Tracheal rupture after endotracheal intubation is uncommon, occurring in approximately 0.005 percent to 0.37 percent of intubations, yet it carries substantial morbidity and mortality when recognition is delayed. The risk is concentrated in older women of short stature, and cases involving emergency, repeated, or stylet-assisted intubation. The characteristic lesion is a longitudinal laceration of the posterior membranous wall. Management is individualized. Superficial lesions in stable patients are often managed conservatively, whereas full-thickness tears with a large air leak, mediastinal contamination, or ventilatory compromise generally require operative repair. Cardillo’s morphological classification is widely used to frame these decisions.
Case
An 84-year-old woman sustained an iatrogenic tracheal rupture immediately following endotracheal intubation. She developed respiratory instability and massive cervicothoracic subcutaneous emphysema. Computed tomography confirmed extensive subcutaneous emphysema and pneumomediastinum, and bilateral chest drains had been placed at the referring hospital. Flexible bronchoscopy demonstrated a 3 cm longitudinal tear of the posterior membranous trachea that extended distally toward the right main bronchus. Because the defect was long, extended beyond the reach of a cervical approach and was accompanied by respiratory instability, the multidisciplinary team elected operative repair through a right thoracotomy.
Technique
The patient was positioned in the left lateral decubitus position, and a right thoracotomy was performed through the fourth intercostal space. The mediastinal pleura was incised, and the posterior tracheal wall was exposed. Simultaneous flexible bronchoscopy transilluminated the airway and defined the distal apex of the tear, establishing the limits of repair. The defect was closed primarily with interrupted absorbable sutures material and caliber, which were placed full thickness with knots tied extraluminally, taking care not to narrow the airway. The pedicled intercostal muscle flap was then laid across the suture line and secured to the peritracheal tissue, interposing vascularized tissue between the repair and the esophagus. A bronchoscopic air-leak test under saline confirmed an airtight repair before chest closure and drainage.
Outcome
The patient was extubated on postoperative day two. The bilateral air leaks resolved spontaneously, and both chest tubes were removed on postoperative day four following the complete resolution of the pneumothoraces. Follow-up bronchoscopy confirmed an intact, airtight repair, and the patient was discharged home on postoperative day seven.
Conclusion
Bronchoscopy serves as both the diagnostic and the intraoperative tool for managing post-intubation membranous tracheal rupture; it determines the length and distal extent of the tear, which, in turn, dictates the surgical approach, and it verifies the completed repair. Distal extension toward the carina makes right thoracotomy the appropriate exposure. Reinforcement of the suture line with a pedicled intercostal muscle flap adds vascularized tissue between the trachea and esophagus at minimal cost. Advanced age alone is not a contraindication to operative repair.
- References
- Cardillo G, Carbone L, Carleo F, Batzella S, Dello Jacono R, Lucantoni G, Galluccio G. Tracheal lacerations after endotracheal intubation: a proposed morphological classification to guide non-surgical treatment. Eur J Cardiothorac Surg. 2010;37(3):581–587. doi:10.1016/j.ejcts.2009.07.034
- Miñambres E, Burón J, Ballesteros MA, Llorca J, Muñoz P, González-Castro A. Tracheal rupture after endotracheal intubation: a literature systematic review. Eur J Cardiothorac Surg. 2009;35(6):1056–1062. doi:10.1016/j.ejcts.2009.01.053
- Passera E, Orlandi R, Calderoni M, Cassina EM, Cioffi U, Guttadauro A, Libretti L, Pirondini E, Rimessi A, Tuoro A, Raveglia F. Post-intubation iatrogenic tracheobronchial injuries: the state of art. Front Surg. 2023;10:1125997. doi:10.3389/fsurg.2023.1125997
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