Pneumothorax bilatéral,pneumomédiastin et emphysème sous-cutané cervico-facial après une trachéotomie chirurgicale

Tracheotomy is a surgical procedure for various indications, such as ventilator dependence and airway obstruction. Reported rates in the literature of complications of tracheostomy vary widely. We report an unusual presentation of serious complication after surgical tracheostomy. The correct timing of tracheostomy is still controversial in the literature. A 74-year-old male had emergency surgical tracheostomy under general anesthesia. At the end of the procedure, in recovery room, he developed subcutaneous emphysema of the eyes. There was no pneumothorax seen on chest X-ray. Bronchoscopic examination through the tracheostomy tube showed no evidence of damage to the posterior tracheal wall. Three hours later patient had difficulty breathing requiring sedation with respiratory assistance. X-ray of the chest at this stage showed a right pneumothorax and extensive subcutaneous emphysema of the chest wall. Pneumothorax was managed using a chest tube. Two days after, a control CT scan of the chest showed a left pneumothorax and pneumomediastinum. The pneumothorax was managed using a chest tube. Bronchoscopic examination showed no obvious lesion in the tracheobronchial tree. The patient was treated successfully with supportive care and large doses of antibiotic to prevent mediastinitis. Seven days later, recovery was rapid and complete and CT scan of the chest was completely normal. The patient was discharged from the hospital on the 13th postoperative day. This case illustrates that complications occurring after surgical tracheostomy could be dramatic. Management of tracheotomy is important to prevent complications. There is still debate on optimal timing of tracheotomy. The last three trials have shown no interest to perform an early tracheotomy, neither in terms of vital prognosis nor in terms of the duration of mechanical ventilation.     

Percutaneous dilational tracheostomy. Indications--techniques--complications

Tracheostomy is a generally accepted procedure that assures free access to the airways in long-term lung ventilation. Apart from surgical tracheostomy, percutaneous dilational tracheostomy (PDT) has been increasingly employed in intensive care units. Presently, five dilatation methods are available, all equally allowing the performance of a secure and low-risk, bedside tracheostomy in the intensive care unit. Exact knowledge of the anatomy of the neck region and of the entire procedure are preconditions for a safe intervention. Percutaneous procedures offer advantages over surgical tracheostomy in terms of complications. To minimize the risks, expertise in airway management during PDT and knowledge of the particularities of cannula replacement in dilational tracheostoma, are compulsory. Endoscopic control assures that the tracheostoma can be placed correctly and that possible complications can be recognised early. The incidence of a serious tracheal stenosis after PDT is low.     

Perkutane Dilatationstracheotomie

Tracheostomy is a generally accepted procedure that assures free access to the airways in long-term lung ventilation. Apart from surgical tracheostomy, percutaneous dilational tracheostomy (PDT) has been increasingly employed in intensive care units. Presently, five dilatation methods are available, all equally allowing the performance of a secure and low-risk, bedside tracheostomy in the intensive care unit. Exact knowledge of the anatomy of the neck region and of the entire procedure are preconditions for a safe intervention. Percutaneous procedures offer advantages over surgical tracheostomy in terms of complications. To minimize the risks, expertise in airway management during PDT and knowledge of the particularities of cannula replacement in dilational tracheostoma, are compulsory. Endoscopic control assures that the tracheostoma can be placed correctly and that possible complications can be recognised early. The incidence of a serious tracheal stenosis after PDT is low.     

Tracheostoma

Tracheostomy has gained importance due to recent developments in critical care medicine. This procedure is the most frequent surgical intervention on intensive care wards. Indications for tracheostomy (conventional versus dilatational) should consider the duration of the need for a tracheal cannula. The decision for one of the types of tracheostomy may have a relevant impact on the airway management and the rehabilitation of swallowing, because these are dependent on state of the tracheostoma and its subsequent maintenance. Selection of the appropriate cannula helps to avoid complications and improve patient comfort. To minimize the risks during tracheostomy, skills and expertise on the management of life- threatening complications are necessary. Early and late complications can be detected by regular examination of the tracheostoma which may help to repress complications in an early stage and can improve the long term outcome.     

