Iatrogenic tracheal rupture after endotracheal intubation

Tracheobronchial rupture after tracheal intubation is rare in clinical practice. Possible contributory factors are multiple vigorous attempts at intubation, overinflation of the cuff, anatomic alterations, and predisposing individual factors. These lesions can be detected by bronchoscopy, which is the most effective method to confirm the diagnosis and determine the exact location and extent of the tear. We report the case of a woman with membranous tracheal rupture after endotracheal intubation. Subcutaneous emphysema, pneumomediastinum and bilateral pneumothorax were noted after extubation. The diagnosis was confirmed by fiberoptic bronchoscopy and computed tomography scan, and the patient required emergency surgical repair.     

Tracheal stent to repair tracheal laceration after a double-lumen intubation

A 59-year-old woman was referred for a diagnostic video thoracoscopy under general anesthesia. At the end of the procedure, the patient presented with subcutaneous emphysema and cyanosis, abdominal distension, and bradycardia. A rigid bronchoscopy showed a longitudinal laceration in the pars membranacea of the trachea. A tracheal silicon stent was positioned on an emergency basis. She was intubated, positioning the tracheal tube cuff distal of the stent under bronchoscopic vision. A computed tomographic scan performed immediately after the procedure showed left pneumothorax, pneumoperitoneum, pneumopericardium, and diffuse subcutaneous emphysema. The subsequent course of the patient was uneventful. The patient was discharged home on postoperative day 4. After 1 year, the stent was removed with the evidence of complete trachel healing.     

A new retrograde transillumination technique for videolaryngoscopic tracheal intubation

This single‐centre, prospective trial was designed to assess the efficacy of a new retrograde transillumination device called the ‘Infrared Red Intubation System’ (IRRIS) to aid videolaryngoscopic tracheal intubation. We included 40 adult patients, who were undergoing elective urological surgery under general anaesthesia. We assessed the ability to differentiate the transilluminated glottis from other structures and found a median (IQR [range]) larynx recognition time of 8 (5–14 [3–28]) s. The difference in laryngeal visibility on the screen between the deactivated vs. activated device expressed on a visual analogue scale was significant (6 (4–7 [2–10]) vs. 10 (8–10 [4–10]); p < 0.001). The number of laryngoscope insertions was 1 (1–2 [1–3]) and the device showed high values on a visual analogue scale ranging from 0 (lowest score) to 10 (highest score) for helpfulness (6 (5–7 [2–10])), credibility (10 (8–10 [5–10])) and ease of use (10 (9–10 [8–10])). Tracheal intubation with the system lasted 26 (16–32 [6–89]) s. No alternative technique of securing the airway was necessary. The lowest SpO₂ during intubation was 98 (97–99 [91–100])%. We conclude that this method of retrograde transillumination can assist videolaryngoscopy.     

Tracheobronchopathia osteoplastica: cause of difficult tracheal intubation

Tracheobronchopathia osteochondroplastica is a rare benign disorder affecting the trachea and the bronchi. We report a case presenting as difficulty during tracheal intubation. Chest roentgenogram revealed nothing before surgery. Findings on computed tomographic imaging scans show calcified nodular densities protruding into the tracheal lumen, with an abnormally irregular tracheal morphology and decreased lateral diameter. The fiber optic bronchoscopy, which was unable to pass more than 4 to 5 cm, showed enormous prominent protrusion with significant narrowing of the tracheal lumen. The diagnosis was confirmed by virtual bronchoscopy, which showed a tracheal narrowing with a beaded appearance and an irregular border that extended into the trachea and main bronchi.     

Prompt correction of endotracheal tube positioning after intubation prevents further inappropriate positions

Study Objective

To determine whether the timely correction of endotracheal tube (ETT) positioning prevents further inappropriate positions.

Design

Prospective crossover study.

Setting

University-affiliated hospital.

Patients

44 adult, ASA physical status 1, 2, and 3 patients undergoing open or laparoscopic abdominal procedures.

Interventions

ETT positioning was verified by both auscultation and fiberoptic bronchoscopy (FOB), after intubation, and before extubation. In laparoscopic procedures, two additional measurements were performed: after maximal abdominal gas insufflation and with head-down position. An ETT in the bronchus or at the carina was considered an inappropriate placement. An ETT ≤ one cm from the carina was considered a critical placement.

Measurements

The frequency of inappropriate and critical ETT positioning with both auscultation and FOB and the number of ETTs that remained in an incorrect position despite repositioning.

Main Results

FOB detected 5 inappropriately positioned ETTs, 4 of which were also detected by chest auscultation (P = 0.99). Critical positioning was detected by FOB in 6 patients, three of which were also detected by auscultation (P = 0.24). There were 15 other "out-of-desired range” positions (out of the 3-5 cm range) - one placed too high and 14 placed too low, while 18 were placed within the range of positions. All patients with inappropriate ETT positioning were women (P = 0.005). Age, body mass index, Mallampati grade > 3, thyromental distance < 6 cm, or laryngoscopy grade ≥ 2 were not associated with either inappropriate or critical placement. No episodes of inappropriate or critical positioning were detected by FOB or auscultation at the end of surgery.

Conclusions

Early detection and prompt correction of inappropriate ETT positioning after intubation prevented further ETT migration into undesired positions.     

