Case of tracheal rupture after endotracheal intubation: clinical risk management and medico-legal considerations.

Background: Tracheal injury may be a rare complication of the endotracheal intubation procedure. Incidence and determinant factors are not well known, nevertheless a greater incidence have been recognized with a difficult maneuver or the use of nitrogen peroxide. The therapeutic approach can be conservative or surgical, depending on the characteristics of the lesion and of the patient and therefore the outcomes of medico-legal interest can be different. Case description: It is a case of alleged medical liability regarding a 70-year-old woman, that during the intubation procedure was pouncing on the right. Furthermore, nitrous oxide was used as an anaesthetic. A few hours after the operation the patient showed swelling on the right half of the face and on the right lateral region of the neck. The emergency chest CT scan highlighted subcutaneous emphysema and pneumomediastinum. In the operating room, fibrobronchoscopy was performed with a double-lumen bronchial tube which confirmed the hypotheses lesion; then, right posterolateral thoracotomy was perfor-med followed by suturing of the tracheal lesion. Subsequently, the patient was discharged in good clinical conditions but with a scar in the region of the right hemithorax. Conclusions: Iatrogenic tracheal injury is a rare and fearful complication of the orotracheal intubation procedure. Although risk factors that increase the probability of its onset have been recognized, in most cases it is not possible to identify the cause. From a medico-legal point of view, tracheal injury after intubation is unpredictable and inevitable, so in the case reported it was decided to proceed with a conciliatory solution.

Case report: video-assisted thoracoscopic repair of right main bronchus transection after blunt chest injury.

Background: Traumatic tracheobronchial injury is a rare manifestation after blunt chest injury. The current standard treatment has wide spectrum from conservative treatment to open thoracotomy with repair airway regarding to severity of the disease. However, to the best of our knowledge, no one has reported airway repair in trauma using video-assisted thoracoscopic surgery (VATS) before. Hence, we describe the successful management and repair of a transected right main bronchus using VATS. Case Description: A 43-year-old male patient presented with chest tightness after a traumatic blunt chest injury; a chest computed tomography revealed multiple rib fractures and suspected right main bronchus injury with large pneumomediastinum and subcutaneous emphysema. Although the current standard treatment is to perform open thoracotomy with tracheal repair, we performed VATS repair of right main bronchus in purpose to reduce the stress from tissue trauma and minimally invasive fashion. Emergency surgery was scheduled for injury repair, and the transected right main stem bronchus and mediastinum hematoma were intraoperatively identified. The right main bronchus was repaired using polypropylene 4-0 interrupted sutures under uniportal VATS and covered with pericardial fat pad tissue. After the surgery, the patient had no air leak from chest tube drainage and recovered well. The patient was performed diagnostic bronchoscopy to confirm the patent airway at day 3 then discharged 7 days after surgery and was doing well at a 1-month follow-up. Conclusions: VATS repair is safe and feasible as an alternative approach to conventional thoracotomy approach in the treatment of traumatic tracheobronchial injury.

[Post-intubation rupture of thoracic trachea in a patient with iatrogenic esophageal perforation and mediastinitis]. / Postintubatsionnyi razryv grudnogo otdela trakhei u bol'noi s perforatsiei pishchevoda pri fibroendoskopii i mediastinitom.

Iatrogenic injuries of the esophagus and trachea are rare. However, these are life-threatening events due to severe complications. The authors report iatrogenic perforation of cervical esophagus with a long false passage in posterior mediastinum in an 83-year-old patient undergoing endoscopic retrograde cholangiopancreatography for choledocholithiasis. Post-intubation rupture of thoracic trachea was diagnosed early after suturing the defect of esophagus and drainage of mediastinum. Treatment strategy was analyzed and conservative management of tracheal injury was substantiated.

Conservative medical management combined with follow-up multidetector computed tomography of tracheobronchial injury caused by penetrating injuries: A case report.