Difficult airway management during emergency tracheostomy in a patient with severe rheumatoid arthritis

We experienced difficult airway management in a 65-year-old woman with acute dyspnea due to bilateral recurrent nerve palsy suffering from severe rheumatoid arthritis for fifty years. Her cervical spine was ankylosed and could not be extended at all. Tracheostomy was planned under local anesthesia because of difficulty of endotracheal intubation, possibility of airway obstruction and laryngeal edema. In this condition, the surgical area was narrow and difficult to approach. The surgical bleeding and blood-aspiration into the tracheostomy site occurred followed by airway obstruction. A rigid tracheal tube could not be inserted through the tracheal incision and SpO2 decreased to 81%. We inserted a percutaneous cricothyroidotomy cannula through the tracheal incision and superimposed HFJV on her spontaneous ventilation. Assisting the ventilation in this way finally, a spiral endtracheal tube was inserted and her oxygenation became stable.     

Iatrogenic aortic arch injury after unsuccessful percutaneous tracheostomy

Tracheostomy is a procedure that creates a direct opening to the airway through an incision in the anterior wall of the trachea. These days it is usually performed percutaneously as it is generally regarded as a safe procedure. We present the case of an unusual complication of aortic arch injury after percutaneous tracheostomy (PT) performed at an outside hospital. Major vascular injury was managed with sternotomy and direct aortic repair with a successful outcome. We believe PT should be performed under direct bronchoscopy visualization to limit any possible complications. Intensivists should be aware of this extremely rare complication of PT, which requires emergency cardiac surgery intervention and a team effort for appropriate management.     

Percutaneous tracheostomy after trauma and critical illness.

A method of percutaneous tracheostomy (PT) using a tracheostome, which permits insertion of a full-sized cuffed tracheostomy tube, was evaluated in 61 critically ill or injured patients (89% had trauma). Of the 54 trauma patients, 65% had brain injuries, 14% had injuries to the cervical spinal cord, 33% had face or jaw injuries, and 15% had lung injuries. The indications for PT were coma (46%), acute airway obstruction (5%), face or jaw injury (20%), pneumonitis (39%), adult respiratory distress syndrome (12%), and sepsis (21%). Tracheostomy was done in 51% of all cases specifically for managing pulmonary secretions, in 37% for prolonged intubation, and in 25% for neurologic lesions. The tracheostomy was done as an emergency in 5%, as urgent in 28%, and electively in 77%. Percutaneous tracheostomy was successful in 90% of the cases, and in 8% it was converted to a surgical tracheostomy after an initial percutaneous attempt. In 46% it was performed at the bedside, in 46% in the operating room, and in 7% in the emergency suite. A full-sized tracheostomy tube (#6 to #8) was used in all cases and was considered optimal or larger than needed in 87% of cases. With three exceptions the complications of PT were minor, but 30% of the patients died of their primary disease. In one case death occurred because of bronchospasm and cardiac arrest during the PT, but appeared to be independent of the type of tracheostomy. Healing after in-hospital removal (37%) was excellent in 95% of cases and 97% of physicians indicated that they would use the device again.     

Upper airway compromise secondary to edema in Graves’ disease

PURPOSE: We report an unusual case of upper airway compromise in a patient with Graves' disease. We speculate that this complication may be due, in part, to poorly controlled hyperthyroidism. CLINICAL FEATURES: A 26-yr-old female suffering from Graves' disease underwent a total thyroidectomy. Awake fibreoptic intubation was attempted because of a large goiter and orthopnea. Upper airway edema impeded the passage of an armored 7.5 mm endotracheal tube. She was subsequently intubated awake with a regular 7.5 mm endotracheal tube under direct laryngoscopy over an Eschmann bougie. The patient was extubated in the operating room over a tube exchanger. Two hours later she developed stridor and upper airway obstruction. Using direct laryngoscopy, she was reintubated with difficulty because of upper airway edema. At this time, she manifested signs of thyrotoxicosis which were managed medically. On postoperative day three she underwent a tracheostomy after failing a trial of extubation. The upper airway was edematous with minimal vocal cord movement. On postoperative day nine the tracheostomy was downsized and the patient was sent home. The vocal cords were still edematous with minimal movement. Three weeks later, she demonstrated normal right vocal cord movement and weak left vocal cord movement, and the tracheostomy was decannulated. CONCLUSIONS: Uncontrolled hyperthyroid patients with large goiters secondary to Graves' disease may develop edema of the upper airway. A high degree of vigilance for airway obstruction is necessary, with a carefully planned approach at each stage of the patient's hospital course to treat this potentially life-threatening situation.     

