Enfisema subcutáneo masivo asociado a lesión traqueal posterior a intubación endotraqueal de urgencia: reporte de un caso / Massive subcutaneous emphysema associated with tracheal injury after emergency endotracheal intubation: a case report

El enfisema subcutáneo se produce como complicación frecuente en intervenciones quirúrgicas, técnicas invasivas, ventilación mecánica, lesiones traqueales y neumotórax. La progresión fuera del tórax con afectación facial, abdominal e incluso inguinal puede producir un síndrome compartimental con compresión de estructuras aledañas como la tráquea y vasos del cuello, tal situación se ha denominado enfisema subcutáneo masivo. En este documento se reporta el caso de un paciente que desarrolló un enfisema subcutáneo masivo como signo precoz de lesión traqueal asociada a la intubación y ventilación a presión positiva.

Subcutaneous emphysema occurs as a frequent complication in surgical interventions, invasive techniques, mechanical ventilation, tracheal injuries and pneumothorax. Progression outside the thorax with facial, abdominal, and even inguinal involvement can produce compartment syndrome with compression of surrounding structures such as the trachea and neck vessels. This situation has been called massive subcutaneous emphysema.This document reports the case of a patient who developed massive subcutaneous emphysema as an early sign of tracheal injury associated with intubation and positive pressure ventilation.

Lesión traqueal como hallazgo radiológico. A propósito de un caso / Tracheal injury as a radiological finding. Case report

Tracheal injury can occur as a rare complication of endotracheal intubation, associated with multiple anatomical and mechanical factors that have been described; however, the actual incidence is unknown due to the few series of documented cases that are reported worldwide. It is considered a fatal complication when it occurs and a diagnosis is not established in a timely manner. We present the case of a patient with active SARS-CoV-2 infection and a history of congenital malformation, who presented a tracheal lesion secondary to reintubation as a radiological finding.

La lesión traqueal puede ocurrir como complicación rara de una intubación endotraqueal, asociada a múltiples factores que han sido descritos de tipo anatómico y mecánico, sin embargo, la incidencia real se desconoce por las pocas series de casos documentados que se reportan a nivel mundial. Considera como una complicación mortal cuando se presenta y no se establece un diagnóstico de forma oportuna. Presentamos el caso de un paciente con infección activa de SARS-CoV-2 y antecedente de malformación congénita, que presentó como hallazgo radiológico una lesión traqueal secundaria a reintubación.

Lesión traqueobronquial secundaria a trauma torácico cerrado en paciente pediátrico: Reporte de un caso / Tracheobronchial injury, secondary to blunt thoracic trauma in a pediatric patient: A case report

Las lesiones traqueobronquiales son raras y presentan un alto índice de mortalidad, falleciendo el 80% antes de llegar al hospital por lo cual existen pocos reportes de casos. Se describe que alrededor del 80% de los casos se pueden manejar con maniobras no quirúrgicas o manejo quirúrgico tardío. Del 15% al 20% ameritará manejo quirúrgico temprano y al ser estos de mayor gravedad presentarán un alto riesgo de complicaciones posteriores. En esta revisión presentamos un caso de lesión traqueobronquial secundaria a trauma torácico cerrado manejado en la unidad de terapia intensiva de nuestro hospital que requirió corrección quirúrgica temprana y presento complicaciones tardías que al final la llevaron a su fallecimiento.

Tracheobronchial injuries are rare and have a high mortality rate, 80% dying before reaching the hospital, so there are few case reports. It is described that about 80% of cases can be managed with non-surgical maneuvers or late surgical management. From 15% to 20% merit early surgical management and as these are more serious, they present a high risk of subsequent complications. In this review, we present a case of tracheobronchial injury secondary to blunt chest trauma managed in the intensive care unit of our hospital that required early surgical correction and presented late complications that ultimately led to her death.

Conservative Management of a Traumatic Tracheal Tear: A Case Report

We describe here a case of traumatic anterior tracheal walltear managed conservatively with a successful outcome.Conservative treatment has a high likelihood of success inpatients who meet strict selection criteria and are closelymonitored in ICUs or elsewhere. This case highlights the roleof conservative management in treating such crucial cases inthe presence of limited resources, especially in a governmentset up in India.

