The dangers of playing with
sharp sticks
Cheryl Pirozzi, MD
Pulmonary Grand Rounds
October 13, 2011
Case
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43 yo woman presented to OSH with SOB,
productive cough with hemoptysis, and
weakness
PMH
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CVID with ↓ IgG and IgM, treated with monthly IVIG
Multiple recent hospitalizations (x7 in 2011), mult for
pneumonia, most recent 8/8-9/2011
Adrenal insufficiency due to chronic steroids: unclear why
Chronic hypoxemia: 3LPM
Asthma
 PFTs 12/10: mildly reduced FEV1, nl DLCO
Chronic pain, narcotic abuse
Psych issues: bipolar d/o, borderline personality d/o, prior
overdoses on narcotics, tricyclics, atarax
Papillary thyroid Ca, s/p thyroidectomy
VRE skin and UTI infections
DM2
? Crohns disease – negative biopsy
PMH
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PSH: gastric bypass, CCY, tonsillectomy,
sinus surgeries x2, hiatal hernia repair, PFO
closure
SH: on disability, married. Denies EtOH,
tobacco, IDU
Meds
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Prednisone 20 mg qd
Lortab 10 q4 hrs
Tapentadol 100 mg q4h
Albuterol
Budesonide
Lasix
Atarax
Synthroid
cytomel
IVIG 30 g q mo
Nexium
Lunesta
Seroquel 800 mg qHS
Metoprolol
Zofran
Cymbalta
Case
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PE
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T 38.5, p116, 85/40 → 111/56, R 18, 84%/3L
Ill-appearing, alert but tangental
Bilateral crackles and rhonchi
Labs:
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WBC 16, 20% bands, hgb 11, plt 266
Lactate 3.7, BUN 22, Cr 0.8
Initial CXR OSH 8/30/11
Hospital Course
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Initially treated for HCAP with Zosyn,
Levaquin, and Vancomycin
Stress dose steroids
IVIG
CXR 8/31/11
9/1/11
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Reportedly, patient’s husband sneaks her
extra antihistamine, dramamine, seroquel
and tapentadol, and she has an aspiration
event
Acute hypoxic respiratory failure
Emergent intubation
CXR 9/1/11
9/1/11
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Soon after intubation, patient has bronch with
BAL
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“proximal airways were normal in appearance”
BAL grows MRSA
A few hours later, she is noted to acutely
decompensate and “blow up”
9/1/11
9/1/11
9/4/11
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Patient again decompensates, with increased hypoxia and
subcutaneous emphysema, and transfer to IMC is requested
9/4/11 transfer to IMC
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T 38.1, p123, 122/87, R 24 FiO2 100%, PEEP 11, Vt 6 ml/kg
Diffuse subcutaneous emphysema, crackles, edema
What would you do next?
CT 9/4/11
CT 9/4/11
CT 9/4/11
CT 9/4/11
CT 9/4/11
What is going on?
Bronch 9/8/11
Bronch 9/8/11
CT 9/8/11
CT 9/8/11
Hospital Course
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Recurrent infectious complications and intermittent
septic shock:
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Acromobacter PNA
Persistent MRSA tracheobronchitis
C.diff colitis
VRE UTI
Treated with Vanc, linezolid, zosyn, ceftaroline, flagyl
Severe ARDS
Self extubation with emergent re-intubation on 9/13
Eventually stabilizes, but unable to wean from vent
Bronch 9/24/11
Hospital Course
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Trach on 9/27/11
Bronch 9/28/11
Tracheal injury associated with endotracheal
intubation
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Clinical presentation
How often does this happen?
What are the risk factors? How do we avoid
it?
What is the treatment?
Tracheal injury/rupture
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Rare condition with high morbidity and
mortality
Most common cause is head and neck injury
Most common iatrogenic cause is orotracheal
intubation; also can occur with tracheostomy,
bronchoscopy, placement of stents,
esophagectomy
Usually longitudinal rupture in distal third of
membranous trachea
Miñambres et al. European Journal of Cardio-thoracic Surgery 35 (2009) 1056—1062
Tracheal injury associated with endotracheal
intubation
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Clinical presentation:
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Most common: subcutaneous emphysema,
pneumomediastinum, pneumothorax, respiratory
distress
dyspnea, dysphonia, cough, hemoptysis, and
pneumoperitoneum
signs often develop immediately or soon after
intubation, but can take several days to appear
Miñambres et al. European Journal of Cardio-thoracic Surgery 35 (2009) 1056—1062
Diagnosis
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Requires high clinical suspicion based on
clinical s/sx
Confirmed by direct visualization of lesion
with bronchoscopy
CT
Radiographic signs
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Subcutaneous emphysema
Pneumomediastinum
Overdistended ETT cuff
On CT tracheal defect/perforation
Am J Emerg Med 2004;22:289-293.