Tracheobronchial injury

We studied 6 cases of tracheobronchial injury due to the blunt chest truma in our department. All patients were male of 19 to 60 years of age. Injured sites were main bronchus in 2, tracheobronchial portion in 2, cervical trachea and main bronchus in 1, cervical trachea in 1. In a case of cervical tracheal injury and 2 cases of tracheobronchial injury, emergent operation was performed on the day of accident. Other cases with the main bronchial injury underwent conservative treatment at first, but subsequent bronchoplasty was necessary for them due to the bronchial stenosis. After the surgery for 2 cases of tracheobronchial injury, mechanical ventilation with double lumen tube was continued to reduce the airway pressure for the anastomotic sites. In conclusion, early surgical treatment is recommended for the airway injury and the respiratory management using double lumen tube after surgery may be helpful in preventing trouble at the anastomosis.     

Airway obstruction in a patient using a cuff button-like silicone cannula for tracheal stoma

We described a case of postoperative airway obstruction in a patient using a cuff button-like silicone cannula for tracheal stoma. A 59-year-old woman with rheumatoid arthritis, was admitted to the hospital for total knee arthroplasty. She had been managed by a long-term tracheostomy for rheumatic cricoarytenoid arthritis. Preoperative examination revealed no cardiopulmonary compromise. The surgery was performed under combined spinal-epidural anesthesia without any respiratory problems. Fifteen hours after surgery, she complained of dyspnea. Her oxygen saturation by pulse oximeter was 22-28%. We immediately removed the silicone cannula and inserted a tracheostomy tube. Her condition was dramatically improved next few minutes after the insertion. There were no dyskinesia and neurological disorders. We considered that airway obstruction occurred with the inadequate position of the cuff button-like silicone cannula, attached to the posterior wall of the trachea, sputum augmenting the obstruction.     

Lethal vascular erosion after percutaneous dilatation tracheostomy

We report on a patient who underwent dilatational tracheostomy (Ciaglia technique) because of ARDS. 29 days after the procedure she died of hemorrhage from an arrosion of the bracheocephalic trunk, caused by the cuff of the tracheal cannula. This complication has, so far, been reported only after surgical tracheostomy. The fracture of tracheal cartilages is considered to be the specific cause of this fatal complication. The consequent loss of circular stability of the trachea demands increased cuff insufflation and pressure to tighten the airway. Prevention and therapy consist in control of the cuff pressure and caudal placement of the tracheal cannula.     

Suprastomal tracheal stenosis after dilational and surgical tracheostomy in critically ill patients

We have previously reported cases of severe suprastomal stenosis after tracheostomy. In this observational study we investigated the occurrence of suprastomal stenosis as a late complication. Patients with persistent tracheostomy after intensive care underwent an endoscopic examination of tracheostoma, larynx and trachea. A percutaneous dilational tracheostomy was employed in 105 (71.9%) and surgical tracheostomy in 41 (28.1%) of the cases (n = 146). The incidence of severe suprastomal stenosis (grade II > 50% of the lumen) was 23.8% (25 of 105) after dilational tracheostomy and 7.3% (3 of 41) after surgical tracheostomy (p = 0.033). Age, gender, underlying disease, ventilation time, and swallowing ability were not significantly associated with the tracheal pathology. This study suggests that dilational tracheostomy is associated with an increased risk of severe suprastomal tracheal stenosis compared to the surgical technique.     

Loss of the airway during tracheostomy: rescue oxygenation and re-establishment of the airway