Iatrogenic Tracheal Posterior Wall Perforation Repaired with Bronchoscope-Guided Knotless Sutures Through Tracheostomy

A 68-year-old man presented with a posterior tracheal wall injury caused by percutaneous dilatational tracheostomy. The wound was immediately covered with an absorbable polyglycolic acid sheet. Ten days after the injury, the perforation was closed with knotless sutures using a Castroviejo needle-holder through the tracheostomy. The successful repair in this case indicates the feasibility of the knotless suture technique for perforations. The technique is described in detail in this report. The patient was weaned from the mechanical ventilator on postoperative day 25. In cases of posterior tracheal posterior wall perforation, every effort should be made to repair the perforation through an existing opening.

Right Main Bronchus Rupture Presenting with Pneumoperitoneum

We report the case of a 16-year-old male patient who was involved in a traffic accident and transferred to the emergency department with mild chest pain. We initially did not find evidence of tracheal injury on computed tomography (CT). Within an hour after presentation, the patient developed severe dyspnea and newly developed subcutaneous emphysema and pneumoperitoneum were discovered. Abdominal CT showed no intra-abdominal injury. However, destruction of the right main bronchus was identified on coronal images of the initially performed CT scan. Emergency exploratory surgery was performed. The amputated right main bronchus was identified. End-to-end tracheobronchial anastomosis was performed, and the patient recovered without any complications.

A clinical study of percutaneous tracheostomy in medical ICU by non surgical doctors.

Introduction: Tracheostomy is one of the oldest surgical procedures to access the airway. The majority of cases who require tracheostomy are in ICUs. The ICUs are monitored by intensivists who are mostly Anesthesiologists or Physicians (non-surgical personnel). While doing surgical tracheostomy, there is dependency on other departments like surgeons of ENT department. In most cases, critically ill patients are made to shift to operating room, where we may have to wait for the availability of operating table. Method: This clinical study was carried out to access the airway when required by nonsurgical doctors like anesthesiologists or physicians at bed side and to save cost and operation theatre time. Result: Sixteen male & twelve female patients with an average age of 28 Years (range, 19 to 40Years) underwent PCT from Oct. 2008 to Oct.2011. Fourteen patients were of snake bite, 10 were of organo-phosphorus poisoning & 4 were of G.B. Syndrome. Conclusion: Percutaneous tracheostomy has replaced the surgical route in several intensive care units and it is indeed the procedure of choice in the majority of cases. [Rajan N NJIRM 2014; 5(1):6-9] Key Words: Percutaneous Tracheostomy (PCT), Surgical Tracheostomy (ST), Medical intensive care unit (MICU), critically ill, complications, tracheal injury, bleeding.

Study on mechanism of sulfur mustard induced acute tracheal injury in rat / 重庆医学

Objective To establish the sulfur mustard (SM ) induced tracheal injury model in rat and to investigate its mecha-nism .Methods Male rats (SD) were anesthetized and intra-tracheally intubated .The SM group was intra-tracheally injected by 2 mg/kg of diluted SM ,while the propylene glycol control group only by 0 .1mL of propylene glycol and the normal control group had no any treatment .The tissue and blood samples were taken for conducting the HE and immunohistochemical staining and measuring serum enzymes and andinflammatory factors .Results In the SM group ,a large number of lymphocytes infiltration in submucosa were observed;the positive expression of caspase-3 and caspase-9 were observed in epithelium and submucosa ;serum levels of TNF-α,IL-1β,IL-6 reached the peak in 24 h;serum levels of LDH ,GP ,BARS reached the peak in 6h ,so did GGT in 24 h .In the propyl-ene glycol control group and the normal control group ,lymphocytes ,macrophages and neutrophils were rare in submucosa .Conclu-sion The mechanism of SM (2 mg/kg) induced acute tracheal injury involves the inflammatory reaction ,apoptosis and oxidative stress ,moreover the lesion degree has the correlation with time .

Anesthetic management of penetrating neck injury patient with embedded knife: A case report / 대한마취과학회지

Penetrating neck injuries can be a fatal event and they are difficult to manage for both surgeons and anesthesiologists. So, adequate preoperative evaluation is important to improve the patients' outcomes, but this can not be done for hemodynamically unstable or uncooperative patient. Here we present our clinical experience with a patient with a penetrating neck injury and who was hemodynamically stable, but she was uncooperative and the knife was still embedded in her neck. The surgical exploration and bronchoscopic examination were successfully done under monitored anesthesia care.

