singh S, Garg A, Lamba N, Vishal. Anaesthetic management of intraoperative tracheo-bronchial injury. Respir Med Case Rep 2019; 29:100970. [PMID: 31828009 PMCID: PMC6889322 DOI: 10.1016/j.rmcr.2019.100970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 11/14/2019] [Accepted: 11/14/2019] [Indexed: 11/29/2022] Open
Abstract
Intraoperative tracheobronchial injury (TBI) may manifest clinically as pneumothorax, pneumomediastinum, subcutaneous emphysema, cyanosis, and respiratory insufficiency and has serious implications if it remains undetected or is managed improperly. The outcome of such injuries is affected by the extent of the lesion, pulmonary status & the surgical reconstruction undertaken. The recommended airway management of an intraoperative tracheal tear is to bypass the injured side by intubating the healthy bronchus with a single lumen endotracheal tube (ETT) and the use of a bronchial blocker or double lumen endotracheal tube (DLT) and becomes a very challenging situation. We report successful anaesthetic management of an accidental traumatic rupture of the left main bronchus during surgical dissection in an elderly lady of Carcinoma Oesophagus who underwent a Video Assisted Thoracoscopic surgery (VATS), and was managed by one lung ventilation of the contralateral (right) side manipulating the same DLT and lung protective ventilation.
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Affiliation(s)
- Shivinder Singh
- Department of Anesthesia & Intensive Care, Command Hospital, Chandimandir, 134107, India
| | - Anurag Garg
- Department of Anesthesia & Intensive Care, Command Hospital, Chandimandir, 134107, India
| | - Navdeep Lamba
- Department of Anesthesia & Intensive Care, Command Hospital, Chandimandir, 134107, India
| | - Vishal
- Department of Anesthesia & Intensive Care, Command Hospital, Chandimandir, 134107, India
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Song SH, Lee WH, Chung W, Lee JY, Ann MY. Acute traumatic injury and delayed airway obstruction after the use of a GlideScope in a patient with a difficult airway -A case report-. Anesth Pain Med (Seoul) 2017. [DOI: 10.17085/apm.2017.12.2.187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Seung Hyun Song
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Won Hyung Lee
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - WooSuk Chung
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Ji Yong Lee
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Misun Youn Ann
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea
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Comparing McGRATH® MAC, C-MAC®, and Macintosh Laryngoscopes Operated by Medical Students: A Randomized, Crossover, Manikin Study. BIOMED RESEARCH INTERNATIONAL 2016; 2016:8943931. [PMID: 27703983 PMCID: PMC5040779 DOI: 10.1155/2016/8943931] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 08/16/2016] [Accepted: 08/18/2016] [Indexed: 12/21/2022]
Abstract
We hypothesized that the McGRATH MAC would decrease the time of intubation compared to C-MAC for novices. Thirty-nine medical students who had used the Macintosh blade to intubate a manikin fewer than 3 times were recruited. The participants performed sequential intubations on the manikin in two simulated settings that included a normal airway and a difficult airway (tongue edema). The intubation time, success rate of intubation, Cormack-Lehane grade at laryngoscopy, and difficulty using the device were recorded. Each participant was asked to identify the device that was most useful. The intubation time decreased significantly and by a similar amount to the McGRATH MAC and C-MAC compared to the Macintosh blade (P < 0.001 and P = 0.017, resp.). In the difficult airway, the intubation times were similar among the three devices. The McGRATH MAC and C-MAC significantly increased the success rate of intubation, improved the Cormack-Lehane grade, and decreased the difficulty score compared to the Macintosh blade in both airway settings. The majority of participants selected the McGRATH MAC as the most useful device. The McGRATH MAC and C-MAC may offer similar benefits for intubation compared to the Macintosh blade in normal and difficult airway situations.
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Abstract
The thoracic cavity encompasses three vital organ systems: the lungs with the major airways, the heart with the major blood vessels, and the spinal cord. Therefore, traumatic injury to the thoracic cavity presents a unique clinical challenge to the anesthesiologist. Itstems from the gravity of the patients' situation, the need to rapidly diagnose and treat cardiopulmonary injuries, and to coordinatethese steps with a multidisciplinary trauma team. It is importanttobe well prepared and to review the fundamentals of securing an airway in many different traumatic scenarios. Good communication between team members is the key to a positive outcome. The anesthesiologist, therefore, may play a key role in airway management, diagnosis, respiratory management, and pain management throughout the perioperative continuum of the thoracic trauma patients' care.
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Jones TS, Sullivan A, Damle S, Weyant MJ, Mitchell JD, Weitzel NS, Meguid RA. Assessment and Management of Post-Intubation Airway Injuries. Semin Cardiothorac Vasc Anesth 2016; 21:99-104. [PMID: 27166401 DOI: 10.1177/1089253216647488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Tracheal laceration is a known complication of endotracheal intubation. This rare complication remains a diagnostic and management challenge for today's practitioners. This clinical challenge report highlights current surgical and anesthetic management strategies.
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Affiliation(s)
| | | | - Sagar Damle
- 3 Nebraska Heart Institute, Lincoln, NE, USA
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Hyeon Oh J, Jun Hong S, Soo Kang S, Mi Hwang S. Successful Conservative Management of Tracheal Injury After Forceful Coughing During Extubation: A Case Report. Anesth Pain Med 2016; 6:e39262. [PMID: 27843784 PMCID: PMC5100632 DOI: 10.5812/aapm.39262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 07/04/2016] [Accepted: 07/18/2016] [Indexed: 11/16/2022] Open
Abstract
A-56-year-old woman underwent carpal tunnel release surgery under general anesthesia. Thirty minutes after extubation, the patient complained of chest discomfort with dyspnea. Swelling of the neck and upper anterior chest was observed. Computed tomography of the chest showed tracheal rupture at the brachiocephalic trunk level, and bronchoscopy demonstrated a 5 cm linear tracheal defect in the posterior membranous wall, 6 cm proximal to the carina. Surgical repair of the tracheal injury was impossible due to its location. The patient was managed with intubation, mechanical ventilator care, and antibiotics. She made a full and uncomplicated recovery and was discharged 18 days after the original injury. When suspicious symptoms appear in patients receiving mechanical ventilation support, an immediate and accurate diagnostic process should be undertaken to rule out endotracheal tube-related tracheal injuries and to avoid potentially lethal complications.