Tracheobronchial injury (TBI) associated with penetrating injuries has various clinical symptoms and often requires urgent surgical repair. A tracheal tube and/or placement of a drainage tube combined with multidetector computed tomography (CT) could be used to manage TBI without surgical repair in eligible patients. In this case report, we describe an 86-year-old woman with subcutaneous emphysema and suspected TBI caused by three knife wounds in her neck. After tracheal intubation at a local hospital, she was transferred to our hospital. On admission, she was diagnosed with subcutaneous and mediastinal emphysema due to TBI, as well as bilateral pneumothorax. We adjusted the position of the tracheal tube to a distal location from the TBI, and placed bilateral thoracic drainage tubes by referring to the CT images taken on admission and during the follow-up. The follow-up CT images revealed healing of the TBI. She did not show any worsening of her symptoms and she was successfully extubated on day 10 of her hospital stay. On day 18, she was considered self-reliant and was transferred to her previous hospital. Based on our experience in this case, we believe that ventilation with appropriate sedation, placement of a tracheal tube, and drainage are important conservative therapies for TBI caused by penetrating injuries. CT is also useful for evaluating the status of TBI.

Delayed tracheal rupture following transoral endoscopic thyroidectomy vestibular approach: Case report and review of the literature.

BACKGROUND: Although the transoral endoscopic thyroidectomy vestibular approach (TOETVA) has been proven to be a safe procedure for select patients, as it is a novel approach, all associated complications require adequate attention. METHODS: We presented a 49-year old woman who underwent TOETVA developed delayed tracheal rupture 1 week after surgery. An extensive search of literature was carried out using PubMed, Embase, and Web of Science for studies reporting tracheal injury following endoscopic thyroidectomy. RESULTS: Thirteen cases of endoscopic thyroidectomy were analyzed, including eight cases of TOETVA. Tracheal injury occurred during various procedures, including accidental dissection, surgical needle puncture, Hegar dilation and trocar placement, and thermal injury by the energy device. CONCLUSIONS: Tracheal injury following TOETVA is an underreported complication that can be induced by various factors. Thermal injury to the trachea is more likely to cause a delayed rupture. Careful blunt dissection and standardized use of energy devices are suggested.

[Life-threatening complications following endoscopic recanalization of cicatricial tracheal stenosis]. / Zhizneugrozhayushchie oslozhneniya pri endoskopicheskoi rekanalizatsii rubtsovykh stenozov trakhei.

The authors report an attempt of tracheal stenosis bougienage complicated by tracheal rupture. Particularities of diagnosis and treatment of patients with cicatricial stenoses of breathing pathways are analyzed.

Iatrogenic Tracheal Rupture Related to Prehospital Emergency Intubation in Adults: A 15-Year Single Center Experience.

OBJECTIVE: Iatrogenic tracheal rupture is an unusual and severe complication that can be caused by tracheal intubation. The frequency, management, and outcome of iatrogenic tracheal rupture due to prehospital emergency intubation in adults by emergency response physicians has not yet been sufficiently explored. METHODS: Adult patients with iatrogenic tracheal ruptures due to prehospital emergency intubation admitted to an academic referral center over a 15-year period (2004-2018) with consideration of individual risk factors were analyzed. RESULTS: Thirteen patients (eight female) with a mean age of 67 years met the inclusion criteria and were analyzed. Of these, eight tracheal ruptures (62%) were caused during the airway management of cardiopulmonary resuscitation (CPR). Stylet use and difficult laryngoscopy requiring multiple attempts were documented in eight cases (62%) and four cases (30%), respectively. Seven patients (54%) underwent surgery, while six patients (46%) were treated conservatively. The overall 30-day mortality was 46%; five patients died due to their underlying emergencies and one patient died of tracheal rupture. Three survivors (23%) recovered with severe neurological sequelae and four (30%) were discharged in good neurological condition. Survivors had significantly smaller mean rupture sizes (2.7cm versus 6.3cm; P <.001) and less cutaneous emphysema (n = 2 versus n = 6; P = .021) than nonsurvivors. CONCLUSIONS: Iatrogenic tracheal rupture due to prehospital emergency intubation is a rare complication. Published risk factors are not consistently present and may not be applicable to identify patients at high risk, especially not in rescue situations. Treatment options depend on individual patient condition, whereas outcome largely depends on the underlying disease and rupture extension.

Traumatic Pediatric Tracheal Rupture After Blunt Force Sporting Injury: Case Report and Review of the Literature.

OBJECTIVE: This paper presents the case of a traumatic tracheal rupture in a pediatric patient. The body of literature of the clinical features, evaluation, and management of this uncommon presentation is discussed. CASE: A 13-year-old boy sustained an intrathoracic tracheal rupture whilst playing Australian Rules football. He developed hallmark clinical features of air extravasation and was intubated prior to transfer to a tertiary pediatric center for further management. After a short trial of conservative management, his respiratory status deteriorated and he was taken to the operating theater for open surgical repair of the defect. CONCLUSION: Traumatic rupture of the trachea is a rare injury in children. This case demonstrates the dynamic nature of this serious injury and the need for multidisciplinary care in achieving the optimal outcome.