J Bras Pneumol. 2009;35(8):809-813
Tracheal injury associated with endotracheal
intubation
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How often does this happen?
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Case reports, several case series and reviews
Incidence estimates from 0.005% - 0.37% of
intubations, more common with double lumen
tubes
Medina et al. J Bras Pneumol. 2009;35(8):809-813
Miñambres et al. European Journal of Cardio-thoracic Surgery 35 (2009) 1056—1062
Tracheal injury associated with endotracheal
intubation
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Miñambres et al. Tracheal rupture after endotracheal
intubation. Eur J Cardiothorac Surg. 2009;35(6):1056-62
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182 cases of postintubation tracheal rupture.
mortality 22%
86% women
Intubations: 14% “difficult”, 27% emergent
Increased mortality associated with age ( p =
0.015) and emergency intubation (RR = 3.11; p
= 0.001)
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Miñambres et al. European Journal of Cardio-thoracic Surgery 35 (2009) 1056—1062
Variables associated with mortality
Miñambres et al. European Journal of Cardio-thoracic Surgery 35 (2009) 1056—1062
Risk factors / mechanism for tracheal rupture
with intubation
Am J Emerg Med 2004;22:289-293.
Risk factors for tracheal injury with intubation
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Why women?
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Shorter, with use of improperly long tubes
Smaller tracheal diameters- more vulnerable to cuff
overinflation
Anesth Analg 2001;93:1270–1
How do I avoid tracheal injury with emergent
intubation?
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Recommendations for emergent intubation:
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Select the proper size of endotracheal tube
Check all equipment before intubation
Check position of stylet (tip not beyond murphy’s eye)
Intubate gently and use RSI when necessary
Retract the stylet when balloon cuff passes through vocal
cords
Inflate the cuff slowly with proper volume and pressure
Fix ETT tightly to reduce the possibility of tube movement
Deflate the cuff first when repositioning the tube
Am J Emerg Med 2004;22:289-293.
Management of tracheal laceration or rupture
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Traditionally early surgical repair was mainstay
Now many recommend conservative treatment if
rupture < 2 cm, and if minimal non-progressive
sxs and no air leak
If > 2 cm, surgical vs conservative is debated.
In Miñambres et al. meta-analysis, surgical
repair was associated with a 2x increased
mortality
Meyer et al. case series: surgical repair in
critically ill pts is high risk, mortality up to 71%.
Miñambres et al. European Journal of Cardio-thoracic Surgery 35 (2009) 1056—1062
Meyer M. Thorac Cardiovasc Surg 2001;49:115—9.
Management of tracheal laceration or rupture
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Most recent studies recommend conservative
management if
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stable pt, no air leakage, no esophageal damage,
minimal mediastinal collections, no clinical
progression, no sign of infection
Conservative management = intubation with
cuff distal to lesion, continuous tracheal
aspiration, pleural drain, empiric abx
Surgical repair if unstable, large defect
(>4cm), any evidence of mediastinitis
Medina et al. J Bras Pneumol. 2009 Aug;35(8):809-13
Miñambres et al. European Journal of Cardio-thoracic Surgery 35 (2009) 1056—1062
Management of tracheal laceration or rupture
Am J Emerg Med 2004;22:289-293.
Management of tracheal laceration or rupture
Am J Emerg Med 2004;22:289-293.
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In retrospect, had we known what was going
on, would probably have at least evaluated
for surgical repair earlier.
Small rupture, but distal to ETT and with
demonstrated clinical deterioration
Questions/comments?
References
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Sternfeld D, Wright S. Tracheal rupture and the creation of a false
passage after emergency intubation. Ann Emerg Med. 2003
Jul;42(1):88-92.
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
Jun;35(6):1056-62.
Fan CM, Ko PC, Tsai KC, Chiang WC, Chang YC, Chen WJ, Yuan
A. Tracheal rupture complicating emergent endotracheal intubation.
Am J Emerg Med. 2004 Jul;22(4):289-93
Chen EH, Logman ZM, Glass PS, Bilfinger TV. A case of tracheal
injury after emergent endotracheal intubation: a review of the
literature and causalities. Anesth Analg. 2001 Nov;93(5):1270-1
Medina CR, Camargo Jde J, Felicetti JC, Machuca TN, Gomes Bde
M, Melo IA. Post-intubation tracheal injury: report of three cases and
literature review. J Bras Pneumol. 2009 Aug;35(8):809-13.
Meyer M. Iatrogenic tracheobronchial lesions—a report on 13 cases.
Thorac Cardiovasc Surg 2001;49:115—9.