Comparación de la presión del manguito del tubo orotraqueal estimada por palpación frente a la medición tomada con un manómetro / Comparison of the Orotracheal Tube Cuff Pressure Estimated by Palpation vs. the Measurement Taken with a Manometer / Comparação da pressão do balonete do tubo endotraqueal vs. palpação estimou a medida realizada com um manômetro

La presión que ejerce el manguito del tubo orotraqueal (TOT) sobre la mucosa al ser insuflado debe mantenerse en un rango de seguridad que evite complicaciones por sobreinflación o por desinsuflación. En nuestro medio, los instrumentos de medición objetiva no son de uso común. Objetivo: evaluar la concordancia de la presión del manguito del TOT estimada por palpación frente al uso de un manómetro manual en pacientes adultos sometidos a anestesia general. Materiales y métodos: se realizó un estudio de corte transversal que incluyó a 40 pacientes, a quienes, una vez intubados, dos anestesiólogos enmascarados, diferentes al que los intubó, palparon el manguito del TOT categorizándolo como sobreinflado, normal o desinflado; posteriormente, uno de los investigadores registró la medida con un manómetro en fase inspiratoria y espiratoria. Se consideró como rango normal de 20 a 30 cm H2O. Resultados: la concordancia de la estimación por palpación entre los dos anestesiólogos fue débil (Kappa = 0,21, ES: 0,11). La concordancia entre la estimación por palpación y la medición con el manómetro manual fue muy débil. Entre el primer anestesiólogo y el investigador en fase inspiratoria, k 0,08 (ES: 0,09), y en espiración, k 0,08 (ES: 0,07). Entre el segundo anestesiólogo y el investigador, k 0,05 (ES: 0,07) y 0,02 (ES: 0,06), respectivamente. Conclusión: el estudio muestra que la concordancia entre los métodos subjetivo y objetivo para determinar si el manguito del TOT está adecuadamente inflado fue débil. Se sugiere el empleo de métodos más objetivos para su determinación.

The pressure exerted by the cuff of endotracheal tube (ETT) on the mucosa to be blown, should be kept in a safe range to avoid complications by on inflation or deflation. In our context, the objective measurement instruments are not commonly used. Objective: To evaluate the correlation between ETT cuff pressure estimated by palpation, and that obtained with a manual gauge in adult patients undergoing general anesthesia. Materials and methods: It was performed a cross-sectional study by obtaining the sample of adult patients undergoing general anesthesia requiring endotracheal intubation. We included forty patients who were intubated and then two blind anesthesiologists, other than the one who intubated, estimated insufflation of ETT cuff by palpation categorizing as over-inflated, normal or deflated. One of the observers subsequently, carried out the measurement of pressure with a manometer, both in inspiration and expiration. It was considered as normal pressure range 20 to 30 cm H2O. Results: The correlation of the estimation by palpation between the two anesthesiologists was weak (Kappa = 0.21, ES: 0.11). The correlation of the estimation by palpation and measurement with manual gauge was very weak. Between the first anesthesiologist and observers, in inspiration the k was 0.08 (ES: 0.09), in expiration was 0.08 (ES: 0.07), also between the second anesthesiologist and the observers, k 0.05 (ES: 0.07) and 0.02 (ES: 0.06) respectively. Conclusion: The study shows that the correlation between subjective and objective methods to determine if the cuff of ETT is properly inflated was weak. It suggests the use of more objective methods for its determination.

A pressão que exerce o manguito do tubo orotraqueal (TOT) sobre a mucosa ao ser insuflado deve manter-se em um rango de segurança que evite complicações por sobre inflação ou por desinsuflação. Em nosso meio, os instrumentos de medição objetiva não são de uso comum. Objetivo: avaliar a concordância da pressão do manguito do TOT estimada por palpação versus o uso de um manômetro manual, em pacientes adultos submetidos à anestesia geral. Materiais e métodos: realizou-se um estudo de corte transversal que incluiu 40 pacientes aos quais, uma vez intubados, dois anestesiologistas mascarados, diferentes ao que intubou, palparam o manguito do TOT categorizando-lhe como super-inflado, normal ou desinflado, posteriormente um dos pesquisadores registrou a medida com um manômetro em fase inspiratória e expiratória. Considerou-se como rango normal de 20 a 30 cmH2O. Resultados: a concordância da estimação por palpação entre os dois anestesiologistas foi fraca (kappa = 0.21, ES: 0.11). A concordância entre a estimação por palpação e s medição com o manômetro manual foi muito fraca. Entre o primeiro anestesiologista e o pesquisador em fase inspiratória, k 0.08 (ES: 0.09) e em expiratória, k 0.08 (ES: 0.07). Entre o segundo anestesiologista e o pesquisador k 0.05 (ES: 0.07) y 0.02 (ES: 0.06) respectivamente. Conclusão: o estudo mostra que a concordância entre os métodos subjetivo e objetivo para determinar se o manguito do TOT está adequadamente inflado foi fraco. Sugere-se o emprego de métodos mais objetivos para sua determinação.

