Spontaneous Tracheal Rupture: a Case Report

We report the case of a spontaneous posterior tracheal wall rupture following a cough. A 67-year-old woman with a history of longstanding treatment with corticosteroids (8 years) for Giant Cell Arteritis had general anesthesia for cataract removal. Surgery and anesthesia were uneventful. In the recovery room, the patient coughed and soon after developed subcutaneous emphysema of the neck. Chest radiography confirmed the clinical diagnosis of marked subcutaneous emphysema and showed huge pneumomediastinum and minor right pneumothorax. A thoracic CT scan revealed a large laceration of the posterior tracheal wall (a 4 cm longitudinal tear), extending from the middle of the trachea to the level of the carina. Surgical repair consisted in closure of the dilaceration using an autolo-gous pericardial patch.

It seems reasonable to suspect the facilitating role of connective tissue fragility due to chronic corticosteroid administration in the development of this tracheal rupture following cough. Tracheal rupture is a potentially lethal injury, which can be repaired successfully if the diagnosis is made early. Risk factors, diagnosis and principles of treatment of this lesion are discussed.     

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 Bronchoscopy through the tracheal tube withdrawn to the level of the vocal cords revealed a 1-cm long posterior longitudinal tear approximately 2-3 cm below the cords.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.     

Tracheal Rupture After Blunt Trauma

Tracheal injuries are uncommon after blunt trauma. Early diagnosis and urgent treatment are primordial to reduce both mortality and morbidity. We describe the case of a 45-year-old man who met with a traffic accident and was brought to the emergency department. Progressively, he developed dyspnoea and coughing. The diagnosis of a tracheal rupture was established and the rupture was closed surgically. The management of the patient with suspected tracheal rupture is discussed.     

艾司洛尔对依托咪酯诱导气管插管时脑氧供需平衡和能量代谢的影响

目的:观察艾司洛尔对依托咪酯诱导气管内插管时脑氧供需平衡和能量代谢的影响。方法:将24例择期腹部手术患者随机分为艾司洛尔(A)组和对照(B)组,每组各12例。A组全麻诱导应用依托咪酯、咪达唑仑、芬太尼和维库溴铵,并在插管前30s静注艾司洛尔1mg/kg;B组除不用艾司洛尔外,其他与A组相同。分别于全麻诱导前、气管插管后即刻采集颈内静脉和桡动脉血,检测血糖、血乳酸盐及血气,记录MAP和HR;并计算脑动-静脉血氧含量差(Da-jvO2),脑氧摄取率(CERO2),葡萄糖摄取率(GluER),脑动-静脉血乳酸盐浓度差(Da-jvLac)。结果:与诱导前比较,A组插管后即刻MAP、HR无显著变化(P0.05),SjvO2增高、Da-jvO2和CERO2降低(P均0.05);B组插管后即刻MAP、HR及SjvO2明显增高(P0.01),Da-jvO2和CERO2显著降低(P0.01)。B组插管后即刻MAP、HR及SjvO2水平明显高于A组(P0.01),而Da-jvO2和CERO2水平明显低于A组(P0.05)。两组GluER和Da-jvLac无显著变化(P0.05)。结论:麻醉诱导时给予艾司洛尔1mg/kg可减轻依托咪酯诱导气管内插管对脑氧供需平衡的影响,但不影响脑的能量代谢。     

气管插管病人胃管置入方法研究

目的 探讨气管插管病人胃管置入方法。方法 将264例气管插管病人随机分为卡弗放气组(A组)、卡费不放气组(B组)、头部前倾组(C组)和镇静状态下牵拉气管组(D组)各66例；观察并比较一次置管成功率，置管前后HR、SpO2及置管过程中呛咳发生率。结果①一次置管成功率比较，A组与B组差异无显著性意义(P＞0．05)，C组显著低于A、B组(均P＜0．05)，D组显著高于其它各组(均P＜0．01)。②置管后HR、SpO2与各自置管前相比，B、D组无显著性意义(均P＞0．05)，A、C组HR明显加快、SpO2明显降低(P＜0．05，P＜0．01）；C组置管过程中呛咳发生率显著高于其他各组(均P＜0．01)。结论 对气管插管病人在镇静状态下牵拉气管的同时置入胃管准确性高、不良反应少。     

Successful difficult intubation Tracheal tube placement over a gum-elastic bougie

A randomised study was carried out to assess the effect of tracheal tube rotation on the passage of a tube over a gum-elastic bougie into the trachea in 100 patients. The effect of the presence or absence of a laryngoscope on successful tube placement was also assessed. A grade 3 difficult intubation was simulated in patients with a laryngoscope. There was a significant difference in the rates for successful first-time intubation in those patients with tube orientation of -90 degrees (with the bevel facing posteriorly) as compared with a tube orientation of 0 degrees (the normal orientation with the bevel facing left). The unsuccessful first-time intubations with a 0 degree orientation were frequently converted to successful intubations with the -90 degrees position at a second attempt. The presence of a laryngoscope in the mouth while rail-roading a tube over the bougie also made a significant difference to the rate of successful first-time intubations. The most successful method was to leave the laryngoscope in the mouth and rotate the tube to -90 degrees.     