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Affiliation(s)
- Joo Hyeon Oh
- Department of Anesthesiology and Pain Medicine, College of Medicine, Hallym University, Seoul, Korea
| | - Sung Jun Hong
- Department of Anesthesiology and Pain Medicine, College of Medicine, Hallym University, Seoul, Korea
| | - Sang Soo Kang
- Department of Anesthesiology and Pain Medicine, College of Medicine, Hallym University, Seoul, Korea
| | - Sung Mi Hwang
- Department of Anesthesiology and Pain Medicine, College of Medicine, Hallym University, Chuncheon, Korea
- Corresponding author: Sung Mi Hwang, Department of Anesthesiology and Pain Medicine, College of Medicine, Hallym University, Chuncheon, Korea. Tel: +82-332405155, Fax: +82-332510941, E-mail:
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Tazi-Mezalek R, Musani AI, Laroumagne S, Astoul PJ, D'Journo XB, Thomas PA, Dutau H. Airway stenting in the management of iatrogenic tracheal injuries: 10-Year experience. Respirology 2016; 21:1452-1458. [PMID: 27439772 DOI: 10.1111/resp.12853] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 05/16/2016] [Accepted: 05/16/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND OBJECTIVE Iatrogenic tracheal injury (ITI) is a rare yet severe complication of endotracheal tube (ETT) placement or tracheostomy. ITI is suspected in patients with clinical and/or radiographic signs or inefficient mechanical ventilation (MV) following these procedures. Bronchoscopy is used to establish a definitive diagnosis. METHODS We conducted a retrospective, single-centre chart review of 35 patients between 2004 and 2014. Depending on the nature and location of ITI and need for MV, patients were triaged to surgical repair, endoscopic management with airway stents or conservative treatment consisting of ETT or tracheotomy cannula (TC) placement distal to the wound and bronchoscopic surveillance. RESULTS Three of the four patients (11.43%) presenting with tracheoesophageal fistula (TEF) underwent surgery. Seven patients (20%) who did not require MV underwent endoscopic surveillance. Of the 24 ventilated patients (68.57%), 7 with ITI in the lower trachea were treated with silicone Y-stent (ETT or TC was placed inside the stent) and 17 patients with ITI in the upper trachea were managed by placing ETT or TC cuff distal to the injury. Overall management success, defined as complete healing of the ITI, was seen in 88.57% of patients. Four patients (11.43%) died of non-ITI-related comorbidities. CONCLUSION Conservative management should be considered in non-ventilated patients with ITI and when ITI is located in the upper trachea of ventilated patients where ETT or TC bypasses the injury. Airway stenting should be considered in ventilated patients with ITI located in the lower trachea. Surgery should be reserved for TEF and conservative and endoscopic management failure.
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Affiliation(s)
- Rachid Tazi-Mezalek
- Thoracic Oncology, Pleural Diseases and Interventional Pulmonology Department, North University Hospital, Marseille, France
| | - Ali I Musani
- Interventional Pulmonology, Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Sophie Laroumagne
- Thoracic Oncology, Pleural Diseases and Interventional Pulmonology Department, North University Hospital, Marseille, France
| | - Philippe J Astoul
- Thoracic Oncology, Pleural Diseases and Interventional Pulmonology Department, North University Hospital, Marseille, France
| | - Xavier B D'Journo
- Department of Thoracic Surgery, North University Hospital, Marseille, France
| | - Pascal A Thomas
- Department of Thoracic Surgery, North University Hospital, Marseille, France
| | - Hervé Dutau
- Thoracic Oncology, Pleural Diseases and Interventional Pulmonology Department, North University Hospital, Marseille, France.
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Iatrogenic injuries to the trachea and main bronchi. POLISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2016; 13:113-6. [PMID: 27516782 PMCID: PMC4971264 DOI: 10.5114/kitp.2016.61043] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Accepted: 05/25/2016] [Indexed: 12/04/2022]
Abstract
Introduction Iatrogenic tracheobronchial injuries are rare. Aim To analyse the mechanism of injury, symptoms and treatment of these patients. Material and methods Retrospective analysis of hospital records of all patients treated for main airway injuries between 1990 and 2012 was performed. Results There were 24 patients, including 21 women and 3 men. Mean time between injury and initiation of treatment was 12 hours (range: 2-48). In 16 patients the injury occurred during tracheal intubation, in 1 during rigid bronchoscopy, in 1 during rigid oesophagoscopy, in 1 during mediastinoscopy and in 5 during open surgery. Mean length of airway tear was 3.8 cm (range: 1.5-8). In 1 patient there was an injury to the cervical trachea and in the remaining 23 in the thoracic part of the airway. The treatment included repair of the membranous part of the trachea performed via right thoracotomy in 10 patients (in 1 patient additionally coverage with a pedicled intercostal muscle flap was used), a self-expanding metallic stent in 1 patient, suture of the right main bronchus and the oesophagus in 1, left upper sleeve lobectomy in 1, right upper lobectomy in 1, implantation of a silicone Y stent in 3, mini-tracheostomy in 1, and conservative treatment in 5 patients. Conclusions Intubation is the most frequent cause of iatrogenic main airway injuries. Patients with these life-threatening complications require an individualised approach and treatment in a reference centre.