Conservative Management of Tracheal Injury After Endotracheal Intubation in a Neonate with Subglottic Stenosis and Esophageal Atresia with Tracheoesophageal Fistula

Tracheal injury is a rare complication of endo-tracheal intubation. However in neonates, the rates of morbidity and mortality are high. Recommendations for treatment are based on the several reports of this injury and are individualized. Conservative management can be effective in some cases. We describe the case of a neonate who presented with subcutaneous emphysema after intubation in a neonatal intensive care unit. This patient suffered full VACTERL syndrome and had 1.7mm diameter subglottic stenosis. Conservative management resulted in no further increase in subcutaneous emphysema and after 10 days the patient was stable.

Diagnostic Methods of Traumatic Tracheobronchial Injury / 대한흉부외과학회지

BACKGROUND: The aim of this study was to identify the distinguishing clinicoradiologic findings of traumatic tracheobronchial injury. MATERIAL AND METHOD: Between January 2003 and December 2009, six patients who underwent surgical repair for traumatic tracheobronchial injury due to blunt trauma were included in this study. We evaluated the mechanism of the injury, the coexisting injuries, the time until the making diagnosis and treatment, the diagnostic methods, the anatomic location of the injury and the surgical outcomes. RESULT: The mechanisms of injury were traffic accident and crushing forces. The frequent symptoms were subcutaneous emphysema, dyspnea and pain, and the common radiologic findings were pneumothorax, mediastinal emphysema, rib fracture and lung contusion. Only 2 patients were diagnosed by chest CT and the others were not diagnosed preoperatively. The location of injury was the trachea in 2 patients and the bronchial tree in 4 patients. There was no postoperative mortality or anastomotic leak; however, vocal cord palsy occurred in one patient. The most distinguishing sign was persistent lung collapse even though the chest tube was connected with negative pressure. CONCLUSION: Although it was not easy to diagnose traumatic tracheobronchial injury without a clinical suspicion, the distinguishing clinical symptoms and CT findings could help to make an early diagnosis without performing bronchoscopy.

Treatment of a Nail in the Intestine after a Neck Injury from Accidental Firing of the Nail Gun: A case report / 대한흉부외과학회지

A 42-year-old male was admitted because of an anterior neck injury due to accidental firing of a nail gun. On chest X-ray, the nail was stuck in the anterior neck, migrated to the chest, and then to the abdomen. Only the trachea was damaged, leaving no injury in the esophagus. The nail in the intestine was removed by colonoscopy. The patient showed complete recovery without complications after fasting and conservative treatment. We report this case with a literature review.

Subcutaneous Emphysema and Inflammation of the Neck after Tracheal Puncture by an Intubating Stylet / 영남의대학술지

Laryngo-tracheal perforation caused by the use of a stylet during tracheal intubation is a rare complication. We present a case of subcutaneous emphysema and connective tissue inflammation after tracheal intubation. The patient was a 41-year-old male undergoing general anesthesia for an appendectomy. The intubation was difficult during laryngoscopy (Cormack-Lehane Grade III). An assistant provided an endotracheal tube with a stylet inside while the laryngoscope was in place. During intubation, a short, dull sound was heard with a sudden loss of resistance after the distal tip of the endotracheal tube passed the rima glottis. A sonogram and computerized tomography revealed subcutaneous emphysema from the neck to the upper mediastinum and fluid collection between the trachea and the thyroid. This lesion appeared to have been caused by the protruded, loose stylet. Anesthesiologists should be aware of the damage a loose stylet protruding beyond the tip of the endotracheal tube can cause.

Bilateral Pneumothorax Induced by Tracheal Injury during Total Thyroidectomy with Modified Radical Neck Dissection: A case report / 대한마취과학회지

We experienced one case of bilateral pneumothorax developed after total thyroidectomy with modified radical neck dissection in a 44-year-old male patient with thyroid carcinoma. After the conclusion of the operation, the patient was extubated after confirming recovery of consciousness and spontaneous respiration. Soon after the extubation, sudden-onset dyspnea with desaturation was developed. Rapid re-intubation was performed. Bilateral pneumothorax with severe subcutaneous emphysema was recognized on chest radiograph and successfully treated by chest tube insertion. Secondary operation was performed and tracheal injury was proved to be the source of the pneumothorax. The patient was discharged uneventfully 14 days later.

