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Abstract
Introduction
Case Report
Discussion
Conclusion
References
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  Table of Contents 
CASE REPORT
Year : 2017  |  Volume : 18  |  Issue : 1  |  Page : 14-18
 

Iatrogenic tracheal rent: When oxygen supply was cut off by the surgeon!


Department of Anaesthesia, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India

Date of Web Publication27-Jun-2017

Correspondence Address:
Shagun Bhatia Shah
H. No: 174-175, Ground Floor, Pocket-17, Sector-24, Rohini, New Delhi - 110 085
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_27_16

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  Abstract 

Airways of postradiotherapy and postchemotherapy female oncosurgical patients on steroid therapy are devitalized and any airway handling in such patients commands caution. We report a case of a large iatrogenic tracheal rent occurring during manipulation of a flexometallic tube through a tracheostomy stoma created in a patient with postcricoid carcinoma undergoing esophagectomy and gastric pull-up surgery. The timely detection, emergent, and postoperative management strategies are discussed below.


Keywords: Esophagectomy, iatrogenic tracheal rent, postcricoid cancer, tracheostomy, ventilatory management


How to cite this article:
Shah SB, Chowdhury I, Pathak S, Bhargava AK. Iatrogenic tracheal rent: When oxygen supply was cut off by the surgeon!. Indian Anaesth Forum 2017;18:14-8

How to cite this URL:
Shah SB, Chowdhury I, Pathak S, Bhargava AK. Iatrogenic tracheal rent: When oxygen supply was cut off by the surgeon!. Indian Anaesth Forum [serial online] 2017 [cited 2019 Nov 21];18:14-8. Available from: http://www.theiaforum.org/text.asp?2017/18/1/14/208964



  Introduction Top


Any breach in tracheal integrity jeopardizes life. Esophagus forms a close posterior relation of the trachea and esophagectomy with gastric pull-up makes the trachea vulnerable to injury, especially if the trachea is already devitalized with a postcricoid tumor and radiotherapy.[1],[2],[3] Eternal vigilance and preparedness for this rare but fatal complication can be life-saving.[1],[4] We discuss below the sequence of events leading to the occurrence, timely diagnosis, and efficient management of an inadvertent tracheal tear which complicated an esophagectomy for a postcricoid carcinoma.