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Long B, Koyfman A. Resuscitating the tracheostomy patient in the ED. Am J Emerg Med 2016; 34:1148-55. [PMID: 27073134 DOI: 10.1016/j.ajem.2016.03.049] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 03/18/2016] [Accepted: 03/19/2016] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Emergency physicians must be masters of the airway. The patient with tracheostomy can present with complications, and because of anatomy, airway and resuscitation measures can present several unique challenges. Understanding tracheostomy basics, features, and complications will assist in the emergency medicine management of these patients. OBJECTIVE OF REVIEW The aim of this review is to provide an overview of the basics and features of the tracheostomy, along with an approach to managing tracheostomy complications. DISCUSSION This review provides background on the reasons for tracheostomy placement, basics of tracheostomy, and tracheostomy tube features. Emergency physicians will be faced with complications from these airway devices, including tracheostomy obstruction, decannulation or tube dislodgement, stenosis, tracheoinnominate fistula, and tracheoesophageal fistula. Critical patients should be evaluated in the resuscitation bay, and consultation with ENT should be completed while the patient is in the department. This review provides several algorithms for management of complications. Understanding these complications and an approach to airway management during cardiac arrest resuscitation is essential to optimizing patient care. CONCLUSION Tracheostomy patients can present unique challenges for emergency physicians. Knowledge of the basics and features of tracheostomy tubes can assist physicians in managing life-threatening complications including tube obstruction, decannulation, bleeding, stenosis, and fistula.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, San Antonio Military Medical Center, Houston, TX 78234.
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, TX 75390.
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Warner MA, Fox JF. Direct Laryngoscopy and Endotracheal Intubation Complicated by Anterior Tracheal Laceration Secondary to Protrusion of Preloaded Endotracheal Tube Stylet. ACTA ACUST UNITED AC 2016; 6:77-9. [DOI: 10.1213/xaa.0000000000000235] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Geltner C, Likar R, Hausegger K, Rauter M. Management of Postintubational Tracheal Injury by Endoscopic Stent Placement: Case Report and Review of the Literature. Thorac Cardiovasc Surg Rep 2016; 5:8-12. [PMID: 28018811 PMCID: PMC5177452 DOI: 10.1055/s-0035-1570376] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 11/16/2015] [Indexed: 11/04/2022] Open
Abstract
Endobronchial stent placement is a novel therapy for treatment of iatrogenic tracheal tears. A review of the available literature shows surgery and long-term intubation being the established treatment strategy. We describe the case of a 64-year-old woman with a tracheal rupture following endotracheal intubation for routine surgery. Pneumo-mediastinum and chest pain were the predominant symptoms. She was treated with a covered self-expandable metal stent that closed the tear and led to immediate symptom relief. After six weeks and complete healing of the trachea, the stent could be explanted. No stent complications occurred. A new algorithm for the treatment of these ruptures has been proposed.
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Affiliation(s)
| | - Rudolf Likar
- Anesthesia and Intensive Care, Klinikum Klagenfurt, Klagenfurt, Austria
| | - Klaus Hausegger
- Department of Radiology, Klinikum Klagenfurt, Klagenfurt, Austria
| | - Markus Rauter
- Department of Pulmonology, Klinikum Klagenfurt, Klagenfurt, Austria
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Association of Oversized Tracheal Tubes and Cuff Overinsufflation With Postintubation Tracheal Ruptures. Clin Exp Otorhinolaryngol 2015; 8:409-15. [PMID: 26622963 PMCID: PMC4661260 DOI: 10.3342/ceo.2015.8.4.409] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Revised: 08/16/2014] [Accepted: 09/08/2014] [Indexed: 01/07/2023] Open
Abstract
Objectives Postintubation tracheal ruptures (PTR) are rare but cause severe complications. Our objective was to investigate the tracheal pattern of injury resulting from cuff inflation of the tracheal tube, to study the two main factors responsible for PTR (cuff overinsufflation and inapplicable tube sizes), and to explain the context, why small women are particularly susceptible to PTR. Methods Experimental study performed on 28 fresh human laryngotracheal specimens (16 males, 12 females) within 24 hours post autopsy. Artificial ventilation was simulated by using an underwater construction and a standard tracheal tube. Tube sizes were selected according to our previously published nomogram. Tracheal lesions were detected visually and tracheal diameters measured. The influence of body size, sex difference and appropriate tube size were investigated according to patient height. Results In all 28 cases, the typical tracheal lesion pattern was a longitudinal median rupture of the posterior trachea. Appropriate tube sizes according to body size caused PTR with significantly higher cuff pressure when compared with oversized tubes. An increased risk of PTR was found in shorter patients, when oversized tubes were used. Sex difference did not have any significant influence. Conclusion This experimental model provides information about tracheal patterns in PTR for the first time. The model confirms by experiment the observations of case series in PTR patients, and therefore emphasizes the importance of correct tube size selection according to patient height. This minimizes the risk of PTR, especially in shorter patients, who have an increased risk of PTR when oversized tubes are used.
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Wallace CD, Foulds LT, McLeod GA, Younger RA, McGuire BE. A comparison of the ease of tracheal intubation using a McGrath MAC(®) laryngoscope and a standard Macintosh laryngoscope. Anaesthesia 2015; 70:1281-5. [PMID: 26336853 DOI: 10.1111/anae.13209] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2015] [Indexed: 11/30/2022]
Abstract
We compared the McGrath MAC(®) videolaryngoscope when used as both a direct and an indirect laryngoscope with a standard Macintosh laryngoscope in patients without predictors of a difficult tracheal intubation. We found higher median Intubation Difficulty Scores with the McGrath MAC as a direct laryngoscope, 1 (0-3 [0-5]) than when using it as an indirect videolaryngoscope, 0 (0-1 [0-5]) or when using the Macintosh laryngoscope, 0 (0-1 [0-5]), p = 0.04. This was mirrored in the subjective user reporting, scored out of 10, of difficulty for each method 3.0 (2.0-3.4 [0.5-80]); 2.0 (1.0-3.9 [0-70]) and 2.0 (1.0-3.3 [0-70]), respectively (p = 0.01). This difficulty is in part explained by the poorer laryngeal views recorded using the Cormack and Lehane classification system (p < 0.001) and reflected in the higher than normal operator force required (25%, 4%, 8% for each method, respectively, p < 0.001) and the increased use of rigid intubation aids (21%, 6%, 2%, respectively, p < 0.001). There was no difference between the groups in time taken to intubate or incidence of complications. There was no statistical difference in the performances as measured between the McGrath MAC used as an indirect videolaryngoscope and the Macintosh laryngoscope. We cannot recommend that the McGrath videolaryngoscope be used as a direct laryngscopic device in place of the Macintosh.