Complete Transsection of the Trachea by Blunt Trauma / 대한흉부외과학회지

Tracheobronchial rupture due to blunt chest trauma is an uncommon injury although the incidence is increasing. Early diagnosis and primary repair of tracheobronchial rupture not only restore a normal lung function but also avoid the difficulties and complications associated with delayed diagnosis and repair. We present one case of the tracheal transsection caused by traffic accident. Patient suffered from progressive dyspnea, subcutaneous emphysema on the neck and anterior chest wall and tension pneumothorax at both sides were noted. Although both closed thoracostomy were done, massive air leakage through the chest tube continued and subcutaneous emphysema spread to the anterior abdominal wall and scrotum and the degree of dyspnea aggravated. With the impression of tracheobronchial injury, we performed the emergency operation. Preoperative bronchoscopy at the operation room was proceeded, which revealed the trachea was near totally transsected in transverse direction. Operation was performed through collar incision on the anterior neck, and the trachea was anastomosed with 4-0 Vicryl(R) interruptedly. Postoperative course were uneventful and patient discharged without any complications.

Complete Rupture of Cervical Trachea after Compressed Chest Injury in a Child / 대한흉부외과학회지

Cervical tracheal rupture is one of the rare injuries after blunt chest trauma, and this can be explained by several mechanisms. Early diagnosis and treatment of tracheal rupture after trauma can reduce the mortality and morbidity. We report here on a surgical experienced case of complete rupture of the cervical tracheal that was due to increased intra-tracheal pressure after a compression injury to the chest of an 8 years old child. We also include a review of the literature.

Delayed Detection of a Penetrating Tracheal Foreign Body / 대한흉부외과학회지

The finding of a tracheal penetrating injury that's caused by a foreign body is rare in adulthood. A 42-year-old man had experienced penetrating trauma due to a glass fragment 10 years ago. He presented with blood tinged sputum and dyspnea on exertion, and this had developed 1 year previously. Chest CT scan and bronchoscopy revealed a foreign body crossing the tracheal lumen and the object arose from outside of the trachea; this was all associated with airway edema. We removed the foreign body, which was a 5cm length of glass fragment, and we repaired the tracheal defect using a simple primary suture. The postoperative course of the patient was uneventful and he is now being followed up at the outpatient department; he has had no additional symptoms.

The Changes of Cuff Pressure from Endotracheal Intubation for Long-term Mechanical Ventilation / 결핵

BACKGROUND: A tracheal stenosis is caused by mucosal ischemic injury related to a high cuff pressure (Pcuff) of the endotracheal tube. In contrast, aspiration of the upper airway secretion and impaired g as exchange due to cuff leakage is related to a low Pcuff. To prevent these complications, the Pcuff should be kept appropriately because the appropriate Pcuff appears to change according to the patients' bedside. To address the necessity of continuous Pcuff monitoring, the change in the Pcuff was evaluated at various Vcuff levels on a daily basis in patients with long-term mechanical ventilation. The utility of mercury column sphygmomanometer for the continous monitoring Pcuff was also investigated. METHOD: The change in Pcuff according to the increase in Vcuff was observed in 17 patients with prolonged endotracheal intubation for mechanical ventilation for 2 week or more. This maneuver measured the change in Pcuff daily during the mechanical ventilation days. In addition, the Pcuff measured by mercury column sphygmomanometer was compared with the Pcuff measured by an automatic cuff pressure manager. RESULTS: There were no statistically significant changes of Pcuff during more than 14 days of intubation for mechanical ventilation. However the Vcuff required to maintain the appropriate Pcuff varied from 1.9cc to 9.6cc. In addition, the intra-individed variation of the Pcuff was observed from 10cmH2O to 46cmH2O at constant 3cc Vcuff. The Pcuff measured by the bedside mercury column sphymomanometer is well coincident with that measured by the automatic cuff pressure manager. CONCLUSION: Continuous monitoring and management of the Pcuff to maintain the appropriate Pcuff level in order to prevent cuff related problems during long-term mechanical ventilation is recommended. For this purpose, mercury column sphygmomanometer may replace the specific cuff pressure monitoring equipment.

Tracheal Laceration Due to Thyroid Cartilage Fracture: One Case Report / 대한흉부외과학회지

A 50-year-old male visited the emergency room due to the cervical edema caused by a traffic accident. At the cervial CT, diagnosis was confirmed as extensive cervical subcutaneous emphysema secondary to tracheal laceration as a thyroid cartilage fracture. The patient showed loss of symptom after conservative treatment. Thyroid cartilage fracture is rare and tracheal laceration as a result of thyroid cartilage fracture has never been reported in the literatures. Thus we herein report this one case.