Management of post-intubation tracheal membrane ruptures: A practical approach
In the emergency department, a 76-year-old woman, intubated out of hospital, following a prolonged seizure, developed acute airway obstruction, which resolved on endotracheal suctioning of mucosal tissue debris. Cardiac arrest with pulseless electrical activity ensued. Bilateral tension pneumothoraces, apparently related to jugular central venous catheterization, were relieved by thoracocentesis and tube thoracostomy. Spontaneous cardiac output and oxygenation were restored. However, progressive abdominal distension developed. A plain chest radiograph (CXR) [] demonstrated subphrenic and subcutaneous air. Computed tomography [Figures and ] confirmed extensive subcutaneous air, residual pneumothoraces, pneumomediastinum and tension pneumoperitoneum. Gastrograffin contrast imaging excluded oesophageal perforation.\nIn the intensive care unit (ICU), she was stable. The abdomen was distended, but soft. There was no acidosis, normal lactate, and negative diagnostic peritoneal lavage. Diagnostic laparotomy was deferred and fiberoptic bronchoscopy was performed.\nBronchoscopy demonstrated a 4 cm long full thickness defect in the posterior membranous trachea, 1 cm proximal to the carina []. Following consultation, thoracic surgical repair of the tracheal tear or complex stenting were ruled out due to the high operative risk. A conservative approach was necessary. Bridging the defect by double lumen endotracheal tube (ETT) beyond the distal end of the tear was not possible due to the proximity of the main carina, and risk of the herniation of the ETT cuff into the posterior wall defect, Therefore, a cuffed ETT was placed proximal to the defect, and a low volume lung ventilation strategy was adopted, to allow the defect to recover without over-distension and exacerbating pneumomediastinum. Mechanical ventilation was as follows: Volume (5-6 ml/kg), frequency (25/min), pressure limited (mean airway pressure <25 cm H2O) ventilation with permissive Hypercapnia. Tazobactam-piperacillin was commenced empirically for suspected mediastinitis and pneumonia. As part of a cluster care strategy, blind tracheal suctioning, and patient rotation were avoided to prevent ETT migration. Post-pyloric feeding was established after confirming an intact esophagus and twice-daily bronchoscopy for airway clearance, and correct ETT position above the proximal defect.\nThe patient was weaned with percutaneous tracheostomy and discharged from ICU after 27 days. Follow-up bronchoscopy [] revealed complete linear mucosal healing.