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Affiliation(s)
- C D Wallace
- Department of Anaesthetics, Ninewells Hospital, Dundee, UK
| | - L T Foulds
- Department of Anaesthetics, Ninewells Hospital, Dundee, UK
| | - G A McLeod
- Institute of Academic Anaesthesia, University of Dundee, Dundee, UK
| | - R A Younger
- Department of Anaesthetics, Perth Royal Infirmary, Perth, UK
| | - B E McGuire
- Department of Anaesthetics, Ninewells Hospital, Dundee, UK
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Chamberlain S, Rahman H, Frunza G, Wickham A. Massive surgical emphysema secondary to iatrogenic tracheal laceration. BMJ Case Rep 2015; 2015:bcr-2014-207621. [PMID: 25750221 DOI: 10.1136/bcr-2014-207621] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 78-year-old woman was admitted for a revision total hip replacement following a failed dynamic hip screw placed emergently 4 months earlier. Anaesthetic management consisted of general anaesthesia with endotracheal intubation and femoral nerve block. The patient's perioperative course was unremarkable except for a promptly recognised and corrected oesophageal intubation and a short period of breathing against a closed adjustable pressure limiting valve. In recovery, following a period of hypotension resistant to fluid therapy, she suddenly desaturated, developed severe facial and upper thoracic subcutaneous emphysema and type 2 respiratory failure. She was diagnosed with bilateral pneumothoraces, pneumomediastinum, pneumopericardium and surgical emphysema. This was treated emergently with supplemental oxygen and bilateral chest drains. A CT scan demonstrated a tracheal laceration, which was managed conservatively in the critical care unit. The patient had a tracheostomy on day 5 to treat an on-going air leak and later made a full recovery.
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Affiliation(s)
| | - Habib Rahman
- Department of Medicine, St Mary's Hospital, London, UK
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Bouattour K, Prost-Lapeyre A, Hauw-Berlemont C, Diehl JL, Guérot E. [A post-intubation tracheal rupture in intensive care unit]. ACTA ACUST UNITED AC 2014; 33:590-2. [PMID: 25450732 DOI: 10.1016/j.annfar.2014.09.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 09/08/2014] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Tracheal rupture is one of the most serious post-intubation complication. However, it is widely underestimated. CLINICAL CASE An 86-year-old patient with a history of pancreas adenocarcinoma treated with gemcitabin was admitted in intensive care unit for an acute respiratory failure with no identified etiology. The worsening of her respiratory status required invasive mechanical ventilation. One laryngoscopy, performed by a trained operator, found a Cormack 1. Intubation was realized without stylet and the cuff inflated with a syringe. Hemodynamic instability, impaired gas exchange and an extensive subcutaneous emphysema occurred immediately. A CT-scan showed a supracarinal tracheal rupture. COMMENT The etiological analysis of this case identifies several causes of pars membranosa fragility, such as female sex, age greater than 50 years and the short stature. The emergency intubation and the cuff inflated by a syringe were the risk factors of tracheal rupture in this patient. CONCLUSION Special care should be paid to this complication, early diagnosis has probably a prognostic value. Training operators in the use of stylets and monitoring cuff pressure are required.
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Affiliation(s)
- K Bouattour
- Service de réanimation médicale, hôpital européen Georges-Pompidou, Assistance publique-Hôpitaux de Paris, 20, rue Leblanc, 75908 Paris cedex 15, France; Faculté de médecine, université Paris-Descartes, 75006 Paris, France
| | - A Prost-Lapeyre
- Service de réanimation médicale, hôpital européen Georges-Pompidou, Assistance publique-Hôpitaux de Paris, 20, rue Leblanc, 75908 Paris cedex 15, France; Faculté de médecine, université Paris-Descartes, 75006 Paris, France
| | - C Hauw-Berlemont
- Service de réanimation médicale, hôpital européen Georges-Pompidou, Assistance publique-Hôpitaux de Paris, 20, rue Leblanc, 75908 Paris cedex 15, France; Faculté de médecine, université Paris-Descartes, 75006 Paris, France
| | - J-L Diehl
- Service de réanimation médicale, hôpital européen Georges-Pompidou, Assistance publique-Hôpitaux de Paris, 20, rue Leblanc, 75908 Paris cedex 15, France; Faculté de médecine, université Paris-Descartes, 75006 Paris, France
| | - E Guérot
- Service de réanimation médicale, hôpital européen Georges-Pompidou, Assistance publique-Hôpitaux de Paris, 20, rue Leblanc, 75908 Paris cedex 15, France; Faculté de médecine, université Paris-Descartes, 75006 Paris, France.
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20
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Xu X, Xing N, Chang Y, Du Y, Li Z, Wang Z, Yan J, Zhang W. Tracheal rupture related to endotracheal intubation after thyroid surgery: a case report and systematic review. Int Wound J 2014; 13:268-71. [PMID: 24871935 DOI: 10.1111/iwj.12291] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 03/31/2014] [Indexed: 11/28/2022] Open
Abstract
Tracheobronchial rupture is an uncommon but potentially serious complication of endotracheal intubation. The most likely cause of tracheal injury is massive overinflation of the endotracheal tube cuff and pre-existing tracheal wall weakness. We review the relevant literature and predisposing factors contributing to this complication. Only articles that reported at least the demographic data (age and sex), the treatment performed and the outcome were included. Papers that did not detail these variables were excluded. We also focus on a case of tracheal laceration after tracheal intubation in a patient with severe thyroid carcinoma. This patient received surgical repair and recovered uneventfully. Two hundred and eight studies that reported cases or case series were selected for analysis. Most of the reported cases (57·2%) showed an uneventful recovery after surgical therapy. The overall mortality was 19·2% (40 patients). Our patient too recovered without any serious complication. Careful prevention, early detection and proper treatment of the problem are necessary when tracheal rupture occurs. The morbidity and mortality associated with tracheal injury mandate a high level of suspicion and expedient management.
