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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 3  |  Issue : 2  |  Page : 91-93

Establishing life-saving airway by withdrawing a deliberately placed endobronchial tube in a polytrauma patient


Department of Anaesthesia and Intensive Care, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India

Date of Submission05-Jul-2020
Date of Acceptance11-Aug-2020
Date of Web Publication30-Aug-2020

Correspondence Address:
Dr. Aadhar Khutell
S/o Dr. N. P. Singh, A.3, Govindpuram, Ghaziabad - 201 013, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ARWY.ARWY_25_20

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  Abstract 


Airway management in polytrauma patients can create unanticipated challenges, particularly in the presence of tracheal injury. A 24-year-old male who suffered a road traffic accident was diagnosed with complete tracheal disruption with a gap of 3.5 cm with minimal external signs of injury. Initial intubation attempts revealed resistance at 18 cm from the angle of the mouth with the endotracheal tube creating a visible contour just below the skin in the midline of the neck. Associated palpable crepitus in the neck led to the suspicion of tracheal disruption. The patient was then intubated using a bougie. The tube was pushed into the bronchus distal to the suspected gap and then withdrawn to lie just above the carina, thereby providing adequate ventilation and preventing further development of subcutaneous emphysema. Associated injuries were managed by multidisciplinary consultations. Prompt thinking and quick clinical decisions with respect to the airway proved to be life-saving for the patient.

Keywords: Bougie-assisted intubation, difficult intubation, intentional endobronchial intubation, intubation in airway trauma


How to cite this article:
Khutell A, Sharma V, Chandra M, Usha G. Establishing life-saving airway by withdrawing a deliberately placed endobronchial tube in a polytrauma patient. Airway 2020;3:91-3

How to cite this URL:
Khutell A, Sharma V, Chandra M, Usha G. Establishing life-saving airway by withdrawing a deliberately placed endobronchial tube in a polytrauma patient. Airway [serial online] 2020 [cited 2020 Sep 18];3:91-3. Available from: http://www.arwy.org/text.asp?2020/3/2/91/293964




  Introduction Top


Airway management in a patient with polytrauma is one of the most challenging and crucial aspects of management in such patients. The incidence of blunt trauma causing tracheal injury is only 0.34%–1.5%.[1] Around 80% of patients with tracheal injury succumb to associated injuries in the first 24 h.[2] The injury mostly occurs within 3 cm of the carina.[3] However, in this case, a complete tracheal disruption of 3.5 cm was present between the second and the third tracheal rings. Early recognition of tracheal injuries and prompt airway control can be life-saving.[4]


  Case Report Top


A 24-year-old male was brought to our emergency room with a history of road traffic accident. The patient presented with altered sensorium (Glasgow Coma Score of 8) and breathlessness. On examination, the airway was patent but gurgling sounds were heard; respiratory rate was 36 per minute and oxygen saturation was 85% with the patient receiving an FIO2 of approximately 0.8 with a non-rebreathing mask. Auscultation revealed reduced bilateral basal air entry. There was no evidence of external injury anywhere in the body, except an abrasion over the right lateral aspect of the occipital area.

In view of poor Glasgow Coma Score, suspected aspiration and low arterial saturation, it was decided to intubate the patient using modified rapid sequence intubation with manual-in-line-stabilisation and Sellick's manoeuvre. The patient was preoxygenated for 3 min. Direct laryngoscopy was performed which revealed blood clots. After pharyngeal suctioning, a Cormack–Lehane grade 1 laryngeal view was obtained, and a cuffed 8.0 mm ID endotracheal tube (ETT) was inserted.

Although the tube passed the vocal cords easily, resistance was appreciated with the tip of the tube at 18 cm from the angle of the mouth. As the tube was being pushed, its contour could be seen just below the skin in the neck. This led to the suspicion of a tracheal injury and Sellick's manoeuvre was abandoned. A fibreoptic bronchoscope was called for immediately as it was not available in the resuscitation zone. Intubation attempt with a smaller sized ETT was unsuccessful. Mask ventilation done in between attempts led to the development of neck swelling with palpable crepitus. Intubation was then attempted with a bougie. While inserting the bougie, it was observed that the tracheal clicks vanished and were felt again following which the bougie was held up. This suggested possible placement of the bougie beyond the suspected tracheal injury. An 8.0 mm ID ETT was railroaded over the bougie till the 24 cm mark was at the angle of the mouth.

After inflation of the cuff, positive pressure ventilation was attempted which produced significant increase in subcutaneous emphysema. The cuff was then deflated and the ETT was further advanced until it was intentionally positioned endobronchially as clinically confirmed by bilateral auscultation of the chest. The tube was then slowly withdrawn until bilateral air entry became equal on chest auscultation. This was done so that the tip of the ETT was clinically positioned just above the carina. The cuff was then inflated and the ETT fixed at 28 cm. At this position, positive pressure ventilation did not produce any further increase in the neck bulging or crepitus.

