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CASE REPORT Table of Contents   
Year : 2008  |  Volume : 11  |  Issue : 2  |  Page : 123-126
Anaesthetic management of a patient with complete tracheal rupture following blunt chest trauma


1 Departments of Anaesthesiology, Perioperative Medicine and Pain, Apollo Gleneagles Hospitals, Kolkata, India
2 Department of Critical Care Medicine, Apollo Gleneagles Hospitals, Kolkata, India
3 Department of Surgery, Apollo Gleneagles Hospitals, Kolkata, India

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   Abstract 

Complete tracheal resection is extremely rare after blunt chest trauma. A high degree of suspicion is essential to identify these cases and early intervention is associated with better outcome. We report a patient with complete tracheal resection, in whom the airway was secured whilst the patient remained awake, breathing spontaneously under fibreoptic bronchoscopic guidance. As a precautionary measure, we had kept cardiopulmonary bypass set up in readiness. Anaesthetic management needed to be modified during repair of the trachea, by using total intravenous anaesthesia with propofol and rocuronium infusion and insertion of a separate endotracheal tube into the distal portion of the trachea whilst reconstruction of the trachea took place. The usual inhalational technique could not be used. The anaesthesiologist managing such a case should be aware of the difficulties during securing the airway and during repair of the trachea. Proper planning and keeping back-up plans ready helps in successful management of these patients.

Keywords: Airway and anaesthetic management, blunt trauma, complete tracheal resection

How to cite this article:
Sengupta S, Saikia A, Ramasubban S, Gupta S, Maitra S, Rudra A, Maitra G. Anaesthetic management of a patient with complete tracheal rupture following blunt chest trauma. Ann Card Anaesth 2008;11:123-6

How to cite this URL:
Sengupta S, Saikia A, Ramasubban S, Gupta S, Maitra S, Rudra A, Maitra G. Anaesthetic management of a patient with complete tracheal rupture following blunt chest trauma. Ann Card Anaesth [serial online] 2008 [cited 2020 Sep 28];11:123-6. Available from: http://www.annals.in/text.asp?2008/11/2/123/41582


Tracheobronchial disruption is uncommon following blunt thoracic trauma, but can be life-threatening. Failure to diagnose the condition early may lead to disastrous acute or delayed complications. [1] Common presenting signs include subcutaneous emphysema, dyspnoea, sternal tenderness, and haemoptysis. The radiographical findings include pneumothorax or pneumomediastinum associated with either fracture of the clavicle or the first rib. Rigid as well as fibreoptic bronchoscopy are accurate methods of diagnosis. The delay in diagnosis can increase the likelihood of postoperative complications. [1] Blunt trauma contributes to most tracheal injuries, predominantly involving the membranous portion of the intrathoracic trachea. This occurs as a result of a sudden increase in the intra-airway pressure with a closed glottis at the time of impact. [2] The posterior membranous part of the trachea is the commonest site of rupture. [3] Anterior rupture of the trachea near the carina is not only rare but can be catastrophic. The air leak from the site of trauma can spread through the mediastinum and along the great vessels. It can cause cardiac tamponade by spreading into the pericardium. In civilian life, tracheobronchial injuries occur relatively rarely. Other injuries associated with the tracheal injury determine the outcome.

Operative management of tracheobronchial injuries can be achieved by different approaches depending upon the site of injury. Independent of mechanism or anatomical location of injury, delay in diagnosis is one of the important factors influencing the outcome. Early recognition of the tracheobronchial injury and expedient institution of appropriate surgical intervention are essential in these potentially lethal injuries. [4] Bronchoscopic detection of the rupture of the trachea or bronchus is commonly the main indication for surgery. [5]

The difficulties encountered in the anaesthetic management of these cases are during induction and securing the airway, maintenance of anaesthesia during tracheal reconstruction, prevention of aspiration, as well as effective nutrition in the postoperative period.


   Case Report Top


A 32-year-old gentleman presented to the Accident and Emergency Department following a blunt trauma to the front of his chest. Following this incident, the patient was not able to phonate and he had haemoptysis. On examination, he was conscious but had respiratory difficulty. He did not have any open injury [Figure 1]. There was surgical emphysema around the neck. He was haemodynamically stable, with a heart rate of 86 beats/min, blood pressure of 100/76 mm of Hg, respiratory rate of 22/min, and was maintaining an oxygen saturation of 87% on room air and 95% with oxygen supplementation. Arterial blood gas analysis at admission showed pH of 7.48, partial pressure of carbon dioxide was 48 mm Hg, and partial pressure of oxygen was 72 mm Hg. The patient had sustained fractures to the first and second ribs and the right glenoid in addition to the tracheal injury. Airway assessment was unremarkable. There was no associated haemothorax or pneumothorax based on radiological assessment.

Based on these findings, trauma to the bronchial tree was suspected and an emergency computed tomography (CT) scan was performed, which revealed: [Figure 2]

  1. Tracheal injury at the level of the thoracic inlet for a length of 5 cms.
  2. Surgical emphysema of neck and mediastinum.
  3. Air locule in the right paraglottic space anteriorly.
  4. Fractures of the right first rib and scapula.