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Affiliation(s)
- Xiaohan Xu
- Department of Anesthesiology, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Na Xing
- Department of Anesthesiology, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Yanzi Chang
- Department of Anesthesiology, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Yingying Du
- Department of Anesthesiology, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Zhisong Li
- Department of Anesthesiology, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Zhongyu Wang
- Department of Anesthesiology, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Jie Yan
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Wei Zhang
- Department of Anesthesiology, The First Affiliated Hospital of Zhengzhou University, Henan, China
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21
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Arthur ME, Odo N, Parker W, Weinberger PM, Patel VS. CASE 9--2014: Supracarinal tracheal tear after atraumatic endotracheal intubation: anesthetic considerations for surgical repair. J Cardiothorac Vasc Anesth 2014; 28:1137-45. [PMID: 24439170 DOI: 10.1053/j.jvca.2013.08.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2013] [Indexed: 12/27/2022]
Affiliation(s)
- Mary E Arthur
- Departments of Anesthesiology and Perioperative Medicine.
| | - Nadine Odo
- Departments of Anesthesiology and Perioperative Medicine
| | | | | | - Vijay S Patel
- Surgery, Medical College of Georgia, Georgia Regents University, Augusta, GA
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22
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False passage to the trachea after emergency intubation in a victim of near hanging. Case Rep Emerg Med 2013; 2013:281307. [PMID: 23762656 PMCID: PMC3666308 DOI: 10.1155/2013/281307] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2013] [Accepted: 04/23/2013] [Indexed: 12/18/2022] Open
Abstract
Emergency medicine physicians should have enough knowledge and experience to deal with emergent and traumatic difficult airway. In this paper, we present a case of near hanging with neck soft tissue injury, tracheal and esophageal rupture that is complicated by a displaced intubation and false passage to the trachea.
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23
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Cook T, MacDougall-Davis S. Complications and failure of airway management. Br J Anaesth 2012; 109 Suppl 1:i68-i85. [DOI: 10.1093/bja/aes393] [Citation(s) in RCA: 269] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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Abstract
Although disposable double-lumen tubes have been used for many years, there is still controversy regarding what size and which side to use for thoracic procedures requiring lung isolation. Thoracic and nonthoracic anesthesiologists often debate performance, efficiency, and outcome of small and large double-lumen tubes, and left- and right-sided tubes. This article focuses on current data in the literature and expert opinion on the topic.
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Affiliation(s)
- Alessia Pedoto
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA.
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25
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Yamamoto S, Endo S, Endo T, Mitsuda S. Successful silicon stent for life-threatening tracheal wall laceration. Ann Thorac Cardiovasc Surg 2012; 19:49-51. [PMID: 22785447 DOI: 10.5761/atcs.cr.11.01768] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We report an 86-year-old woman with a large tracheal laceration caused by tracheal intubation at cardiopulmonary arrest who underwent a successful stent procedure. Tracheal laceration developed in the membranous portion longitudinally 6 cm in length to 2 cm above the carina. Following 9 days' tracheal intubation, a Y-shaped silicon stent was inserted over the lacerated trachea. Four months after the stenting procedure, we removed the Y-shaped silicon stent from the healed membranous wall. The patient returned to daily life without requiring thoracotomy.
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Affiliation(s)
- Shinichi Yamamoto
- Department of General Thoracic Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan.
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26
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Iatrogenic tracheal flap mimicking tracheal stenosis with resultant stridor. The Journal of Laryngology & Otology 2012; 126:751-5. [DOI: 10.1017/s0022215112000795] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractObjective:To illustrate a case of an iatrogenic mucosal tear in the trachea which caused a one-way valve effect, obstructing the airway and manifesting as post-extubation stridor.Case report:We report a case of iatrogenic tracheal mucosal tear secondary to violent movement during intubation. The patient presented with post-extubation stridor that worsened over three days. Initial evidence suggested tracheal stenosis. Computed tomography scans revealed a mucosal tear at the level of the seventh cervical to second thoracic vertebrae. The tear was caused by forceful inflow of air as breathing became more and more difficult, resulting in a false tract. A tracheostomy changed the direction of airflow, bypassing the tear. The inflated tracheostomy tube cuff acted as a stent to keep the flap in place as healing occurred.Conclusion:Iatrogenic laryngotracheal injuries are common, especially when endotracheal intubation is performed under unfavourable emergency conditions. A tracheal mucosal tear is a rare entity which is almost always undiagnosed. However, a tracheal mucosal flap may be suspected when changes in patient position alter the nature and severity of the resultant stridor and/or respiratory distress. In such cases, an inflated tracheostomy tube cuff should be kept in place for an adequate period, to act as a stent and help keep the flap in place while healing occurs.
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27
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Lim H, Kim JH, Kim D, Lee J, Son JS, Kim DC, Ko S. Tracheal rupture after endotracheal intubation - A report of three cases -. Korean J Anesthesiol 2012; 62:277-80. [PMID: 22474557 PMCID: PMC3315660 DOI: 10.4097/kjae.2012.62.3.277] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Revised: 07/23/2011] [Accepted: 07/27/2011] [Indexed: 11/10/2022] Open
Abstract
Tracheal rupture is a rare but serious complication that occurs after endotracheal intubation. It usually presents as a linear lesion in the membranous wall of the trachea, and is more prevalent in women and patients older than 50 years. The clinical manifestations of tracheal injury include subcutaneous emphysema and respiratory distress. We report the cases of three female patients of old age presenting tracheal rupture after endotracheal intubation. Two cases received surgical repair without complication and one recovered uneventfully after conservative management. We presume that the tracheal injuries were caused by over-inflation of cuff and sudden movement of the tube by positional change. Therefore, we recommend cuff pressure monitoring during general anesthesia and minimized movement of the head and neck at positional change.