Non-contrast computed tomography (NCCT) of the neck revealed an absence of tracheal wall [Figure 1] for a length of 3.5 cm from the infracricoid trachea. Subcutaneous emphysema was confirmed. A chest CT revealed a fractured third rib on the left side with bilateral mild pneumothorax. NCCT of the head revealed subarachnoid haemorrhage.
Figure 1: Non-contrast computed tomography neck showing absent tracheal wall. The white ring ventral to cervical vertebra represents the endotracheal tube which is not surrounded by any soft tissue in sections marked with an arrow (last 4 frames) indicating tracheal disruption

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An intercostal drain was inserted in the fifth left intercostal space. The patient was then taken up for tracheal repair in less than 12 h of his arrival to the hospital, and an elective tracheostomy performed under general anaesthesia. Blunt dissection revealed a tracheal injury between the second and the third tracheal rings with irregular lacerated margins of the inner mucosa over the posterior wall of trachea which was repaired and a tracheostomy tube was inserted. A stout sternomental suture was placed to prevent inadvertent extension of the head and neck in the postoperative period.

The patient was shifted to the intensive care unit for elective postoperative mechanical ventilation and was shifted to the ward breathing room air after 14 days with a tracheostomy tube in situ. He was subsequently decannulated and discharged from the ward.


  Discussion Top


Sixteen per cent of inpatient deaths among polytrauma patients are caused by failure to intubate or secure/protect the airway.[5] This may be because of the fact that only 3% of emergency intubations were done by an anaesthesiologist. The remaining were done by emergency physicians (87%) and physicians from other specialities (10%). The authors conclude that the most experienced airway manager must be made responsible for securing the airway in patients with maxillofacial trauma.[5]

ETT is considered as the gold standard for securing the airway.[5] The American Society of Anesthesiologists trauma airway management has recommended that awake intubation is the preferred strategy to secure the airway in the presence of suspected major laryngeal or tracheal/bronchial tear provided the patient is awake, cooperative, haemodynamically stable and able to maintain oxygen saturation.[6] However, our patient was not maintaining oxygen saturation and urgent intubation was planned to protect the airway.

Tracheal disruption was strongly suspected when significant bulging in the anterior aspect of the neck was seen with intermittent positive pressure ventilation through an ETT positioned with its tip at 24 cm from the angle of the mouth. The neck bulging vanished when the ETT was advanced and fixed at 28 cm (probably just above carina by clinical evaluation through chest auscultation). In retrospect, the advancement of the ETT by 4 cm could have resulted in the tip of ETT crossing the disrupted segment of the trachea that not only ensured an adequate seal but eventually also proved to be life-saving. The patient was ventilated after repositioning of the ETT without any further increase in subcutaneous emphysema.

Tracheal injuries can make intubation difficult even in patients with a normal mouth opening and good Cormack–Lehane grades. The airway was established successfully by passing a bougie blindly beyond the tracheal defect while appreciating tracheal clicks and placing the ETT just above the carina. However, lower tracheal injuries may require an ETT with shorter width of the cuff or even necessitate the use of a double lumen tube to ensure that the inflated cuff lies beyond the fractured trachea completely in the distal segment and does not cause further tracheal injury.

Tracheal injury in blunt trauma is rare but should be suspected in symptomatic patients even with no external signs of injury. Expertise in the use of various airway devices with an algorithmic approach results in less panic. Difficult airway equipment should always be kept ready in an emergency setting. Intubation should be done early, and an attempt made to position the cuff of the ETT in the distal segment of disrupted trachea to achieve adequate ventilation and prevent the development of subcutaneous emphysema. A multidisciplinary team approach with strong leadership along with clear and prompt communication leads to a quicker and better management.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Barrett E. Management of a traumatic tracheal tear: A case report. AANA J 2011;79:468-70.  Back to cited text no. 1
    
2.
Karmy-Jones R, Avansino J, Stern EJ. CT of blunt tracheal rupture. AJR Am J Roentgenol 2003;180:1670.  Back to cited text no. 2
    
3.
Santiago-Rosado LM, Sigmon DF, Lewison CS. Tracheal Trauma. Treasure Island (FL): StatPearls Publishing; 2020. Available from: https: //www.ncbi.nim.nih.gov/books/NBK500015/. [Last update on 2020 Apr 28].  Back to cited text no. 3
    
4.
Wei P, Yan D, Huang J, Dong L, Zhao Y, Rong F, et al. Anesthetic management of tracheal laceration from traumatic dislocation of the first rib: A case report and literature of the review. BMC Anesthesiol 2019;19:149.  Back to cited text no. 4
    
5.
Barak M, Bahouth H, Leiser Y, Abu El-Naaj I. Airway management of the patient with maxillofacial trauma: Review of the literature and suggested clinical approach. Biomed Res Int 2015;2015:724032.  Back to cited text no. 5
    
6.
Pierre EJ, McNeer RR, Shamir MY. Early management of the traumatized airway. Anesthesiol Clin 2007;25:1-11, vii.  Back to cited text no. 6
    


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