Tracheal laceration is a rare but potentially devastating complication of endotracheal intubation. History of trauma or difficulty during intubation in combination with the clinical findings of hemoptysis, subcutaneous emphysema, and new stridor may lead towards the diagnosis of tracheal injury. Traditional treatment has been surgical repair, however a non-operative approach is appropriate under certain conditions.
A 19-year-old female presented to an outpatient facility for an elective abortion. During the dilation and curettage the patient received intracervical injection of .25% marcaine and 2 units of vasopressin. Following the procedure the patient became dyspneic and was given metaproterenol without relief. Progressive respiratory distress ensued with subsequent respiratory and cardiac arrest. CPR was initiated and subcutaneous epinephrine was administered for anaphylaxis. The patient was ventilated using bag-mask ventilation only. Spontaneous cardiac activity returned and the patient continued to be ventilated utilizing bag-mask ventilation. Orotracheal intubation was then attempted unsuccessfully. Oxygenation became suboptimal and a combitube was placed with improvements in oxygenation. Following transport to the emergency department, physical exam revealed diminished breath sounds on the left side. A chest x-ray confirmed right main stem intubation therefore a 7.0 endotracheal tube was placed with appropriate positioning and improvements in oxygentation. The patient was then transferred to the MICU. Physical exam revealed subcutaneous emphysema at the neck anteriorly and bilateral breath sounds. Fiberoptic evaluation was performed to evaluate for airway trauma. This revealed a 2.5 x 1.0 x 0.5 cm laceration in the posterior membranous portion of the trachea extending to the carina. Following evaluation by thoracic surgery it was determined that operative repair of the trachea was not indicated. Subsequently, the patient underwent nasopharyngoscopy as well as gastrograffin swallow, both of which were normal. Ampicillin/sulbactam was started due to a concern for mediastinitis. Bronchoscopy performed on hospital day two revealed no extension of tracheal laceration or glottic edema and the patient was extubated without complications. Over the ensuing four months the patient underwent fiberoptic bronchoscopy three additional times that confirmed complete wound healing.
Tracheal laceration has traditionally been managed surgically, however non-operative management of tracheal laceration has been described. The patient should exhibit hemodynamic stability without difficulty in ventilation. Furthermore, there should be no evidence of esophageal injury, mediastinitis or progressive pneumomediastinum.1 Conditions which may actually favor non-operative management include chronic corticosteroid use, potential surgical traumitization and old age.2 Transmural lacerations or tears involving the paracarinal region have generally been surgically repaired, and surgical repair of lacerations greater than two cm has been advocated although not uniformly.3 Placement of the endotracheal tube distal to the tear appears to be agreed upon as well as early extubation, if possible. No consensus of single or double-lumen endotracheal tubes exists. Further characterization of the extent of injury is important and includes evaluation for esophageal leak and progressive pneumomediastinum. Additional recommendations include the use of liberal sedation and/or paralysis to prevent coughing and low-pressure ventilation as well as the use of prophylactic antibiotics to prevent the development of mediastinitis.
Tracheal laceration can be managed in a non-operative manner in carefully selected cases. Systematic evaluation may allow for appropriate patient selection. Non-operative management in these cases may optimize patient outcome.
J.P. Gagermeier, None.