  Case Report Top


Our patient was a 40-year-old woman who presented with progressive breathing difficulty. In spite of receiving hydrocortisone 100 mg, dexamethasone 8 mg thrice daily, and bronchodilators, bilateral rhonchi were audible on chest auscultation. Her computed tomography scan revealed squamous cell carcinoma postcricoid region. She had undergone chemotherapy, radiotherapy, and esophageal dilatation (6 days back) for the same and was now posted for wide local excision of the growth and esophagectomy with gastric pull-up surgery. An intravenous line was secured with a 16-gauge cannula, nebulization with 5 ml 4% lignocaine for 20 min, and premedication with 1 mg midazolam and 0.2 mg glycopyrrolate were administered. A size 7 portex-cuffed nasotracheal tube presoftened by immersing in hot water was passed through the right nostril after adequate preparation of nostril with xylometazoline nasal drops. The tube was negotiated through the narrowed carcinomatous cricoid zone and guided into the trachea fiberoptic bronchoscopically. Fentanyl 100 μg and propofol 70 mg were injected intravenously after auscultatory and capnographic confirmation of endotracheal tube (ETT) placement. Vecuronium 5 mg and morphine 6 mg were also injected. Volume-controlled ventilation mode was selected in Drager Primus workstation, and a cutoff pressure of 30 mmHg was set. After excision of the postcricoid tumor which took about an hour, the patient was tracheostomized with a size 7 flexometallic-cuffed ETT (FMCETT) secured in place with silk sutures. The gastric pull-up surgery proceeded uneventfully through the abdominal incision for another 2 h [Figure 1]. After esophagectomy, laryngectomy, gastric pull-up and anastomosis, the midline skin incision, and flap lifted in the neck for excision of postcricoid tumor were closed leaving the skin in the midline around the FMCETT to be sutured and fashioned into a skin stoma for the tracheostomy tube. Removal and reinsertion of the FMCETT through the stoma were done by the surgeons while suturing the edges of the skin to the tracheostomy opening on the anterior surface of the trachea (airway manipulation for the third time during this surgery) after which there was sudden inability to ventilate the lungs. There was no chest rise, and a flat line appeared in place of the ETCO2 curve. Manual ventilation was attempted, but there was no chest rise even with extremely high peak (45 mmHg) and plateau pressures. The breathing circuit was disconnected, and an Ambu bag was used. Still, we were unable to ventilate the patient. The arterial blood oxygen saturation (SPO2) rapidly fell to 85%. The FMCETT was replaced by a tracheostomy tube; however, ventilation was still not possible, and the saturation further dipped. Large volume of air was found to be leaking through the left-sided chest drain (placed after gastric pull-up) with every positive pressure breath. This made us suspect a tracheal breach, and tracheal mucosa was visualized fiberoptic bronchoscopically after the removal of FMCETT; at the same time, the surgeons palpated the internal walls of the tracheal lumen to identify a rent in the posterior tracheal wall which had probably occurred while manipulating the FMCETT toward the completion of surgery. Approximately, a 4 cm rent in the posterior membranous tracheal wall extending from stoma till beyond mid-trachea was confirmed. It was not detected earlier as the distal end of the FMCETT extended till beyond the level of the rent. Omental fat from gastric pull-up bulged into the trachea from the rent and obstructed the breathing channel [Figure 2]. A pneumomediastinum had resulted, and ventilation was impossible. The bulging omentum was quickly replaced back into the mediastinum, and the rent temporarily sealed by the surgeon's finger and later by surgical gauze. The rent was repaired by placing surgical sutures, and a chest tube was secured. This repair was done under apneic ventilation and lasted 45 min. The FMCETT was placed at the mouth of the tracheal stoma to insufflate oxygen into the airway [Figure 3]. Intermittent push of the oxygen flush button aided oxygenation. The surgeons were guided by light from the fiberoptic bronchoscopy (FOB) during repair. An arterial blood gas sample at this juncture revealed a PaO2 of 110 and a PaCO2 of 60 mmHg. Anesthesia was not reversed, and the patient was shifted with the FMCETT in situ(inserted deep until the distal black ring on the tube) and electively ventilated (pressure controlled mode pressure 22 mmHg; respiratory rate 17 breaths/min). Antibiotic cover included tazobactam-piperacillin. The pupils were reactive to light, and the SPO2 was 100% before shifting the patient to the surgical intensive care unit. After 2 days, she was allowed spontaneous breathing with humidified 40% oxygen inhalation through a “T” piece (without continuous positive airway pressure [CPAP]) attached to her ETT.
Figure 1: Intraoperative image of gastric pull-up surgery

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Figure 2: Omental fat from gastric pull-up bulged into the trachea through the rent and obstructed the breathing channel

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Figure 3: Flexometallic-cuffed endotracheal tube placed at the mouth of tracheal stoma to insufflate oxygen into the airway

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Seven days later, the FMCETT was removed and the integrity of sutures examined by inserting a fiberoptic bronchoscope through the tracheostomy stoma [Figure 4]. The patient was discharged after another 3 days. Monthly follow-up by fiberoptic bronchoscopy for adequate healing and detection of tracheal stenosis revealed a healthy, unobstructed repair site.
Figure 4: Integrity of sutures being examined by inserting a fiberoptic bronchoscope through the tracheostomy stoma

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  Discussion Top


The most common cause of tracheal rupture is blunt trauma to the chest. An iatrogenic tracheal tear maybe a postintubation injury (with 22% mortality) caused by the intubating anesthesiologist [1],[4] or rarer still by the surgeon as in the case being discussed. Female gender,[1] postchemotherapy and postradiotherapy status, as well as the on-going steroid therapy and esophageal surgery, were predisposing factors for tracheal tear in our patient.[1],[2],[3] High-ETT cuff pressures (>25 mmHg) for prolonged periods of time can cause ischemic pressure necrosis of the tracheal mucosa leading to fistula formation. Hence, the requirement of intermittent ETT cuff pressure monitoring, especially if nitrous oxide is being used.