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Affiliation(s)
- Hyungsun Lim
- Department of Anesthesiology and Pain Medicine, Chonbuk National University Medical School, Jeonju, Korea
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28
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Kim KH, Kim MH, Choi JB, Kuh JH, Jo JK, Park HK. Postintubation Tracheal Ruptures - A case report -. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2012; 44:260-5. [PMID: 22263165 PMCID: PMC3249316 DOI: 10.5090/kjtcs.2011.44.3.260] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/22/2010] [Revised: 12/31/2010] [Accepted: 05/10/2011] [Indexed: 11/17/2022]
Abstract
Tracheobronchial ruptures (TBR) rarely complicate surgical procedures under general anesthesia. Seemingly uneventful intubations can result in injury to the trachea, which often manifests as hemoptysis and subcutaneous emphysema. We present 2 patients with postintubation TBR who were treated surgically and discuss considerations in the management of this potentially lethal injury.
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Affiliation(s)
- Kyung Hwa Kim
- Department of Thoracic and Cardiovascular Surgery, Chonbuk National University Hospital, Chonbuk National University Medical School, Korea
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29
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Abstract
Tracheal injuries are altogether rare events and can be divided into three broad categories: tracheobronchial injuries caused by external violence, iatrogenic ruptures of the trachea and inhalation trauma. Successful management of tracheobronchial injuries requires a fast and straightforward diagnostic evaluation. In all severely injured patients with cervicothoracic involvement an injury of the tracheobronchial system should be actively excluded. Although it is commonly agreed that posttraumatic injuries require surgical intervention the management of iatrogenic injuries is presently shifting towards a more conservative treatment.
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Affiliation(s)
- E Palade
- Abt. für Thoraxchirurgie, Universitätsklinikum Freiburg, Deutschland
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30
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Kim J, Lim T, Bahk JH. Tracheal laceration during intubation of a double-lumen tube and intraoperative fiberoptic bronchoscopic evaluation through an LMA in the lateral position -A case report-. Korean J Anesthesiol 2011; 60:285-9. [PMID: 21602980 PMCID: PMC3092965 DOI: 10.4097/kjae.2011.60.4.285] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2010] [Revised: 10/06/2010] [Accepted: 10/08/2010] [Indexed: 11/10/2022] Open
Abstract
A 76-year-old, 148-cm woman was scheduled for right upper lobectomy. A 32 Fr left-sided double lumen tube was placed using a conventional technique. Despite several attempts under fiberoptic bronchoscope-guidance, we could not locate the double lumen tube properly. We thus decided to proceed with the bronchial tube in the right mainstem bronchus. During surgery, 8-cm-long laceration was noted on the posterolateral side of the trachea. To check the possibility of laceration of the proximal trachea, the double lumen tube was changed to an LMA for use as a conduit for fiberoptic bronchoscopic evaluation in the lateral position. A plain endotracheal tube with the cuff modified and collapsed was re-intubated after evaluation. And then she was transferred to SICU.
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Affiliation(s)
- Joohee Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
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31
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Danguy des Déserts M, Commandeur D, Fourel D. Intubation difficile préhospitalière compliquée d’une rupture trachéale. ANNALES FRANCAISES DE MEDECINE D URGENCE 2011. [DOI: 10.1007/s13341-011-0040-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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32
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Welter S, Krbek T, Halder R, Stamatis G. A new technique for complete intraluminal repair of iatrogenic posterior tracheal lacerations. Interact Cardiovasc Thorac Surg 2010; 12:6-9. [PMID: 20921002 DOI: 10.1510/icvts.2010.248641] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Tracheal laceration is a rare complication of endotracheal intubation. Early surgical treatment is mandatory in cases of pneumomediastinum with difficulty in ventilation to prevent mediastinitis and stricture. Surgical access to the posterior tracheal wall is via a right posterolateral thoracotomy, transcervical tracheotomy or tracheostomy, each of which is associated with specific morbidities. We developed a new optical needle holder consisting of a 12° HOPKINS telescope in a fixed attachment with an endoscopic needle holder to allow for complete intraluminal repair of posterior tracheal wall lacerations. Four patients were admitted with an iatrogenic tracheal laceration due to emergency intubation. In all cases, the repair of the tracheal laceration started with the introduction of a 14-mm rigid tracheoscope and subsequent jet-ventilation. Three of the tears were successfully repaired endotracheally with a running suture. In one case, the repair had to be converted to an open closure via posterolateral thoracotomy. Two patients were discharged extubated for further treatment of their underlying diseases. One patient died from a third cardiac infarction two days after the tracheal repair. We think that an exclusively endoluminal repair of longitudinal tracheal lacerations is feasible. This repair has convincing advantages including little surgical trauma, lack of scars and diminished postoperative pain.
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Affiliation(s)
- Stefan Welter
- Department of Thoracic Surgery, Ruhrlandklinik Essen, Tüschener Weg 40, 45239 Essen, Germany.
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33
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Kaslow O, Holak EJ, Owen HL, Woosencraft D, Tisol WB, Pagel PS. Anterior Chest Discomfort and Right Neck Pain in a Young Woman 2 Days After an Appendectomy. J Cardiothorac Vasc Anesth 2010; 24:519-22. [DOI: 10.1053/j.jvca.2009.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2009] [Indexed: 11/11/2022]
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34
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Maassen R, Lee R, Hermans B, Marcus M, van Zundert A. A Comparison of Three Videolaryngoscopes: The Macintosh Laryngoscope Blade Reduces, but Does Not Replace, Routine Stylet Use for Intubation in Morbidly Obese Patients. Anesth Analg 2009; 109:1560-5. [DOI: 10.1213/ane.0b013e3181b7303a] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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35
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Lin YT, Zuo Z, Lo PH, Hseu SS, Chang WK, Chan KH, Yuan HB. Bilateral tension pneumothorax and tension pneumoperitoneum secondary to tracheal tear in a patient with relapsing polychondritis. J Chin Med Assoc 2009; 72:488-91. [PMID: 19762318 DOI: 10.1016/s1726-4901(09)70413-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Relapsing polychondritis (RP) is a rare disease that is characterized by recurrent inflammation and destruction of cartilage and connective tissues. RP can have significant airway pathology that may require procedures to maintain airway patency and thus may have serious implications for anesthesiologists. Anesthesiologists must be prepared to deal with the possible complications that may occur during airway manipulation in patients with RP. Here, we present a case of life-threatening bilateral tension pneumothorax and tension pneumoperitoneum that developed after a tracheal tear during Montgomery T-tube insertion in a patient with tracheal stenosis due to RP. Correct diagnosis was delayed due to a misdiagnosis of airway obstruction. As a result, we emphasize that bilateral tension pneumothorax should be considered during refractory cardiac arrest in patients with increased airway pressure. A high index of suspicion and adequate management are mandatory for patients to survive these life-threatening complications.