Pancuronium for rapid induction technique for tracheal intubation

Suxamethonium in a dose of 2 mg.kg-1 was compared to pancuronium in three different dosages (0.1 mg.kg-1, 0.15 mg.kg-1, 0.2 mg. kg-1) for a rapid induction (crash) technique for tracheal intubation. Pancuronium 0.1 mg.kg-1 was inferior to suxamethonium, but the larger doses of pancuronium were equally satisfactory. In those instances where suxamethonium is either contraindicated or undesirable, pancuronium in a dose of 0.15 mg.kg-1 is a suitable alternative for rapid induction for tracheal intubation.     

A case of tracheal injury after emergent endotracheal intubation: a review of the literature and causalities.

IMPLICATIONS: Tracheal lacerations are rare, but potentially fatal, complications of intubations. Diagnosis of such conditions is difficult, and thus a high level of suspicion must be kept. We present a case and review the literature for factors that indicate high-risk patients.     

Repair of iatrogenic distal tracheal rupture by left thoracotomy

The trachea is readily accessed through a right thoracotomy. Further exposure of the distal trachea may be accomplished using a median sternotomy through a transpericardial approach. We report our experience of a case of iatrogenic tracheal rupture in a patient with a large left-sided posterior mediastinal tumor. Surgical resection of the mass and subsequent repair of the tracheal rupture was accomplished through a left thoracotomy.     

Conditions for endotracheal intubation after atracurium and suxamethonium

Intubating conditions following 2 different dosage levels of atracurium, a new non-depolarising muscle relaxant was compared with suxamethonium. The dosage levels of atracurium were 0.5 mg/kg and 0.7 mg/kg while the dosage of suxamethonium chloride was 1 mg/kg. A total of 60 patients with 20 patients in each of the three groups were studied. Premedication was with oral diazepam 10 mg. Anesthesia was induced with fentanyl 1 microgram/kg and thiopentone 5 mg/kg and intubation performed in all cases by the same operator. Excellent intubation conditions were obtained in all patients within 60 seconds in the suxamethonium group, 90 seconds in the atracurium 0.7 mg/kg group, and 120 seconds in the atracurium 0.5 mg/kg group. No side effects were observed and there was circulatory stability. It is concluded that atracurium in a dose of 0.7 mg/kg allows more rapid intubation than the 0.5 mg/kg dose. It is however not as rapid as suxamethonium which remains the drug of choice when very rapid intubation is crucial.     

Laryngeal paralysis after tracheal intubation for anesthesia

A 17 year old man was anaesthetized for osteosynthesis of a fractured left femoral diaphysis. Endotracheal intubation was easy, anaesthesia and surgery were both uneventful. On recovery, some hoarseness was noticed. Two months later, an ENT examination showed signs of laryngeal paralysis. The presumed explanation was compression of the recurrent nerve by the high-positioned balloon of the tracheal tube. Recovery was complete four months later.     

魏氏喷射气管导管用于患者气管插管术的效果

目的 评价魏氏喷射气管导管用于患者气管插管术的效果.方法 择期全麻气管插管术患者102例,性别不限,年龄15～50岁,体重40～99 kg,ASA分级Ⅰ～Ⅲ级,Cormack&Lehane分级Ⅰ～Ⅳ级(Ⅰ或Ⅱ级为非困难气道,Ⅲ或Ⅳ级为困难气道).采用随机数字表法,将患者随机分为2组(n=51):常规导管组(C组)和魏氏喷射气管导管组(WJ组).2组根据Cormack&Lehane分级分为2个亚组:困难气道组(n=16)和非困难气道亚组(n=35).C组使用普通Kendall气管导管进行插管;WJ组使用相同内径的魏氏喷射气管导管,在喷射通气同时行气管插管.记录机械通气即刻PETCO2;记录首次气管插管成功情况及气管插管时间;记录气管导管拔除后24h内的并发症发生情况.结果 与C组比较,WJ组气管插管时间延长,困难气道患者气管插管首次成功率升高(P＜0.01).与非困难气道患者比较,WJ组困难气道患者机械通气即刻PETCO2、气管插管时间和首次成功率比较差异无统计学意义(P＞0.05),C组困难气道患者机械通气即刻PETCO2升高,气管插管首次成功率降低(P＜0.01).WJ组未出现气胸、纵隔气肿及皮下气肿等严重气压伤;2组喉痉挛、咽喉痛和胃胀气发生率比较差异无统计学意义(P＞0.05).结论 魏氏喷射气管导管不仅能安全有效地为气管插管全麻患者提供通气,还可提高困难气道气管插管成功几率.     

Tracheal laceration after intubation and application of continuous airflow through the outer cuff of the tracheal tube

We report the case of a man diagnosed with cervical spinal stenosis who underwent a C3-C6 bilateral laminectomy. In the immediate postoperative period he developed subcutaneous emphysema and pneumomediastinum caused by tracheal laceration. Continuous airflow (1 L x min(-1)) through the outer cuff was applied during the operation to compensate for air leak when loss of balloon cuff pressure was detected.     

Unsuspected tracheal web inhibits endotracheal intubation: report of a case

A 66-year-old woman was scheduled for resection of a recurrent brain astrocytoma. During anesthesia induction, endotracheal intubation became impossible. Urgent bronchoscopy under laryngeal mask ventilation visualized a subglottic web 1 cm below the vocal cords. After bronchoscopic ablation with argon plasma coagulation, the airway intubation was successful.