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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 4  |  Issue : 1  |  Page : 51-53

Post-traumatic tracheal rupture: Anaesthetic management


Department of Anaesthesia, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India

Date of Submission31-Dec-2020
Date of Acceptance11-Mar-2021
Date of Web Publication29-Apr-2021

Correspondence Address:
Dr. Nutan Kharge
Assistant Professor, Department of Anaesthesia, Seth GSMC and KEM Hospital, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/arwy.arwy_67_20

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  Abstract 


Traumatic tracheobronchial laceration can be potentially life-threatening and pose significant challenges for anaesthetic management. We would like to share our experience of managing a patient who had traumatic tracheal rupture, multiple rib fractures, bilateral pneumothorax and subcutaneous emphysema. Our presentation will briefly cover the challenges faced with regard to airway management and ventilation options for surgical repair.

Keywords: Anaesthesia, difficult airway, haemopneumothorax, tracheal rupture, ventilation


How to cite this article:
Motghare A, Kharge N, Soitkar R, Kotak N, Hemantkumar I. Post-traumatic tracheal rupture: Anaesthetic management. Airway 2021;4:51-3

How to cite this URL:
Motghare A, Kharge N, Soitkar R, Kotak N, Hemantkumar I. Post-traumatic tracheal rupture: Anaesthetic management. Airway [serial online] 2021 [cited 2021 Jun 20];4:51-3. Available from: https://www.arwy.org/text.asp?2021/4/1/51/315171




  Introduction Top


Tracheobronchial lacerations are the second-most common cause of death, with more than 75% of patients dying before they arrive to the emergency department.[1],[2] The common presenting symptoms of tracheobronchial injuries include dyspnoea, subcutaneous and mediastinal emphysema, cough, haemoptysis, hoarseness, dysphagia, pneumothorax and pneumomediastinum.[3] The posterior membranous part of the trachea is the most common site of rupture.[4] Anterior rupture of trachea near carina is not only rare but can be catastrophic. In rare cases, traumatic dislocations of the first rib could injure the subclavian artery, cervicothoracic ganglion, brachial plexus and trachea.[5]


  Case Report Top


A 35-year-old man presented to the emergency department with alleged history of injury to the neck, chest, left lower limb and abdomen caused by accidental fall of a granite slab. He had complaints of neck pain, back pain, inability to speak, oral bleed and left lower limb pain. The vital signs on admission showed a heart rate of 88 beats/min, respiratory rate of 34/min, blood pressure of 130/80 mm Hg and oxygen saturation of 85% on room air. Significant subcutaneous emphysema in the neck and anterior chest wall with accompanying crepitus was present. Soon after arrival in the emergency department, the patient developed respiratory distress. An immediate tracheostomy was performed with a cuffed 7.0 mm ID tracheostomy tube and mechanical ventilation was initiated.

Computerised tomographic (CT) scan showed defect in anterior tracheal wall at T1 and T2 levels (size 10–32 mm) indicating tracheal rupture [Figure 1], subcutaneous emphysema, fracture of left 1st rib, fracture of body, acromian and coracoid process of right scapula, and glenoid and body of the left scapula, bilateral pleural effusion with basal consolidation suggestive of aspiration pneumonitis with minimal pneumomediastinum. Indirect laryngoscopy revealed right vocal cord palsy. Chest tubes inserted to decompress the haemothorax alleviated the breathing difficulty. Arterial blood gas on ventilator with an FIO2 of 1.0 showed pH 7.42, PaO2 186 mm Hg, PaCO2 43.6 mm Hg and HCO3 27.7 mmol/L. Blood investigations and electrocardiogram were normal.
Figure 1: Computerised tomographic scans showing tracheal injury

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The patient was immediately transferred to the operation theatre for emergency repair of tracheal rupture. A fibreoptic bronchoscope and different sizes of endotracheal tubes (ETTs) were kept ready. Anaesthesia was induced with intravenous (IV) fentanyl 100 µg, propofol 100 mg and atracurium 30 mg. A sterile ventilator circuit was attached to the tracheostomy tube and the patient was ventilated. A cuffed 7.0 mm ID orotracheal tube was passed and fixed at the 14 cm mark at the angle of mouth. After dissection, the tracheostomy tube was removed and an armoured reinforced 7.0 mm ID tube was passed through the tracheostome, cuff inflated and bilateral air entry confirmed. After completion of the posterior tracheo-tracheal anastomosis, the reinforced tube was removed. The preplaced oral ETT was advanced beyond the repaired trachea, cuff inflated and position confirmed with auscultation. Following this, the anterior tracheo-tracheal anastomosis was completed.

Anaesthesia was maintained with desflurane in oxygen: air mixture (50:50) to achieve a minimum alveolar concentration (MAC) of 1. Intermittent boluses of atracurium and IV fentanyl 50 µg/hour were given. Once the tracheal anastomosis was completed, the surgeons suggested that the patient be extubated. Using the Bailey's manoeuvre, the patient was extubated under a deep plane of anaesthesia to avoid coughing or bucking (as that would have caused strain on the tracheal suture line). An i-gel #4 was inserted to enable smooth awakening. Check scopy done later using a C-MAC #3 blade revealed right vocal cord palsy and normal left vocal cord movements.