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Affiliation(s)
- Yu-Ting Lin
- Department of Anesthesiology, Taipei Veterans General Hospital and National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC
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36
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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. [DOI: 10.1016/j.ejcts.2009.01.053] [Citation(s) in RCA: 130] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2008] [Revised: 01/15/2009] [Accepted: 01/22/2009] [Indexed: 10/20/2022] Open
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37
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Chen KT, Lee SC, Ko TL, Wang KC, Chang Y. Tracheal Ring Fracture as a Consequence of External Laryngeal Manipulation During Endotracheal Intubation. ACTA ACUST UNITED AC 2009; 47:103-5. [DOI: 10.1016/s1875-4597(09)60034-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Alagöz A, Ulus F, Sazak H, Camdal A, Savkilioglu E. Two cases of tracheal rupture after endotracheal intubation. J Cardiothorac Vasc Anesth 2008; 23:271-2. [PMID: 18834781 DOI: 10.1053/j.jvca.2007.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2007] [Indexed: 11/11/2022]
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40
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Pazanin L, Misak VB, Goreta N, Mareković Z, Petrovecki V. Iatrogenic tracheal laceration causing asphyxia. J Forensic Sci 2008; 53:1185-7. [PMID: 18643864 DOI: 10.1111/j.1556-4029.2008.00827.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Endotracheal intubation is a simple, rapid, and safe technique that is being used as a standard procedure for airway management. However, airway injury during endotracheal intubation could be a significant source of morbidity or even mortality for patients and a source of liability for physicians as well. We report an unusual case of fatal tracheal occlusion by intraluminal blood clot complicating endotracheal intubation. The patient, a 62-year-old woman, with renovascular hypertension and incipient renal failure was scheduled for renal autotransplantation. The surgery was uneventful but the postoperative course was complicated with a lethal airway obstruction. At autopsy a linear longitudinal tracheal laceration was identified with an intraluminal blood clot obstructing the tracheal lumen. Tracheal laceration as a cause of death is a rare and potentially fatal complication of endotracheal intubation with intratracheal bleeding, clot formation, tracheal occlusion, and subsequent asphyxia.
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Affiliation(s)
- Leo Pazanin
- Department of Neuropathology, Clinical Hospital Center Zagreb, Zagreb, Croatia.
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41
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Harney TJ, Condon ET, Lowe D, McAnena OJ. A novel technique for repair of iatrogenic tracheal tear complicating three-stage oesophagectomy. Ir J Med Sci 2008; 178:337-8. [DOI: 10.1007/s11845-008-0169-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2008] [Accepted: 04/23/2008] [Indexed: 10/21/2022]
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Barbetakis N, Samanidis G, Paliouras D, Tsilikas C. Tracheal laceration following double-lumen intubation during Ivor Lewis esophagogastrectomy. Interact Cardiovasc Thorac Surg 2008; 7:866-8. [PMID: 18577528 DOI: 10.1510/icvts.2007.172387] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A case of a 48-year-old man with an iatrogenic membranous tracheal wall rupture after double-lumen intubation during Ivor Lewis esophagogastrectomy is presented. Tracheal injury was successfully managed surgically with the use of a bovine pericardial patch and reinforcement with the gastric conduit which was moved toward the posterior wall of the membranous trachea sealing the wall laceration.
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Affiliation(s)
- Nikolaos Barbetakis
- Department of Thoracic Surgery, Theagenio Cancer Hospital, Thessaloniki, Greece.
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Barbetakis N, Samanidis G, Paliouras D, Lafaras C, Bischiniotis T, Tsilikas C. Intraoperative tracheal reconstruction with bovine pericardial patch following iatrogenic rupture. Patient Saf Surg 2008; 2:4. [PMID: 18289384 PMCID: PMC2267446 DOI: 10.1186/1754-9493-2-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2007] [Accepted: 02/20/2008] [Indexed: 12/13/2022] Open
Abstract
Introduction Iatrogenic injuries of the membranous trachea have become increasingly common and may trigger a cascade of immediate life-threatening complications. Case presentation A case of a 48-year-old man with an iatrogenic membranous tracheal wall rupture after double-lumen intubation during Ivor Lewis esophagogastrectomy is presented. Tracheal injury was successfully managed surgically with the use of bovine pericardial patch and reinforcement with the gastric conduit which was moved toward the posterior wall of the membranous trachea sealing the wall laceration. Conclusion Our technique was proved to be safe, effective and not technically demanding. Early recognition with prompt surgery is the gold standard of managing such cases, although small tears can be managed conservatively.
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Affiliation(s)
- Nikolaos Barbetakis
- Thoracic Surgery Department, Theagenio Cancer Hospital, A, Simeonidi 2, Thessaloniki, 54007, Greece.