PURPOSE: To describe loss of the airway during tracheostomy and suggest a method for re-establishment of the airway and providing rescue oxygenation. CLINICAL FEATURES: A 22-yr-old female diagnosed with encephalomyelopathy was admitted to the intensive care unit with a progressively deteriorating level of consciousness and respiratory failure requiring intubation and ventilation. Several weeks later, an elective tracheostomy was performed under anesthesia. The surgeon made an anterior tracheal wall incision and inserted a cuffed #6 Shiley tracheostomy tube. No end-tidal CO(2) was detected and the patient could not be ventilated. After another failed attempt at insertion of a second tracheostomy tube, the diagnosis was made of a false passage within the trachea. The Shiley tracheostomy tube was removed and a #6 regular endotracheal tube was introduced in the trachea through the tracheostomy incision. The patient now could be ventilated with difficulty and low readings of end-tidal CO(2) were noted. Despite all efforts to further ventilate the patient, the arterial oxygen saturation never recovered, resulting in cardiac arrest. CONCLUSION: To restore a lost airway during tracheostomy, we recommend that a jet ventilation airway exchange catheter (JVAE) be inserted in the endotracheal tube through a bronchoscope port attachment prior to surgical entry into the trachea. The JVAE will also ensure continued ability to oxygenate the patient.     

A case of long-term respiratory management following resection of a huge facial hemangioma]

A 49 year-old-woman was scheduled for resection of a huge hemangioma of the face and neck region. After the resection, severe edema developed on the tongue, larynx, and pharynx even leaving no space between the tracheal tube and these tissues. Prolonged respiratory management with endotracheal tube intubation was needed to maintain the upper airway for more than three weeks. Tracheostomy was performed 27 days after the operation. Two weeks later, the edema of the upper airway subsided. Thereafter her clinical course was uneventful, and she was discharged 22 days after the tracheostomy. Resection of a huge facial and neck hemangioma should be carefully managed as it can be followed by unexpected severe postoperative upper airway edema leading to suffocation.     

吸入性损伤后预防性气管切开与紧急气管切开的临床研究

目的　探讨预防性气管切开的临床可行性。　方法　对 93例中度或重度吸入性损伤患者均行气管切开。气管切开前出现明显呼吸困难、血氧分压下降、血氧饱和度下降者为紧急气管切开组 (2 1例 ) ;气管切开前未出现明显通气、换气障碍者为预防性气管切开组 (72例 )。预防性气管切开组实施手术时间为伤后 (4 .31± 3.0 4 )h ,紧急气管切开组为伤后 (34.4 7± 2 .79)h。比较两组患者相关生命体征、血氧分压、氧饱和度、呼吸频率及呼吸机使用情况。　结果　紧急气管切开组血氧分压、血氧饱和度、呼吸频率、心率等术前均有明显的异常 ,术后得到显著改善 ,而预防性气管切开组相关生命体征较平稳。紧急气管切开组术后 2d内 2 0例使用呼吸机辅助呼吸 (95 .2 4 % )。预防性气管切开组术后 2d内 6 5例使用呼吸机辅助呼吸 (90 .2 8% )。　结论　对疑有中度以上吸入性损伤的患者应及早行预防性气管切开 ,尽量避免紧急气管切开。气管切开后建议早期使用呼吸机辅助呼吸。     

Two cases of negative pressure pulmonary edema after induction of anesthesia and extubation

Two cases of negative pressure pulmonary edema are described. In one case, tracheal intubation was not successful and airway obstruction occurred after induction of anesthesia. Spontaneous breathing was restored by reversal of neuromuscular blocking action, but airway obstruction persisted. Urgent tracheostomy was therefore performed. A chest x-ray and clinical features indicated pulmonary edema immediately after tracheostomy. Treatment with mechanical ventilation and positive end-expiratory pressure improved pulmonary edema. In the other case, airway obstruction occurred after extubation. Removal of secretion in the oral cavity and assisted ventilation improved airway obstruction, but pulmonary edema was found by chest x-ray. Forced diuresis using furosemide and oxygen inhalation resulted in the improvement of pulmonary edema. Fortunatetly, in both cases, significant complications associated with pulmonary edema did not occur. Care should be taken of the risk of pulmonary edema when the airway was obstructed after induction of anesthesia or extubation under spontaneous breathing.     