The patient was scheduled for emergency tracheal reconstructive surgery. Awake tracheal intubation using fibreoptic bronchoscope was planned. The patient was premedicated with glycopyrrolate 0.2 mg iv, ranitidine 10 mg iv, and metoclopramide 10 mg iv. The upper airway was topically anaesthetised with two puffs of 10% lignocaine spray (20mg) and a further 3 ml of 2% lignocaine over the vocal cords through the sideport of the bronchoscope. The cardiopulmonary bypass machine was kept ready whilst the attempt to secure the airway was in progress. During fibreoptic visualization, complete tracheal resection was detected.

There was discontinuity of both the anterior and posterior walls [Figure 3]. The fiberoscope could be guided beyond the transection into the distal segment and an 8 mm reinforced endotracheal tube (ETT) was railroaded over the fiberoscope. Final confirmation of the presence of the ETT position in the distal trachea was by repeat fiberoscopy and end-tidal carbon dioxide (EtCO 2 ) tracings. General anaesthesia was then induced with 50% oxygen in air with sevoflurane (2 MAC), along with propofol 140 mg intravenously. Neuromuscular blockade for surgical procedure was obtained with an intravenous infusion of rocuronium (0.3mg/kg/hr). During the course of tracheal repair, propofol infusion was administered to maintain anaesthesia. Intraoperative monitoring was done with ECG, SpO 2 , Arterial Blood Pressure (ABP), central venous pressure (CVP), end-tidal carbon dioxide (EtCO 2 ), rectal temperature, and urine output.

Intraoperatively, the patient was placed in a supine position with neck extension. After incising the anterior neck, the manubrium sternum was split for better surgical exposure. Complete tracheal transection was noted just above the aortic arch with an intact oesophagus [Figure 4]. Proximal severed end of the trachea was found 2.5 cm above the sternal notch, whilst the distal severed end was just above the aortic arch with a distance of 5-6 cm between the two ends. Bilateral recurrent laryngeal nerves and thoracic duct were found to be transected. The thoracic duct was ligated. The proximal ends of the recurrent laryngeal nerves could not be located. No vascular injuries were found. Proximal trachea was mobilized by suprahyoid release, distal trachea was mobilized by mediastinal dissection, and tracheal anastomosis was performed.

Whilst the posterior layer of the trachea was being repaired, the initial endotracheal tube was taken out from the distal severed end of the trachea and the second endotracheal tube was inserted by the operating surgeon through the distal severed end of the trachea [Figure 5]. Anaesthesia was maintained during this part by propofol and rocuronium infusion. Intraoperative period was otherwise uneventful except for the occasional desaturation that occurred during the time of anastomosis.

The patient was electively ventilated for 48 hours and was gradually weaned and extubated on the third postoperative day. Fentanyl and midazolam infusion was used for sedation. After tracheal extubation, the patient was fed in a sitting position with his neck flexed. Neck flexion was maintained by a stay suture from the chin to the chest wall. The patient was administered deep venous thrombosis prophylaxis with low molecular weight heparin (LMWH) and mobilized by the seventh day.

An awake fibreoptic laryngoscopy was performed on the eighth day, which revealed bilateral vocal cord palsy with cords in the cadaveric/paramedian position. The patient's voice gradually improved with effective phonation, which was possible in about two weeks' time.


   Discussion Top


Tracheobronchial injuries are rare. The reported incidence is less than 1% [6] with 85% injuries occurring within 2.5 cm of the carina. [7]

The principal anaesthetic consideration is ventilation and oxygenation because of loss of ventilation to the atmosphere due to the open airway. Ventilation can be managed by different ways; manual oxygen jet ventilation, high frequency jet ventilation, distal tracheal intubation, and cardiopulmonary bypass. [11],[12] The perioperative management of lower airway injuries is a difficult clinical problem. The clinical presentation of a lower airway injury may be overt or subtle. The most commonly associated organ to be injured beside the trachea is the oesophagus. [8] Laryngotracheal separation is frequently associated with recurrent laryngeal nerve palsy and bilateral vocal cord paralysis. [9] External signs of injury may not correlate with the site or the extent of injury. [10] Reconstructive surgery of the trachea requires modification of the anaesthetic technique, where the usual inhalational anaesthetic technique cannot be used. One also needs to be aware and vigilant about the possibility of aspiration of blood from the surgical field leading to severe hypoxemia. The most frequent findings in patients with injury to the lower airway are dyspnoea and surgical emphysema. Other findings include cough, haemoptysis, sucking neck or chest wounds, mediastinal emphysema or pneumothorax. Endoscopy with a fibreoptic scope is the technique of choice for diagnosis, airway management, and as a preparatory step in planning of the surgical repair. [7]

Resuscitation and anaesthetic management are directed towards control of the airway, maintenance of adequate pulmonary ventilation, and management of blood loss. [6]