Iatrogenic tracheal rupture in a patient with acute respiratory distress syndrome due to SARS-CoV-2 pneumonia.

Iatrogenic tracheal rupture (ITR) is a serious complication secondary to procedures such as emergent orotracheal intubation or tracheostomy, among others. The management of ITR depends on the size, extension and location of the injury, along with the patient's respiratory status and comorbidities. The priority of treatment is to keep the airway permeable to ensure adequate ventilation. We present the case of a tracheal rupture after performing a percutaneous tracheostomy, in a patient diagnosed with severe acute respiratory distress syndrome secondary to bilateral interstitial pneumonia due to SARS-Cov-2. The issues are discussed, such as the management (conservative vs. surgical) depending on the features of the injury and the patient, in the extraordinary context that the COVID-19 pandemic has entailed.

Finding the bubble: atypical and unusual extrapulmonary air in the chest.

OBJECTIVE: To describe the radiologic findings of extrapulmonary air in the chest and to review atypical and unusual causes of extrapulmonary air, emphasizing the importance of the diagnosis in managing these patients. CONCLUSION: In this article, we review a series of cases collected at our center that manifest with extrapulmonary air in the thorax, paying special attention to atypical and uncommon causes. We discuss the causes of extrapulmonary according to its location: mediastinum (spontaneous pneumomediastinum with pneumorrhachis, tracheal rupture, dehiscence of the bronchial anastomosis after lung transplantation, intramucosal esophageal dissection, Boerhaave syndrome, tracheoesophageal fistula in patients with esophageal tumors, bronchial perforation and esophagorespiratory fistula due to lymph-node rupture, and acute mediastinitis), pericardium (pneumopericardium in patients with lung tumors), cardiovascular (venous air embolism), pleura (bronchopleural fistulas, spontaneous pneumothorax in patients with malignant pleural mesotheliomas and primary lung tumors, and bilateral pneumothorax after unilateral lung biopsy), and thoracic wall (infections, transdiaphragmatic intercostal hernia, and subcutaneous emphysema after lung biopsy).

[Assessment of tracheal elasticity and tracheal anastomosis tension in cicatricial stenosis]. / Otsenka elastichnosti trakhei i natyazheniya trakheal'nogo anastomoza pri rubtsovom stenoze.

OBJECTIVE: To assess the tracheal elasticity and tracheal anastomosis tension for prevention of anastomosis-related complications and estimation of the maximum length of resection. MATERIAL AND METHODS: At the first stage, 20 patients with cicatricial tracheal stenosis underwent tracheoscopy in usual position, under maximum flexion and extension of the head for the period from September 2017 to December 2019. We measured the total length of trachea and length of stenotic segment. Tracheal extensibility was assessed considering the difference in measurements. At the second stage, anastomosis tension was intraoperatively measured using a dynamometer in normal head position, as well as at maximum flexion in 22 patients who underwent tracheal resection. Unlike multiple other studies, we studied tissue tension intraoperatively. RESULTS: Mean length of trachea was 12.8 cm, extensibility - 1.3 cm. Tracheal elasticity was greater in patients with a longer trachea and in patients under 40 years old. Mean length of resection was 3.9 cm (30% of mean length of trachea), anastomosis tension - 2.7 H or 270 g. Head flexion was followed by tension decrease by 0.7 H (26.9%), i.e. 70 g. This approach is less effective in case of resection of more than 30% of trachea length in a particular patient. CONCLUSION: Further experience in measurement of tracheal extensibility and anastomosis tension will make it possible to establish clinical significance of these indicators for prevention of complications.

New acute respiratory management in tracheal rupture caused by chest trauma.

We report a case who is a 33-year-old man admitted to our Emergency room for chest trauma caused by the factory's mechanical arm. Despite the endotracheal tube, the patient's respiratory state was poor and the oxygen saturation did not improve and the subcutaneous emphysema progressed. To improve distressed breathing, we first proposed the concept "mechanical ventilation with dual ventilator" to maintain oxygen saturation of the patient. This is, to our knowledge, the first report of using a special mechanical ventilation method in emergency surgery.