Bedside Percutaneous Tracheostomy: Prospective Evaluation of a Modification of the Current Technique in 100 Patients

Percutaneous dilatational tracheostomy (PDT) is being increasingly used. Concerns have been raised as to its safety, especially when it is done at the bedside. A prospective evaluation was conducted of 100 consecutive, unselected critically ill patients with PDT. The mean intensive care unit (ICU) stay before PDT was 12 days. One surgeon performed PDT alone (5 cases) or assisted residents (95 cases) in all operations; 84 were performed at the ICU bedside. Only the first six patients were taken to the operating room solely for tracheostomy. A modified technique was used: (1) the endotracheal tube was left in place during sequential dilations; (2) dilators were inserted in a 60-degree cephalad orientation to the skin and directed caudally after penetration of the anterior tracheal wall; (3) a digit was inserted through the tracheal opening to guide withdrawal of the endotracheal tube to the level of the vocal cords; and (4) size 8 tracheostomy cannulas were inserted over 28F dilators. The average time from skin incision to insertion of the tracheostomy tube was 12 minutes (< 10 minutes, 41 patients; 10 to 15 minutes, 37 patients; > 15 minutes, 22 patients). Sixty-five percent had unfavorable anatomic conditions due to spinal precautions or diffuse neck edema. Postoperative complications occurred in four patients; surgical emphysema after tracheal lacerations in three, cannula dislodgment in one. All complications were successfully managed without an operation by tube exchange (n= 3) or observation (n= 1); there was no procedure-related mortality. Forty patients were available for long-term follow-up (6–18 months after tracheostomy) by telephone; one had persistent hoarseness without respiratory difficulty. We concluded that bedside PDT is safe and easy to teach when performed with a technique that ensures correct instrumentation.     

Anesthetic management of a patient with Saber-sheath trachea]

A 65-year-old man was scheduled for total gastrectomy. Preoperative chest radiograph showed significant narrowing of the trachea. On chest CT scan the trachea was U-shaped (tracheal index = 36%) and was diagnosed as saber-sheath trachea. During general anesthesia we took care to reduce the irritation by the endotracheal tube, particularly during intubation, and to avoid excessively high airway pressure. The trachea was watched carefully by bronchoscopy after intubation and during extubation not to neglect any complication. There was no complication after the operation.     

Postoperative management in single-lung transplantation for lymphangioleiomyomatosis

A 35-yr-old woman presented with dyspnea has been diagnosed as having lymphangioleiomyomatosis (LAM). Despite treatment with estrogen, her pulmonary function deteriorated progressively. In January 2001, a left single-lung transplantation was performed on her from a cadaveric donor. On admission to the ICU after the transplantation, arterial blood gas analysis showed a severe respiratory acidosis. A double-lumen endotracheal tube (ETT) was replaced by a single-lumen ETT for a better suctioning of secretion. Gas exchange improved after the replacement of ETT and suctioning of secretion by bronchoscopy. Five hours after the admission to the ICU, the breath sound decreased over the right thorax. The chest X-ray showed right pneumothorax, and a chest tube was inserted. The patient was weaned from mechanical ventilation gradually and extubated on the 6th ICU day. The patient was discharged from ICU to the general ward on the 9th ICU day without pneumonia and other complications. The development of pneumothorax in the recipient lung should be kept in mind during the perioperative period of lung transplantation for LAM.     

Tracheal rupture in a child with blunt chest injury

A 10-year-old boy fell from a tree and sustained blunt injury to his chest. He was brought to the hospital (6 h later) with difficulty in breathing and inability to speak. There was a bruise on the neck and extensive subcutaneous emphysema over the neck and chest and decreased air entry over the right hemithorax. Radiographs revealed a right-sided pneumothorax, pneumomediastinum and tracheal deviation. An intercostal drain (with underwater seal) was inserted and he was transferred to the operating room for bronchoscopy. Anesthesia was induced with IV midazolam and ketamine. The trachea was intubated orally and anesthesia maintained with spontaneous breathing of halothane in oxygen. Flexible fiberoptic bronchoscopy performed via the tracheal tube revealed no injury to bronchi or carina. Bronchoscopy through the tracheal tube withdrawn to the level of the vocal cords revealed a 1-cm long posterior longitudinal tear approximately 2-3 cm below the cords. The surgeons planned a definitive tracheostomy distal to the traumatic tracheal opening. This was difficult and initially unsuccessful because of subcutaneous emphysema. A ureteric catheter was introduced through the tracheal tube and a tracheostomy tube mounted on the fiberoptic bronchoscope, which was then inserted through the surgical tracheostome. This followed the ureteric catheter into the distal trachea and the trachea was successfully cannulated. We review the mechanism of tracheal injuries with special reference to its occurrence in children with blunt injury. We discuss the airway management in these potentially life-threatening injuries.