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Yopp AC, Eckstein JG, Savel RH, Abrol S. Tracheal Stenting of Iatrogenic Tracheal Injury: A Novel Management Approach. Ann Thorac Surg 2007; 83:1897-9. [PMID: 17462432 DOI: 10.1016/j.athoracsur.2006.12.040] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2006] [Revised: 12/03/2006] [Accepted: 12/13/2006] [Indexed: 10/23/2022]
Abstract
We report the case of a patient who had an intubation-related tracheal injury who we treated by deployment of a covered tracheal stent. This approach may be preferable to other alternatives in patients with a prohibitive risk of mortality with surgical repair or in an injury with sequelae not suitable for conservative management.
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Affiliation(s)
- Adam C Yopp
- Department of Surgery, Division of Cardiothoracic Surgery, Maimonides Medical Center, Brooklyn, New York 11219, USA.
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Kaneko Y, Nakazawa K, Yokoyama K, Ishikawa S, Uchida T, Takahashi M, Tsunoda A, Makita K. Subcutaneous emphysema and pneumomediastinum after translaryngeal intubation: tracheal perforation due to unsuccessful fiberoptic tracheal intubation. J Clin Anesth 2006; 18:135-7. [PMID: 16563333 DOI: 10.1016/j.jclinane.2005.10.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2004] [Accepted: 10/31/2005] [Indexed: 12/19/2022]
Abstract
A 77-year-old man was scheduled to undergo a cervical lymph node biopsy under general anesthesia. Although awake, nasotracheal fiberoptic intubation was initially planned because of an anticipated difficult airway, the attempt was unsuccessful. Orotracheal intubation was subsequently performed under direct laryngoscopy without difficulty. After initiating positive pressure mechanical ventilation, subcutaneous and mediastinal emphysema developed. The cause of this emphysema was considered to be tracheal perforation after an unsuccessful attempt at fiberoptic tracheal intubation.
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Affiliation(s)
- Yuko Kaneko
- Department of Anesthesiology and Critical Care Medicine, Tokyo Medical and Dental University, Tokyo 1138519, Japan
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Saravanan P, Marnane C, Morris EAJ. Extubation of the surgically resected airway — a role for remifentanil and propofol infusions. Can J Anaesth 2006; 53:507-11. [PMID: 16636037 DOI: 10.1007/bf03022625] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE To report the use of propofol and remifentanil infusions to facilitate smooth extubation of a surgically resected airway. CLINICAL FEATURES A 19-yr-old man weighing 85 kg was scheduled for tracheal resection surgery following postintubation tracheal stenosis. He had a relatively long segment (4 cm) of his trachea resected and anastomosed. Postoperatively, he was sedated and electively ventilated for four days in a chin to chest position by stay sutures. In order to reduce any risk of traumatic disruption to the tracheal anastomosis, we planned to extubate his trachea under light general anesthesia. Attempts to extubate his trachea using propofol and alfentanil infusions failed. We used propofol and remifentanil infusions to achieve a state of sedate cooperation and extubated his trachea with fibreoptic bronchoscope guidance. CONCLUSION Propofol and remifentanil infusions in combination can facilitate successful extubation of the surgically resected airway with high risk of disruption.
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Daniel SR, Morita SY, Yu M, Dzierba A. Uncompensated Metabolic Acidosis: An Underrecognized Risk Factor for Subsequent Intubation Requirement. ACTA ACUST UNITED AC 2004; 57:993-7. [PMID: 15580022 DOI: 10.1097/01.ta.0000114636.49433.7a] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND There are no published reports identifying an inadequate ventilatory response to metabolic acidosis as a predictor of impending respiratory failure. Metabolic acidosis should induce a respiratory alkalosis in which the partial pressure of carbon dioxide (Paco2) is (1.5 [HCO3-] + 8) +/- 2. This study examined the relation between inadequate ventilatory compensation and intubation among trauma patients. METHODS A retrospective chart review was performed for trauma patients admitted between January 1999 and December 2000. Age, gender, Injury Severity Score and combined Trauma and Injury Severity Score, chest injury, history of cardiac or pulmonary disease, partial pressure of oxygen (Pao2), Paco2, Glasgow Coma Score, respiratory rate, systolic blood pressure, base deficit, and ability to compensate were analyzed with respect to intubation and need for ventilator support. RESULTS Of 140 patients with metabolic acidosis, 45 ultimately were intubated. The mean Paco2 for the unintubated patients was 34 +/- 7 mm Hg, as compared with 41 +/- 11 mm Hg for the intubated patients (p < 0.001). Only injury severity and ability to compensate for metabolic acidosis were independent predictors of intubation. Patients with inadequate compensation were 4.2 times more likely to require intubation when control was used for the Injury Severity Score (95% confidence interval, 1.8-9.7; p < 0.001). CONCLUSIONS Inability to mount an adequate hyperventilatory response to metabolic acidosis is associated with an increased likelihood of respiratory failure and a need for ventilatory support. Recognition of this relation should lead to closer monitoring of patients with this condition, and could help to avert unforeseen crisis intubations. This observation needs to be validated in a prospective study.
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Affiliation(s)
- Subashini R Daniel
- University of Hawaii School of Medicine, Department of Surgery, Honolulu, Hawaii 96813, USA
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Abstract
We describe a case of tracheal rupture diagnosed after an apparently routine endotracheal intubation for otherwise uneventful lower abdominal surgery in a 33-year-old woman. Risk factors for tracheal rupture, presenting symptoms and signs, management of tracheal rupture and methods of airway management during the surgical repair of the tracheal laceration are discussed. In this case, "side-by-side" microlaryngoscopy tubes, one endobronchial and the other with the tip in the upper trachea, placed with fibreoptic assistance were used for airway management during the tracheal repair.
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Affiliation(s)
- K Stannard
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Wellington Campus, GPO Box X2213, Perth, W.A. 6847
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Liu H, Jahr JS, Sullivan E, Waters PF. Tracheobronchial rupture after double-lumen endotracheal intubation. J Cardiothorac Vasc Anesth 2004; 18:228-33. [PMID: 15073718 DOI: 10.1053/j.jvca.2004.01.003] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Hong Liu
- Department of Anesthesiology and Pain Medicine, University of California, Davis, Sacramento, CA 95817, USA.
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