1Departments of Pediatric Surgery, 2Pediatric Anaesthesia and 3Neonatal Intensive Care, Childrens Hospital Teresa Herrera, Complexo Hospitalario Juan Canalejo 15006, As Xubias 84, A Coruña, Spain*Corresponding author
Accepted for publication: December 10, 2001
![]() |
Abstract |
---|
![]() ![]() ![]() ![]() ![]() ![]() |
---|
Br J Anaesth 2002; 88: 7223
Keywords: complications, tracheal laceration; intubation orotracheal; intubation tracheal, prolonged; anaesthesia, paediatric
![]() |
Introduction |
---|
![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
Case report |
---|
![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
Discussion |
---|
![]() ![]() ![]() ![]() ![]() ![]() |
---|
There are several anatomical reasons why tracheal injuries can occur more frequently in children than in adults.3 23 Of greater concern are the consequences of prolonged tracheal intubation in neonates and premature infants who survive severe respiratory diseases. These chronic internal tracheal injuries lead to glottic and subglottic stenosis.9 24 Successive tracheal intubations in these patients can result in several complications but the most serious is tracheal perforation: 70% of the paediatric cases reported died. The most probable explanation for the tracheal rupture described here is that superficial injury of the mucosa was caused by the tube when it was passed through scar tissue.
In many of the cases reported, the tracheal rupture was diagnosed at autopsy. The clinical observation of sudden appearance of subcutaneous emphysema, pneumomediastinum and bilateral pneumothoraces following orotracheal intubation suggested disruption of the trachea in our case. It is important to note that a vigorous attempt at intubation, with excessive hyperextension of the head and neck, was made in our case because of the altered anatomy of the larynx. These factors and the summative effects of the previous chronic intubation are likely to be directly involved in the iatrogenic tracheal laceration.
Of the previous cases reported, surgical treatment was the elective therapy except in one case treated with a cuffed tube passed beyond the tracheal tear.6 In our case a cuffed tube was not necessary and the adverse findings progressively resolved after reintubation with an uncuffed tube passed beyond the tear. The other measures important in the conservative management of such cases include drainage of air, use of low ventilatory pressures, and sedation. High frequency ventilation may be beneficial when low pressures cannot be otherwise achieved.
In summary, it is important to emphasize that when performing tracheal intubation in a premature infant, care must be taken to avoid forceful attempts to introduce the tube through the trachea. Other preventive measures include the use of a satin-slip intubating stylet and avoiding hyperextension of the head and neck.15
![]() |
References |
---|
![]() ![]() ![]() ![]() ![]() ![]() |
---|
2 Regragui IA, Fagan AM, Natrajan KM. Tracheal rupture after tracheal intubation. Br J Anaesth 1994; 72: 7056[Abstract]
3 Weymuller EA. Prevention and management of intubation injury of the larynx and trachea. Am J Otolaryngol 1992; 13: 13944[ISI][Medline]
4 Varela G, Jiménez M. Tracheal rupture secondary to intubation or tracheostomy. Arch Bronconeumol 1995; 31: 4213[Medline]
5
Ross HM, Grant FJ, Wilson RS, Burt ME. Nonoperative management of tracheal laceration during endotracheal intubation. Ann Thorac Surg 1997; 63: 2402
6 Finer NN, Stewart AR, Ulan OA. Tracheal perforation in the neonate: treatment with a cuffed endotracheal tube. J Pediatr 1976; 89: 51012
7 Serlin SP, Daily WJ. Tracheal perforation in the neonate: a complication of endotracheal intubation. J Pediatr 1975; 86: 5967[ISI][Medline]
8 McLeod BJ, Sumner E. Neonatal tracheal perforation. A complication of tracheal intubation. Anaesthesia 1986; 41: 6770[ISI][Medline]
9 Othersen HB. Prevention and treatment of tracheal injuries in children. Am Surg 1977; 43: 10813[ISI][Medline]
10 Holcomb GW, Templeton JM. Iatrogenic perforation of the bronchus intermedius in a 1100 grs neonate. J Pediatr Surg 1989; 24: 11324[ISI][Medline]
11 Schild JP, Wuilloud A, Kollberg H, Bossi E. Tracheal perforation as a complication of nasotracheal intubation in a neonate. J Pediatr 1976; 88: 6312[ISI][Medline]
12 Krause MF, Hoehn T. Partial transsection of the neonatal trachea. Resuscitation 1998; 38: 436[ISI][Medline]
13 Purohit DM, Lorenzo RL, Smith CD, Bradford BF. Bronchial laceration in a newborn with persistent posterior pneumomediastinum. J Pediatr Surg 1985; 20: 825[ISI][Medline]
14 Amodio JB, Berdon WE, Abramson SJ, Oh KS, Oudjhane K, Wung JT. Retrocardiac pneumomediastinum in association with tracheal and esophageal perforations. Pediatr Radiol 1986; 16: 3803[ISI][Medline]
15 Aziz EM, Suleiman KA. Tracheoesophageal perforation in the newborn: a case report. Clin Pediatr 1983; 22: 584[ISI][Medline]
16 VanKlarenbusch J, Meyer J, De Lange JJ. Tracheal rupture after tracheal intubation. Br J Anaesth 1994; 73: 5501[Abstract]
17 Jayr C, Escudier B. Rupture tracheále pendant une intubation pour anesthésie générale. Ann Fr Anesth Reanim 1986; 5: 1601[Medline]
18 Mitchell JB, Ward PM. The management of tracheal rupture using bilateral bronchial intubation. Anaesthesia 1993; 48: 2235[ISI][Medline]
19 Smith BA, Hopkinson RB. Tracheal rupture during anaesthesia. Anaesthesia 1984; 39: 8948[ISI][Medline]
20 Bricard H, Sillard B, Leroy G, Quesnel J, Segol P, Gignoux M. Rupture trachéale aprés intubation par sonde de Carlens. Ann Chir 1979; 33: 23841[ISI][Medline]
21
Molins L, Buitrago LJ, Vidal G. Conservative treatment of tracheal lacerations secondary to endotracheal intubation. Ann Thorac Surg 1997; 64: 12278
22 DOdemont JP, Pringot J, Goncette L, Goenen M, Rodenstein DO. Spontaneous favorable outcome of tracheal laceration. Chest 1991; 99: 12902[Abstract]
23 Othersen HB. Intubation injuries of the trachea in children. Ann Surg 1979; 189: 6016[ISI][Medline]
24 Fan LL, Flynn JW, Pathak DR. Risk factors predicting laryngeal injury in intubated neonates. Crit Care Med 1983; 11: 4313[ISI][Medline]