In conclusion, laryngotracheal trauma is rare, but potentially lethal. Airway management is controversial and the options are limited. Tracheostomy has been advocated as the management of choice, for securing the airway in patients with laryngotracheal injury. [7],[13],[14],[15] However, in present patient, we did not perform a tracheostomy as the injury was in the distal trachea. Airway control was achieved with fibreoptic-guided, reinforced endotracheal tube under spontaneous ventilation. [7],[8],[16],[17]

Feeding in the postoperative period is done in the sitting position with the neck flexed to prevent aspiration. This method has been described in the literature as being vital to help prevent aspiration. [18]

 
   References Top

1.Baumgartner F, Sheppard B, de Virgilio C, Esrig B, Harrier D, Nelson RJ, et al . Tracheal and main bronchial disruptions after blunt chest trauma: Presentation and management. Ann Thorac Surg 1990;50:569-74.  Back to cited text no. 1  [PUBMED]  
2.Chen JD, Shanmuganathan K, Mirvis SE, Killeen KL, Dutton RP. Using CT to diagnose tracheal rupture. AJR Am J Roentgenol 2001;176:1273-80.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Karmy-Jones R, Wood DE. Traumatic injury to the trachea and bronchus. Thorac Surg Clin 2007;17:35-46.  Back to cited text no. 3  [PUBMED]  
4.Cassada DC, Munyikwa MP, Moniz MP, Dieter RA Jr, Schuchmann GF, Enderson BL. Acute injuries of the trachea and major bronchi: Importance of early diagnosis. Ann Thorac Surg 2000;69:1563-7.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Balci AE, Eren N, Eren S, Ulku R. Surgical treatment of post-traumatic tracheobronchial injuries: 14-year experience. Eur J Cardiothorac Surg 2002;22:984-9.  Back to cited text no. 5    
6.Devitt JH, Boulanger BR. Lower airway injuries and anaesthesia. Can J Anesth 1996;43:148-59.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]
7.Weisberger EC, Miner JD. Apneic anesthesia for improved endoscopic removal of laryngeal papillomata. Laryngoscope 1988;98:693-7.  Back to cited text no. 7  [PUBMED]  
8.Vourch G, Fischler M, Michon F, Melchior JC, Seigneur F. Manual jet ventilation vs High frequency jet ventilation during laser resection of tracheo-bronchial stenosis. Br J Anaesth; 55:973-5.  Back to cited text no. 8    
9.Benumof JL. Management of the difficult airway. Ann Acad Med Singapore 1994;23:589-91.  Back to cited text no. 9  [PUBMED]  
10.Wheeler M, Ovossapian A. Prediction and evaluation of the difficult airway. In Handbook of difficult airway management. In : Hagberg CA, editor. Philadelphia: Churchill Livingstone; 2000. p. 15-30.  Back to cited text no. 10    
11.Chiu CL, Teh BT, Wang CY. Temporary cardiopulmonary bypass and isolated lung ventilation for tracheal stenosis and reconstruction. Br J Anaesth 2003;91:742-4.  Back to cited text no. 11  [PUBMED]  [FULLTEXT]
12.Wilson WC. Trauma: Airway management. ASA Difficult Airway algorithm modified for trauma and five common trauma intubation scenarios. ASA Newsletter 2005;69:11.  Back to cited text no. 12    
13.Wain JC. Rigid bronchoscopy: The value of a venerable procedure. Chest Surg Clin North Am 2001;11:691-9.  Back to cited text no. 13    
14.Wenig BL, Raphael N, Stern JR, Shikowitz MJ, Abramson AL. Cardiac complications of suspension laryngoscopy: Fact or fiction? Arch Otolaryngol Head Neck Surg 1986;112:860-2.  Back to cited text no. 14  [PUBMED]  
15.Morris IR. Anaesthesia and airway management of laryngoscopy and bronchoscopy. In : Hagberg CA, editor. Benumof's airway management. 2 nd ed. Philadelphia: Mosby; 2007. p. 859-67.  Back to cited text no. 15    
16.Hsu W, Sheen Ts, Lin C, Tan C, Yeh T, Lee S. Clinical experiences of removing foreign bodies in the airway and esophagus with a rigid endoscope: A series of 3217 cases from 1970 to 1996. Otolaryngol Head Neck Surg 2000;120:450-4.  Back to cited text no. 16    
17.Welty P. Anesthetic concerns and complications during suspension microlaryngoscopy procedures. CRNA 1992;3:113-8.  Back to cited text no. 17  [PUBMED]  
18.Robbins J, Gensler G, Hind J, Logeman JA, Lindblad AS, Brandt D, et al . Comparison of 2 interventions for liquid aspiration on pneumonia incidence. Ann Intern Med 2008;148:509-18.  Back to cited text no. 18    

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Correspondence Address:
Saikat Sengupta
Flat 402, Binayak Residency, 6/5D Anil Maitra RD, Kolkata - 700 019
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.41582

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

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