Subcutaneous emphysema of the face,[5] cervical, and anterior thoracic region may be the presenting feature in smaller rents while tension pneumothorax, peumomediastinum, and acute asphyxial death may complicate larger rents.[6] Failure of the lung to reexpand after chest tube insertion indicates major airway injury. Respiratory distress and hemoptysis may occur in spontaneously breathing patients. Mediastinitis and sepsis are late complications. An emergency FOB is vital in establishing the diagnosis and for establishing the site, depth, and extent of the laceration.[6],[7]

Conservative treatment with antibiotic cover and mechanical ventilation (the cuff of ETT being distal to the rent) suffices for small, membranous rents in the upper trachea [8],[9],[10] while immediate surgical measures are mandatory to salvage life in larger (>2 cm), transmural, tracheal rents in lower trachea causing pneumomediastinum, especially when discovered during thoracic surgery.[8],[11],[12] ETT/tracheostomy tube cuff pressure, as well as airway pressure, must be monitored throughout the surgery.

A cascade of events had occurred. The 4 cm long rent in posterior membranous trachea beginning at the stoma at the second cartilaginous ring was probably created during FMCETT manipulation by the surgeons. Alveolar hypoventilation occurred due to inadvertent leaking out of gas through the tracheal rent during attempted ventilation causing pneumothorax/pneumomediastinum which in turn pushed the gastric wall and surrounding omentum (which were now mediastinal contents after the gastric pull-up surgery) to prolapse into the trachea through the tracheal rent leading to acute tracheal obstruction and asphyxia. The prolapsed tissue acted like a ball valve and allowed the inspiratory gases to enter the thorax through the tracheal rent as well as partially to the bronchi while at the same time preventing any expiratory return of the gases. Hence, the flat capnography was in line. The airway pressure was high because of the tracheal obstruction caused by the prolapsed omental tissue. During positive pressure inspiration, at pressure as high as 45 mmHg, <100 ml of gas (as indicated by the volumeter of primus workstation) could be delivered. Most of this was diverted out of the rent into the mediastinum while the small part that reached the bronchi was insufficient to cause a chest rise. The expiratory return of gas from the bronchi as well as from the mediastinum was prevented by the prolapsed omental tissue acting like a ball valve. The amount of gas entering the bronchi during inspiration reduced with each breath as the pneumomediastinum increased and finally no gas entered the bronchi, and there was an inability to ventilate the lungs.

During the acute crisis, saturation fell to 85%, and ventilation was not possible. FMCETT was replaced with tracheostomy tube (again no ventilation). Tracheostomy tube was taken out and fiberoptic bronchoscope was inserted but there was no result. The saturation had fallen to about 60% by this time, but once the rent was detected and omental tissue pushed back by the surgeon's finger, insufflation of 100% oxygen was possible, and the saturation improved to 95% within 90–120 s. The whole episode from no ventilation to detection of rent and resumption of insufflation of oxygen to the tracheobronchial tree took about 5–7 min. The prolapsed omentum was pushed back by the finger, insufflation (using oxygen flush button) through the FMCETT keeping its dital end perpendicular to the stoma was done, and then, sutures were taken during apneic phases. This lasted for 45 min.

