POST-INTUBATION TRACHEAL RUPTURE IN ANESTHESIA: TWO CASE REPORTS

Aim. Post-intubation tracheal rupture is a rare but life-threa- tening complication. It can appear as a linear lesion in the membranous wall of the trachea. Subcutaneous emphysema, pneumothorax, pneumomediastinum and respiratory distress, it usually appears during surgery or in the immediate post- operative period. Diagnostic suspicion is essential, with sub- sequent confirmation by fibrobronchoscopy. Case reports. We report two cases, with similar lesions; the one recovered eventfully after conservative management, and the other received an invasive treatment. These are two tra- cheal rupture after unespected difficult endotracheal intuba- tion in elective surgery. Both cases were transferred to our ICU after the event, and surgery was delayed. Case 1. A 77 years-old woman was scheduled for Miles’abdo- minal perineal amputation. Successful orotracheal intubation was reached at the third attempt by an armed tube with sty- let. Following the intubation subcutaneous emphysema, and oxygen desaturation occurred and caused the admission in ICU. A computer tomography scan visualized a tracheal lesion, pneumothorax and pneumomediastinum. The pneu- mothorax was drained by a Trocar, but the patient needed mechanical ventilation, anymore. In fifth day fibrobronchopy revealed the longitudinal, subglottic, tracheal rupture, and surgical therapy was proposed. Instead, another computer tomography suggested a conservative management, since the full-thickness lesion was no longer visible. So, in tenth day, according to hemogasanalysis (P/F >300) and clinical signs, we performed a safe extubation. When fibrobronchoscopy showed a lesion's improvement, the abdominal surgery was performed successufully in combined spinal epidural anae- sthesia and sedation with spontaneous breath through laryn- geal mask. Case 2. A 56 year-old woman was scheduled for a colecistec- tomy. Successful orotracheal intubation was reached at the third attempt. Subcutaneous emphysema appeared, than a safe estubation failed because of tirage and oxygen desatura- tion caused by glottis oedema. In ICU a fibrobronchoscopy showed a subglottic longitudinal tracheal rupture (lenght: 3 cm) (Fig. 1). We performed a Fantoni’s pecutaneous tracheo- sthomy with not cuffed cannula. This approach allowed the spontaneous breathing, overcoming the glottis obstruction, and it avoided the stress linked to long time mechanical venti- lation. Sudden the patient was orally feed and was able to speak through a phonetic valve. She was transferred in surgi- cal unit, and the tracheostomy cannula was removed in sixth day, when glottis oedema was resolved. Discussion. Prognosis of tracheal ruptures depends both on the underlying disease, general condition of the patient, and on the rapidity of diagnosis and treatment. Traditionally, early surgical repair has been the mainstay of treatment.1 However, some authors opt to conservative treatment in patients with small ruptures, less than 2 cm, and in selected patients with minimal, non-progressive symptoms and with no air leakage on spontaneous breathing. The reported lesions were similar, but needed different treatment. The first case received a con- servative treatment, but the respiratory distress exposed patient to the risks of prolonged mechanical ventilation. In the second case, despite the invasiveness of the tracheostomy and the lesion length(>2 cm), a spontaneous healing of the lesion was possible removing the stress induced by mechani- cal ventilation. References 1. Pinegger S et al. Delayed iatrogenic tracheal post-intubation rupture: A short review of the aetiopathology and treatment. Rev Esp Anestesiol Reanim 2012 May 31.