AJTCCM VOL. 30 NO. 2 2024 71
PICK OF THE PICS
A 52-year-old woman with chronic obstructive pulmonary disease
(COPD) underwent elective lumbar spinal surgery due to spinal
stenosis. e surgery was performed under general anaesthesia, and the
patient was intubated using a 7.0 mm wired orotracheal tube (OT). e
surgical procedure was uneventful until the transition to supine position,
when massive subcutaneous emphysema and acute respiratory failure
suddenly appeared. Achest CT scan revealed posterior tracheal wall
perforation, the tip of the OT in the mediastinum, massive subcutaneous
emphysema, bilateral pneumothoraxes and pneumomediastinum (Fig.
1.). Two intercostal chest drains were placed, and selective right main
bronchus intubation was performed under flexible bronchoscopy.
Subsequently, the patient underwent surgical repair by cervicotomy
with interrupted sutures using absorbable threads. Unfortunately,
she developed extensive cerebral ischemia due to hypo perfusion and
hypoxia, resulting in brain death.
Tracheal rupture aer endotracheal intubation is extremely rare, with
a reported incidence of approximately 0.005%.[1] As reported in this
case, tracheal rupture is usually longitudinal and located in the pars
membranacea of the cervicothoracic trachea. Proposed risk factors
that led to this complication include female gender, COPD and prone
position during surgery which may decrease respiratory compliance,
increase peak airway pressure and displace the OT.[2,3]Other risk
factors include short stature, obesity, tracheomalacia, tracheal
stenosis, use of OT introducers, cu over-ination, OT repositioning
without deating the cu, inappropriate tube size and movements
of the head and neck. The most common clinical manifestations
are subcutaneous emphysema, pneumothorax, dyspnoea and
haemoptysis. [2] Bronchoscopy is mandatory to establish the diagnosis,
and to identify the anatomy to choose the appropriate treatment and
approach. ere are no specic guidelines regarding surgical repair,
generally it is considered in ruptures larger than 2 cm, with air leak,
or under mechanical ventilation.[3,4]
Iatrogenic tracheal rupture is a rare condition with fatal
consequences if not promptly identified and addressed urgently.
Clinicians should be aware of possible risk factors and early signs in
order to make an early diagnosis.
1. Cardillo G, Ricciardi S, Forcione AR, etal.. Post-intubation tracheal lacerations: Risk-
stratication and treatment protocol according to morphological classication. Front
Surg 2022;9:1049126. https://doi.org/10.3389/fsurg.2022.1049126
2. Kwee MM, Ho YH, Rozen WM. The prone position during surgery and its
complications: a systematic review and evidence-based guidelines. Int Surg
2015;100(2):292-303. https://doi.org/10.9738/intsurg-d-13-00256.1
3. Grewal HS, Dangayach NS, Ahmad U, Ghosh S, Gildea T, Mehta AC. Treatment of
tracheobronchial injuries. Chest 2019;155(3):595-604. https://doi.org/10.1016%2Fj.
chest.2018.07.018
4. Miñambres E, Burón J, Ballesteros MA, Llorca J, Muñoz P, González-Castro A. Tracheal
rupture aer endotracheal intubation: a literature systematic review. Eur J Cardiothoracic
Surg 2009;35(6):1056-1062. https://doi.org/10.1016/j.ejcts.2009.01.053
A rare cause of acute post-intubation respiratory failure
L C Costa, MD; J Fernandes, MD; N Príncipe, MD; J A Paiva, PhD
Department of Emergency and Intensive Care Medicine, Centro Hospitalar Universitário de São João; Porto; Portugal
Corresponding author: L C Costa (liliana.castro.costa@gmail.com)
Fig. 1. CT scan images show tracheal perforation in the right lateral-
posterior wall, at the point where the upper third and the lower two
thirds meet, with 1 cm in length and the tip of the OT located in the
mediastinum (red arrow). Extensive subcutaneous emphysema, bilateral
pneumothoraxes and pneumomediastinum are also seen. A) Axial view
B) Corresponding sagittal view.