The key factors in salvaging the patient were first, timely detection of rent in the operation theater itself and apneic ventilation, and oxygen insufflation through the tracheostomy stoma during its repair, and second, elective pressure-controlled ventilation in the postoperative period to avoid barotrauma and promote healing. Transporting the patient to another facility with provision for ECMO, cardiopulmonary bypass, or other sophisticated facility would have cost us the patient's life. Jet ventilation was not attempted even though the provision existed in our setup due to the apprehension that the force of the air jet would have disrupted and widened the tracheal wall rent. In the postoperative period, the set airway pressure of 22 mmHg was adequate in delivering a tidal volume between 300 and 350 ml. Keeping the respiratory rate at 17 bpm provided adequate minute ventilation with a small degree of permissive hypercapnia.[9],[10] No CPAP was applied to the T-piece for the same reasons when the patient was allowed spontaneous ventilation. The neck was slightly flexed at all times and never hyperextended to avoid stress on the suture lines and promote healing. A good antibiotic cover (tazobactam-piperacillin) and regular toileting sufficed to prevent complications such as ventilator-associated pneumonia. Simple bridging by passing a single lumen tube beyond the rent was not possible in our case as the lower border of the rent was just 1 cm above the carina. Bilateral endobronchial intubation using two endobronchial single lumen tubes passed through a large tracheostomy was our plan B which we never required to put to action as low-pressure ventilation sufficed. Fiberoptic bronchoscopy for culture specimens, secretion clearing, and suture line surveillance was done.


  Conclusion Top


Airways of postradiotherapy and postchemotherapy, especially female oncosurgical patients on steroid therapy, must be handled with utmost care. Management of large iatrogenic tracheal tears involves three distinct stages. The first stage is the timely detection, and prompt surgical repair in the operation theater itself during which, simple, immediately available methods of oxygenations such as apneic ventilation, oxygen insufflation, and permissive hypercapnia usually suffice. The second stage (akin to conservative management measures) is in the surgical intensive care unit with adequate antibiotic cover and mechanical ventilatory strategies which limit intrabronchial pressures and a chest tube in situ. The third stage is the follow-up bronchoscopy after a month of discharge.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Marty-Ané CH, Picard E, Jonquet O, Mary H. Membranous tracheal rupture after endotracheal intubation. Ann Thorac Surg 1995;60:1367-71.  Back to cited text no. 1
    
2.
Bick BL, Song LM, Buttar NS, Baron TH, Nichols FC, Maldonado F, et al. Stent-associated esophagorespiratory fistulas: Incidence and risk factors. Gastrointest Endosc 2013;77:181-9.  Back to cited text no. 2
    
3.
Park JY, Shin JH, Song HY, Yi SY, Kim JH. Airway complications after covered stent placement for malignant esophageal stricture: Special reference to radiation therapy. AJR Am J Roentgenol 2012;198:453-9.  Back to cited text no. 3
    
4.
Massard G, Rougé C, Dabbagh A, Kessler R, Hentz JG, Roeslin N, et al. Tracheobronchial lacerations after intubation and tracheostomy. Ann Thorac Surg 1996;61:1483-7.  Back to cited text no. 4
    
5.
Gries CJ, Pierson DJ. Tracheal rupture resulting in life-threatening subcutaneous emphysema. Respir Care 2007;52:191-5.  Back to cited text no. 5
    
6.
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. 6
    
7.
Hofmann HS, Rettig G, Radke J, Neef H, Silber RE. Iatrogenic ruptures of the tracheobronchial tree. Eur J Cardiothorac Surg 2002;21:649-52.  Back to cited text no. 7
    
8.
Goonasekera CD, Esufali ST. Managing iatrogenic tracheal injuries. Indian J Crit Care Med 2005;9:88-91.  Back to cited text no. 8
    
9.
Beiderlinden M, Adamzik M, Peters J. Conservative treatment of tracheal injuries. Anesth Analg 2005;100:210-4.  Back to cited text no. 9
    
10.
Materazzi G, Fregoli L, Ribechini A, Miccoli P. Conservative management of a tracheal leakage occurring 40 days after robotic thyroidectomy. Otolaryngol Head Neck Surg 2013;149:793-4.  Back to cited text no. 10
    
11.
Gabor S, Renner H, Pinter H, Sankin O, Maier A, Tomaselli F, et al. Indications for surgery in tracheobronchial ruptures. Eur J Cardiothorac Surg 2001;20:399-404.  Back to cited text no. 11
    
12.
Berry M, Van Schil P, Van Meerbeeck J, Vanmaele R, Eyskens E. Surgical treatment of iatrogenic tracheal lacerations. Acta Chir Belg 1997;97:308-10.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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