Disnea por rotura espontánea traqueal en ancianos / Dyspnea due to spontaneous tracheal rupture in the elderly

Tracheal rupture is an infrequent complication with high morbidity and mortality, of multifactorial etiology, being orotracheal intubation its main cause. Spontaneous tracheal rupture usually occurs after severe coughing and/or vomiting over a weakened trachea. The diagnosis is non-specific, based on highly suggestive signs and symptoms such as subcutaneous emphysema, pneumomediastinum and respiratory distress, and its confirmation requires the performance of a bronchoscopy. The location and extent of the rupture determines the clinic. This implies the importance of an early diagnosis to avoid a poor prognosis. We present the case of an elderly male patient with a spontaneous tracheal rupture without apparent cause

La rotura traqueal es una complicación infrecuente de etiología multifactorial, con una elevada morbimortalidad, la intubación orotraqueal es su principal causa. La rotura traqueal espontánea suele producirse luego de toser o presentar vómitos intensos, sobre una tráquea debilitada. El diagnóstico es inespecífico, se basa en signos y síntomas altamente sugestivos como enfisema subcutáneo, neumomediastínico y dificultad respiratoria y su confirmación exige la realización de una broncoscopia. La localización y extensión de la rotura determinan la clínica. Esto implica la importancia del diagnóstico precoz para evitar un pronóstico infausto. Se presenta el caso de un paciente varón, de edad avanzada. con una rotura espontánea traqueal sin causa aparente

Prognostic Factors for Iatrogenic Tracheal Rupture: A Single-Center Retrospective Cohort Study.

Iatrogenic tracheal ruptures are rare but severe complications of medical interventions. The main goal of this study was to explore prognostic factors for all-cause mortality and rupture-related (adjusted) mortality. We retrospectively analyzed patients admitted to an academic referral center over a 15-year period (2004-2018). Fifty-four patients met the inclusion criteria, of whom 36 patients underwent surgical repair and 18 patients were treated conservatively. In a 90-day follow-up, the all-cause mortality was 50%, while the adjusted mortality was 13%. Rupture length was identified as a predictor for all-cause mortality (area under the curve, 0.84; 95% confidence interval (CI) 0.74-0.94) with a cutoff rupture length of 4.5 cm (sensitivity, 0.70; specificity, 0.81). Multivariate analysis confirmed rupture length as a prognostic factor for all-cause mortality (adjusted hazard ratio (HR) 1.5; 95% CI 1.2-1.9; p = 0.001), but not for adjusted mortality (HR 1.5; 95% CI 0.97-2.3; p = 0.068), while mediastinitis predicted adjusted mortality (HR 5.8; 95% CI 1.1-31.7; p = 0.042), but not all-cause mortality (HR 1.6; 95% CI 0.7-3.5; p = 0.243). The extent of iatrogenic tracheal rupture and mediastinitis might be relevant prognostic factors for all-cause mortality and adjusted mortality, respectively.

Iatrogenic tracheal rupture in a patient with acute respiratory distress syndrome due to SARS-CoV-2 pneumonia. / Rotura traqueal iatrogénica en paciente con síndrome de distrés respiratorio agudo por neumonía SARS-CoV-2.

Iatrogenic tracheal rupture is a serious complication secondary to procedures such as emergent orotracheal intubation or tracheostomy, among others. The management of iatrogenic tracheal rupture depends on the size, extension and location of the injury, along with the patient's respiratory status and comorbidities. The priority of treatment is to keep the airway permeable to ensure adequate ventilation. We present the case of a tracheal rupture after performing a percutaneous tracheostomy, in a patient diagnosed with severe acute respiratory distress syndrome secondary to bilateral interstitial pneumonia due to SARS-CoV-2. The issues are discussed, such as the management (conservative vs. surgical) depending on the features of the injury and the patient, in the extraordinary context that the COVID-19 pandemic has entailed.

Transmural rupture and cartilage ring fracture in a tracheobronchial tuberculosis patient.

