Pneumomediastinum due to distal tracheal diverticulum after uneventful tracheal intubation and
management of subsequent general anaesthesia
B. Mazul-Sunko,1 D. Zdenčar,1 J. Špiček-Macan,2 I. Kožul,3 D. Stančić-Rokotov,4 N. Hodoba,2 N.
Osmančević,1 N. Chalfe,5 I. Gilja, 3 D. Tonković1
1 Department of Anaesthesiology and Intensive Care, University Hospital Sveti Duh,
Zagreb, Croatia
2 Department of Anaesthesiology and Intensive Care, University Hospital Center Zagreb,
Zagreb, Croatia
3 Department of Urology, University Hospital Sveti Duh, Zagreb Croatia
4 Department of Thoracic Surgery Jordanovac, University Hospital Center Zagreb, Zagreb, Croatia
5 Department of Pulmonary Diseases Jordanovac, University Hospital Center Zagreb, Croatia
Corresponding author : Branka Mazul-Sunko, Department of Anaesthesiology and Intensive Care,
University Hospital Sveti Duh, Sveti Duh 64, 10 000 Zagreb, Croatia,
Telephone: ++385 91 3712 438
e-mail: bmsunko@gmail.com
Financial disclosure: all diagnostic tests and imaging were part of clinical routine and we have received no
financial support or additional funding
Body text: 1207 words
Tracheal diverticulum is a rare anatomic anomaly associated with potentially serious complications during
general anaesthesia (1). It has been diagnosed several times after difficult tracheal intubation or ventilation
(2,3). We report of a patient who developed pneumomediastinum caused by tracheal diverticulum
laceration after uneventful tracheal intubation. The clinical course was complicated by necessity of radical
cystectomy under general anaesthesia shortly after the occurrence of pneumomediastinum. Additional
problem was the location of diverticulum close to tracheal bifurcation so that a standard procedure of
bridging it by orotracheal tube would not provide safe bilateral ventilation.
Case report
An 80-year-old female was admitted to the Department of Urology due to macrohematuria. Three days
after admittance, the patient underwent an emergent endoscopic surgery due to uncontrolled hematuria.
Tracheal intubation was performed without difficulties on first attempt using 7,5 Ch orotracheal tube with
guide wire to provide smooth and fast induction for the emergent procedure . Immediately after extubation
the patient was eupnoic, hemodynamically stabile and awake. 10 minutes after admittance to the Intensive
Care Unit the patient complained of difficult breathing. MSCT (Multisliced Computed Tomography)
revealed extensive pneumomediastinum and discontinuity of the posterior tracheal wall in length of 40 mm
and 30 mm cranially from the tracheal bifurcation.
Two days after surgery, the patient was transferred to the Department of Thoracic Surgery, where
fiberbronchoscopic examination of the trachea showed a 40 mm long diverticulum on the membranous
wall, 30 mm cranial from carina. Under fiberbronchoscopic examination, no sign of laceration or
communication with mediastinal structures was visible .
(Figure 1).
Therefore we concluded that there did exist a minor lesion of a thinner tracheal diverticulm wall which did
not cause clinical problems under spontaneous respiration, but provoked mediastinal air leakage only under
positive pressure ventilation. Given the uneventful clinical course, no further major thoraco-surgical
procedure was indicated.
In the meanwhile, histological analysis revealed invasive carcinoma of urinary bladder, and radical
cystectomy under general anaesthesia had to be planned. Anaesthesiological managment was complicated
by the distal position of tracheal diverticulum. It was described to be 30 mm cranial from carina and
standard orotracheal tube with the tip position 50 to 70 mm above tracheal bifurcation could not bridge it,
but would bend at the level of diverticulum or in the diverticulum itself, causing pneumomomediastinum
again. On the other hand, a more distal position of a standard orotracheal tube, would not provide safe
bilateral ventilation during the prolonged surgical procedure. Therefore, we decided to intubate the patient
using a left-sided Robertshaw tube which has a more distal tube opening and tracheal cuff positioning than
standard orotracheal tube and ensured bypassing the tracheal diverticulum in this way.
10 days after the first surgery for transurethral tumor resection general anaesthesia for radical cystectomy
was planned. Before intubation epidural catheter at T9-T10 level was introduced. Anaesthesia was induced
The trachea was intubated using left sided Robertshaw tube 7,5 Ch. Correct position was bronchoscopically
checked. Anaesthesia was maintained administering isoflurane 0,7-1,2 MAC,
continuous epidural
anaesthesia and vecuronuim for muscle paralysis. The lungs were ventilated without difficulties and there
were no signs of hemodynamic instability throughout the procedure . The patient was extubated in the
operating theatre. Postoperative recovery went uneventful and the patient left hospital 10 days after
surgery.
Discussion
Tracheal diverticulum is a benign and rare entity with prevalence of 1 % in autopsy series (4, 5). It is
characterized by a single or multiple invaginations of tracheal wall. Most cases are asymptomatic or
symptoms are nonspecific. They can be congenital or acquired. It is possible that chronic cough caused by
mild obstructive changes in our patient could cause increased intraluminal pressure to provoke herniation
of the mucosal membrane through the tracheal wall (6).
There are several reports of complications caused by tracheal diverticulum in the context of orotracheal
intubation and positive pressure ventilation (1,2,3,7). In these reports, complications caused by tracheal
diverticulum injury are associated with difficult intubation or ventilation.
Our report points out that
tracheal diverticulum remains an important option in the differential diagnosis of pneumomediastinum after
intubation and positive-pressure ventilation, even when endotracheal intubation was uneventful. A clinical
course indicative of a lesion which could not be confirmed bronchoscopically has been reported before (8).
In both cases the events could reasonably be ascribed to diverticulum lesions or opening too narrow to be
open under conditions of spontaneous respiration.
The possible contributing factors might be those found to predispose to tracheal lesion, like older age,
female gender and cancer (9), which were all present in our patient, precipitated by the use of a guide wire
by the anaesthesiologist.
Another specific aspect of our report is management of subsequent general anaesthesia shortly after
tracheal diverticulum lesion occurred. Bilateral ventilation using endobronchial tube after distal tracheal
diverticulum injury has not been previously reported to our knowledge, although similar management was
described in distal tracheal lesions in the absence of a diverticulum (10). Our experience confirms that
distal tracheal diverticulum lesions can be safely treated in the same way.
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Management of