The patient was shifted to the intensive care unit for postoperative monitoring. A comprehensive rehabilitation programme was planned which included swallowing therapy and speech therapy and the patient was discharged on the 40th day with Shiraz brace[6] to maintain constant complete neck flexion and avoid tension on the tracheal anastomotic site [Figure 2]. The surgeons advised follow-up after 1 month. Later, the patient was posted for fixation of the tibial fracture. A detailed preoperative anaesthesia evaluation was done prior to the left tibial nailing. The patient was on thromboprophylactic treatment (injection clexane 40 mg OD) which was stopped before surgery. He was given a combined spinal-epidural anaesthesia in the lateral position and surgery was done in the supine position with the Shiraz brace in situ to maintain neck flexion. It was an uneventful surgery done under tourniquet with minimal blood loss. The patient was discharged from the orthopaedic ward after 7 days. Further follow-up showed that the patient was doing very well on the Shiraz brace.
Figure 2: Shiraz brace used to protect tracheal repair by immobilising the head and neck

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  Discussion Top


The diagnosis of tracheobronchial lacerations is based on a high index of suspicion and signs of subcutaneous emphysema, pneumothorax or pneumomediastinum CT scan of the chest should be one the initial screening tools.[7] The gold standard for diagnosis is flexible bronchoscopy.[8] In patients with tracheobronchial lacerations, awake intubation with local anaesthetic infiltration may be a safer option to manage the difficult airway. Other ventilatory management options include cricothyrotomy, cardiopulmonary bypass, extracorporeal membrane oxygenation and cross-field ventilation.[2],[9],[10] Cross-field ventilation and single-lung ventilation are generally preferred for patients with carinal or bronchial injuries.[11],[12] Tracheostomy has been advocated as the management of choice for securing the airway in patients with laryngotracheal injury.[13]

In our case, the patient arrived to the emergency department in respiratory distress and hence had an immediate tracheostomy performed under local anaesthesia. The principal consideration was oxygenation and ventilation considering loss of ventilation to the atmosphere due to open airway and presence of bilateral intercostal chest tubes.

Tracheal rupture or transection should be managed by careful suturing and avoiding damage to the recurrent laryngeal nerves.[14] When a patient with a recently repaired trachea comes for incidental surgery, we have to be more cautious as a scarred trachea can be damaged when intubation is done. Since this patient was posted for lower limb surgery and we had time for optimisation, we planned to perform the surgery under regional anaesthesia. The management could however be challenging in an emergency situation or in surgeries which need general endotracheal anaesthesia.

Successful management of tracheobronchial lacerations requires constant communication between the anaesthesiologist and the surgeon. A multidisciplinary approach and effective communication lead to successful outcome in tracheobronchial laceration repair and subsequent surgeries in such patients. We conclude that a comprehensive preoperative evaluation including a focused airway assessment, meticulous planning and good communication between the anaesthetic and surgical teams form the key to success.

Declaration of patient consent

The authors certify that they have obtained appropriate patient consent form. In the form, the patient has given his consent for 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.
Valerio P, Ivan M, Francisco R, Ureña A, Ricard R, Ricardo M, et al. Survival after traumatic complete laryngotracheal transection. Am J Emerg Med 2008;26:837.e3-4.  Back to cited text no. 1
    
2.
Lee WT, Eliashar R, Eliachar I. Acute external laryngotracheal trauma: Diagnosis and management. Ear Nose Throat J 2006;85:179-84.  Back to cited text no. 2
    
3.
Sengupta S, Saikia A, Ramasubban S, Gupta S, Maitra S, Rudra A, et al. Anaesthetic management of a patient with complete tracheal rupture following blunt chest trauma. Ann Card Anaesth 2008;11:123-6.  Back to cited text no. 3
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4.
Karmy-Jones R, Wood DE. Traumatic injury to the trachea and bronchus. Thorac Surg Clin 2007;17:35-46.  Back to cited text no. 4
    
5.
Stoddart S, Handy M, Cleland P, Wall D, Brown A. Traumatic dislocation of the first rib: A case report and review of the literature. Emerg Med Australas 2017;29:746-8.  Back to cited text no. 5
    
6.
Ziaian B, Foroutan A, Tahamtan M, Moslemi S. A new brace for maintaining the neck in a suitable position following tracheal reconstruction. Iran J Med Sci 2014;39:308-10.  Back to cited text no. 6
    
7.
Le Guen M, Beigelman C, Bouhemad B, Wenjïe Y, Marmion F, Rouby JJ. Chest computed tomography with multiplanar reformatted images for diagnosing traumatic bronchial rupture: A case report. Crit Care 2007;11:R94.  Back to cited text no. 7
    
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Paik JH, Choi JS, Han SB, Jung HM, Kim JH. Complete cervical tracheal transection caused by blunt neck trauma: Case report. Ulus Travma Acil Cerrahi Derg 2014;20:459-62.  Back to cited text no. 8
    
9.
Khan SA, Ekeoduru RA, Tariq S. Traumatic tracheobronchial laceration causing complete tracheal resection: Challenges of anesthetic management. A A Pract 2018;11:109-11.  Back to cited text no. 9
    
10.
Juvekar NM, Deshpande SS, Nadkarni A, Kanitkar S. Perioperative management of tracheobronchial injury following blunt trauma. Ann Card Anaesth 2013;16:140-3.  Back to cited text no. 10
[PUBMED]  [Full text]  
11.
Tack D, Defrance P, Delcour C, Gevenois PA. The CT fallen-lung sign. Eur Radiol 2000;10:719-21.  Back to cited text no. 11
    
12.
Barbetakis N, Samanidis G, Paliouras D, Tsilikas C. Tracheal laceration following double-lumen intubation during Ivor Lewis esophagogastrectomy. Interact Cardiovasc Thorac Surg 2008;7:866-8.  Back to cited text no. 12
    
13.
Morris IR. Anaesthesia and airway management of laryngoscopy and bronchoscopy. In: Hagberg CA, editor. Benumof's Airway Management. 2nd ed. Philadelphia: Mosby; 2007. p. 859-67.  Back to cited text no. 13
    
14.
Roxburgh JC. Rupture of the tracheobronchial tree. Thorax 1987;42:681-8.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2]



 

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