Tuberculosis (TB) tracheobronchial stenosis is considered as the worst complication of tracheobronchial TB (TBTB). Endobronchial balloon dilation (EBD) is a promising treatment for adult tracheal stenosis; however, it may be complicated by transmural rupture and cartilage ring fracture. We present a 29-year-old female with a six-month history of cough and chest pain, and three weeks of dyspnoea. She was diagnosed with TBTB with active caseous lesions and had an effective response to anti-TB treatment. Nevertheless, she suffered recurrent tracheobronchial stenosis requiring several bronchoscopic treatments, including EBD. Her eight-month follow-up bronchoscopy showed transmural rupture and cartilage ring fracture of the anterior trachea. The patient finally recovered after 18 months of conservative management. Transmural rupture and cartilage ring fracture on the anterior trachea wall without pneumomediastinum or subcutaneous emphysema in TBTB patients may be best treated with a conservative approach.

Tracheal Rupture: A Rare Complication of Endotracheal Intubation.

Clinicians can encounter various complications after endotracheal intubation as a result of patient anatomy, difficult intubation, and time and number of interventions performed. A life-threatening complication of intubation is iatrogenic tracheal rupture that leads to pulmonary air leak syndromes. In this case report, we present a 10-month-old patient who presented to the healthcare center with cyanosis and cough after foreign body aspiration and underwent endotracheal intubation for hypoxia. In our report, we aim to draw attention to tracheal rupture, a complication that was identified in bronchoscopy and found to be associated with repeated interventions and stylet use.

Thoracotomy for emergency repair of iatrogenic tracheal rupture: single center analysis of perioperative management and outcomes.

BACKGROUND: Iatrogenic tracheal ruptures are rare but life-threatening airway complications that often require surgical repair. Data on perioperative vital functions and anesthetic regimes are scarce. The goal of this study was to explore comorbidity, perioperative management, complications and outcomes of patients undergoing thoracotomy for surgical repair. METHODS: We retrospectively evaluated adult patients who required right thoracotomy for emergency surgical repair of iatrogenic posterior tracheal ruptures and were admitted to a university hospital over a 15-year period (2004-2018). The analyses included demographic, diagnostic, management and outcome data on preinjury morbidity and perioperative complications. RESULTS: Thirty-five patients who met the inclusion criteria were analyzed. All but two patients (96%) presented with critical underlying diseases and/or emergency tracheal intubations. The median time (interquartile range) from diagnosis to surgery was 0.3 (0.2-1.0) days. The durations of anesthesia, surgery and one-lung ventilation (OLV) were 172 (128-261) min, 100 (68-162) min, and 52 (40-99) min, respectively. The primary airway management approach to OLV was successful in only 12 patients (34%). Major complications during surgery were observed in 10 patients (29%). Four patients (11%) required cardiopulmonary resuscitation, one of whom received extracorporeal membrane oxygenation, and another one of these patients died during surgery. Major complications were associated with significantly higher all-cause 30-day mortality (p = 0.002) and adjusted mortality (p = 0.001) compared to patients with minor or no complications. CONCLUSIONS: Surgical repair of iatrogenic tracheal ruptures requires advanced perioperative care in a specialized center due to high morbidity and potential complications. Airway management should include early anticipation of alternative OLV approaches to provide acceptable conditions for surgery.

Successful use of self-expandable metal stents in a case of iatrogenic tracheal rupture.

As an alternative treatment to immediate surgical repair, endotracheal stent placement has been recently proposed in cases of iatrogenic tracheal damages. We report a case of a 91-year-old male who developed sudden subcutaneous emphysema during a total laryngectomy for laryngeal carcinoma. A tracheal tear at the distal third of the posterior tracheal wall was endoscopically assessed about 2 cm above the carina; CT confirmed the breach approximately 4 cm in length with associated pneumomediastinum and bilateral pneumothorax. Two covered self-expandable metal stents were then coaxially released under fluoroscopic control to cover the defect, restoring the tracheal integrity and leading to a normal thoracic appearance at CT and X-ray after 72 hours.

Iatrogenic Tracheal Rupture Caused by Emergency Intubation: A Case Report.

BACKGROUND: Iatrogenic tracheal rupture is a rare but life-threatening complication. If suspected by clinical examination or chest radiograph, a computed tomography scan can confirm the diagnosis, but the criterion standard is a bronchoscopy. There is no consensus on its management. CASE REPORT: A 52-year-old woman was intubated in a prehospital setting after cardiac arrest. A gradual appearance of subcutaneous emphysema was observed after intubation. A computed tomography scan revealed a complicated tracheal rupture, pneumomediastinum, and pneumothorax. The management was surgical. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Intubation in emergency conditions increases the risk of tracheal rupture and a delay in management is an important prognostic factor.