Tracheal Rupture Related to Endotracheal Intubation during Cardiopulmonary Resuscitation.

Postintubation tracheal rupture is rare, but serious. Emergency intubation is often conducted during cardiopulmonary resuscitation (CPR), and the risk of postintubation tracheal rupture can be increased during CPR. We describe here a case of postintubation tracheal rupture in a 65-year-old female who was transferred from another hospital after CPR. Postintubation tracheal rupture in this case is thought to have been related to malposition of the endotracheal tube (ETT), elevation of the intratrachea pressure due to chest compression, and an overinflated cuff. However, the most important factor is considered to be the overinflated cuff, which is often caused by manual palpation. Therefore, emergency physicians should consider using a manometer to check the cuff pressure of the ETT, even during CPR. When spontaneous circulation is restored, the pressure of the cuff must be measured with a manometer.

INTRODUCTION

Although tracheal rupture is commonly associated with chest blunt trauma, it can also occur after tracheal intubation. Emergency intubation and chest compression are often conducted simultaneously in cardiopulmonary resuscitation (CPR). We describe here a case of iatrogenic tracheal rupture after emergency intubation during brief CPR and discuss the methods of prevention and early detection of postintubation tracheal rupture.

CASE REPORT

A 65-year-old female was transferred with endotracheal intubation from another hospital to our emergency medical center. She had not been diagnosed with any other diseases, except hypertension and depression. She had ingested carbamate insecticide in an attempted suicide, but had not taken any other corrosive agent. The patient was found unconscious at home and taken to another hospital. When she arrived at that hospital, respiratory arrest was suspected and she immediately underwent endotracheal intubation and <5 min of CPR. The endotracheal intubation was successful on the first attempt without any difficulties. An aluminum stylet wrapped in polyvinyl chloride was used for the endotracheal intubation, but the stylet was removed when the tube crossed the vocal cord. In addition, a 7 mm size endotracheal tube (ETT) was used, but the cuff pressure was checked by manual palpation conducted by an emergency nurse instead of using a manometer. In addition, no adjustments to the cuff pressure were made after the initial treatment. The patient was then transferred to our hospital with stable vital signs. Her oxygen saturation was 98% on pulse oximetry. The size of the ETT was 7 mm, the insertion depth of ETT was 21 cm, and the cuff pressure was considered appropriate by manual palpation. Chest X-ray was conducted and pneumomediastinum was suspected [Figure 1]. Chest X-ray also revealed that the ETT was inserted too deeply and the tube cuff was overinflated [Figure 1]; however, those findings were overlooked at that time. Chest computed tomography (CT) was performed and showed incorrect position and overinflated cuff of ETT clearly, as well as suspicious posterior trachea tear [Figure 2]. A manometer revealed that the cuff pressure was 40 cmH2O. Tube cuff pressure and depth were corrected to 25 cmH2O and 18 cm, respectively. Follow-up of chest CT 2 days later clearly revealed a posterior tracheal wall rupture [Figure 3a] and bronchoscopy was conducted. A 4 cm size longitudinal rupture was observed at the posterior lower tracheal wall on bronchoscopy [Figure 3b]. However, no esophagography was performed to determine if there was also an esophageal perforation. Emergency surgery for tracheal wall repair was performed because of increased subcutaneous emphysema. Although esophagography was not performed, it was thought that there was no esophageal perforation because the patient was able to eat without any problems from 5 days after the operation and she was discharged at 8 days after tracheal surgery. The patient's written consent has not been obtained. [This study was approved by the institutional review board of Inha University Hospital (INHAUH 2018-04-001). IRB authorized the patient's consent exemption].

Figure 1

Chest X-ray showing subcutaneous emphysema, pneumomediastinum (suspicious), the tip of the endotracheal tube in the right bronchus, and the overinflated tube cuff

Figure 2

Chest computed tomography showing overinflated cuff of endotracheal tube and suspected tear of posterior tracheal wall

Figure 3

(a) Follow-up chest computed tomography showing posterior tracheal wall rupture. (b) Bronchoscopy image showing 4 cm size longitudinal rupture of posterior lower tracheal wall

DISCUSSION

The incidence of postintubation tracheal rupture is reportedly 0.005%–0.03%.[1] Although the mechanisms of postintubation tracheal rupture have not yet been fully identified, known patient-associated factors are older age, female, tracheal disorders, chronic obstructive pulmonary disease, and long-term corticosteroid use, while mechanical risk factors include oversized tube, overinflated tube cuff, use of double lumen tube or rigid stylet, and multiple forced attempts.[123] Thus, during CPR, multiple risk factors can be combined to increase the risk of developing this serious complication. Emergency physicians often conduct emergency intubation without any advance knowledge of patients. Accordingly, it can be challenging to choose an appropriate-sized ETT, place it at an appropriate depth, and produce cuff pressure correctly by manual regulation during CPR. There have been four reported cases of tracheal rupture after emergency intubation during CPR: two with overinflated tube cuff, one after difficult intubation, and one in which there was a malpositioned tube.[245] We assume that, in this case, chest compressions were performed when an ETT with an overinflated cuff was inserted too deeply; thus, the risk of her tracheal rupture was greatly increased. This is because intrathoracic pressure, which is increased by chest compressions, might abruptly increase intratracheobronchial pressure.[5] However, we believe that the most important risk factor in this case was the overinflated tube cuff. The recommended ETT cuff pressure to prevent ischemia of tracheal mucosa while reducing the risk of aspiration is 20–30 cm H2O.[6] However, the cuff pressure by manual palpation is usually underestimated, even by experienced emergency physicians.[37] Therefore, to avoid postintubation tracheal rupture during CPR, it would be better to measure the ETT cuff pressure with a manometer immediately after auscultation for tube position confirmation. In addition, chest X-ray should be checked immediately after return of spontaneous circulation to determine if there are complications such as rib fractures, hemopneumothorax, or pneumomediastinum, which may be caused by CPR. In addition to these complications, the degree of cuff inflation should be checked on chest X-ray and the pressure should be rechecked with a manometer immediately after return of spontaneous circulation. Emergency physicians should also conduct these procedures when patients have been transferred from other hospitals. When these conditions are verified, if other signs such as pneumothorax, pneumomediastinum, or subcutaneous emphysema are present, chest CT and bronchoscopy should be considered. Even if there are no other signs at that time, follow-up for tracheal rupture is prudent. Although our patient received surgical repair because of increased subcutaneous emphysema, postintubation tracheal ruptures have different therapeutic options from tracheal ruptures of traumatic origin, and most cases without mediastinitis have been treated successfully with conservative nonoperative therapy.[48] Therefore, therapeutic options for postintubation tracheal rupture should be determined considering its morphological appearance and related complications.

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Conflicts of interest

There are no conflicts of interest.