Percutaneous tracheostomy and cricothyrotomy techniques

Percutaneous tracheostomy is currently accepted as a standard technique for longer-term airway care in the critically ill patients in many intensive care units (ICUs). Early tracheostomy has not shown any survival benefit compared to late tracheostomy following prolonged tracheal intubation in ICU patients. The main indications for tracheostomy in the ICU setting include weaning from artificial ventilation or airway protection. Nevertheless, many questions about choice of techniques, post-tracheostomy care and decannulation remain unanswered. This review gives an overview of current techniques.     

Mucus Transport and Surface Damage After Endotracheal Intubation and Tracheostomy. An Experimental Study in Pigs

The effects on mucus transport of different grades of tracheal injury produced experimentally by an intubation tube were studied in 26 pigs. Two of them were not intubated and served as controls, while the rest were anaesthetized and either intubated or tracheostomized, or both, and ventilated for approximately 4.5 h. They were then killed and the trachea and larynx were immediately removed and placed in a specially designed chamber at 3 7^oG and 85 % relative humidity. Cardio-green dye was deposited caudally in the trachea as a mucus marker. The mucus transport was observed macroscopically and the ultrastructure of the tracheal wall at the region of mucus arrest was studied by light microscopy and scanning and transmission electron microscopy. In non-intubated pigs the mucus was transported to the posterior larynx. The ciliated epithelium was usually intact along the pathway where cardio-green-stained mucus had travelled. In pigs which had been intubated and/or tracheostomized, mucus transport stopped completely at different levels of the trachea. The damage to the ciliated epithelium varied; in some animals there was almost none at all and in others there was a patchy loss of a large proportion of the cilia, or complete lack of cilia. Lesions which also included epithelial cells were often seen. Tracheal injury due either to a cuffed endotracheal tube or to a tracheostomy tube, with destruction of epithelium and cilia, causes a barrier to mucus transport, leading to arrest and accumulation of mucus further down in the airway. We were unable, however, to demonstrate a direct correlation between grade of damage and tendency to mucus arrest.     

Tracheal intubation under fluoroscopic control X ray-guided orotracheal intubation in three cases of impossible direct laryngoscopy

Three patients are described in whom it was impossible to visualise the larynx at direct laryngoscopy. Tracheal intubation was successfully and rapidly achieved with the aid of continuous fluoroscopy.     

全麻诱导用药对气管狭窄患者插管的影响

目的:比较右美托咪啶-七氟烷、七氟烷复合瑞芬太尼麻醉诱导用于气管狭窄患者插管的效果.方法:气管狭窄需插管全麻的颈胸部手术患者40例,采用随机数字表法分为两组,DS组先静脉恒速泵输注右美托咪啶1μg/kg,然后面罩吸入8%七氟烷;SR组面罩吸入七氟烷,睫毛反射消失时45 s内缓慢静脉注射瑞芬太尼2μg/kg.采用Viby-Mogensen评分法评价气管插管条件.结果:与SR组相比,DS组咳嗽反射、肢体反应的满意率和气管插管首次成功率均升高;气管插管期间SR组有4例发生低血压、2例心动过缓,DS组无1例需提升血压和心率.结论:与瑞芬太尼比较,应用推荐剂量的右美托咪啶1μg/kg复合七氟烷麻醉诱导,能提供更好的插管条件,不良反应少,且可在维持自主呼吸下行气管插管.     

Tracheal intubation through the intubating laryngeal mask in patients with unstable necks

BACKGROUND: In patients with unstable necks, the neck should be stabilized during induction of anaesthesia, but this may make tracheal intubation difficult. Awake intubation may produce straining, which could be detrimental to the unstable neck. METHODS: We studied 20 patients with unstable necks to examine the efficacy of insertion of the intubating laryngeal mask under conscious sedation (to minimize the possibility of losing a patent airway and to facilitate fibrescope-aided intubation) followed by tracheal intubation through the laryngeal mask after induction of anaesthesia (to reduce stress response to intubation). After the patient had been sedated with midazolam (up to 5 mg) and fentanyl (up to 100 microg), the intubating laryngeal mask was inserted. General anaesthesia was then induced with sevoflurane and tracheal intubation attempted. RESULTS: In all patients, tracheal intubation through the laryngeal mask succeeded without airway obstruction. Neither insertion of the mask under conscious sedation nor tracheal intubation after induction of anaesthesia caused straining, and only two patients moved upper extremities at intubation. Insertion of the laryngeal mask did not significantly alter blood pressure or heart rate. Tracheal intubation significantly increased blood pressure and heart rate, but the increase was considered to be small. CONCLUSIONS: In the patient with an unstable neck with a low risk of pulmonary aspiration, insertion of the intubating laryngeal mask while the patient is sedated may minimize difficulty in obtaining a patent airway before tracheal intubation and may facilitate a fibrescope-aided tracheal intubation; subsequent induction of anaesthesia before tracheal intubation may minimize stress response to intubation.     

Tracheal agenesis: management of the first 10 months of life

Tracheal agenesis is a potentially lethal congenital anomaly, appearing only at birth. We describe a newborn preterm infant who presented with immediate respiratory distress and no audible cry. There was almost complete tracheal agenesis with a very short segment of distal trachea (only two tracheal rings) arising from the anterior wall of the esophagus, before dividing into the mainstem bronchi. The anomaly was unsuspected prenatally, as the scan showed pyloric atresia and complex congenital cardiac disease. Despite the patient's difficult course, with correction of the rare-associated malformations (cardiac and gastrointestinal tract anomalies), the fact that the child is lively and neurologically normal for her age, requires that we now consider the patency of the airway and the possibility of surgical correction, in accordance with a good quality of life.     

Spontaneous Hepatic Rupture During Third Trimester of Pregnancy

Hepatic rupture is a rare and devastating complication in pregnancy, mainly associated with pre-eclampsia and HELLP (Hemolysis, Elevated Liver enzymes, Low Platelet count). It has an incidence of 1 case in 45,000225,000 births. Nearly 200 cases have been reported in the international literature. We report a case of a hepatic rupture with severe haemorrhage caused by HELLP in a third trimester pregnancy. The case was managed successfully with no pathological complications for either the mother or the infant. The physician should be aware of this condition when dealing with intra-abdominal haemorrhage during pregnancy.     

Cardiac Arrest After Intragastric Balloon Insertion in a Super-Obese Patient

A super-obese patient who suffered from severe sleep apnea (SSA) and other comorbidities underwent insertion of a BioEnterics intragastric balloon (BIB) before bariatric surgery. During the night, he was victim of cardiac arrest. After cardiopulmonary resuscitation and return of spontaneous circulation, he was transferred to intensive care unit. Two hours later, he developed an unexpected symptomatic bradycardia, and BIB was removed. The patient had no further cardiac complications, but he had a poor neurological outcome. In our opinion, such a severe cardiac event was the result of several causes. The BIB induces vagal nerve activation by stretching the gastric wall. In addition, super-obese patients with sleep apnea and other comorbitities have an increased risk of potentially fatal cardiac arrhythmias especially during the night. For all these reasons, we think that these patients may benefit from further preoperative cardiac investigations and a more intensive control during the first postinsertion day.     

Tracheal intubation and sore throat: a mechanical explanation

Although tracheal intubation remains a valuable tool, it may result in pressure trauma and sore throat. The evidence for an association between these sequelae is not conclusive and sore throat may be caused at the time of intubation. This hypothesis was tested in a mechanical model and the results from tracheal intubation compared with those from insertion of a laryngeal mask airway, which is associated with a lower incidence of sore throat. Use of the model suggests that the tracheal tube and laryngeal mask airway impinge on the pharyngeal wall in different manners and involve different mechanisms for their conformation to the upper airway, but that in a static situation, the forces exerted on the pharyngeal wall are low with both devices. It also suggests that the incidence of sore throat should be lower for softer and smaller tracheal tubes and that the standard 'Magill' curve (radius of curvature 140 +/- 20 mm) is about optimum for the average airway.     

Nasal mask positive pressure ventilation in paediatric patients with type II respiratory failure

We report our experience with nasal mask ventilation in children and adolescents with type II respiratory failure admitted to the paediatric intensive care unit (PICU) over an 18-month period. Seven patients were treated with nasal mask ventilation during part of their PICU stay. All showed significant improvement in arterial pH, Pa_CO2, and Pa_O2/FiO₂ from presentation to discharge, although at discharge Pa_CO2 and Pa_O2/FiO₂ fell outside of the normal range. Complications occurred in four patients. When compared to 11 patients with type II respiratory failure not treated with nasal mask ventilation, the nasal mask ventilation group had a similar PICU length of stay and incidence of complications. We conclude that nasal mask ventilation may be useful in maintaining near normal alveolar ventilation in selected children with type II respiratory failure and that a prospective study of this technique is indicated.