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On-line version ISSN 1806-907X
Rev. Bras. Anestesiol. vol.55 no.6 Campinas Nov./Dec. 2005
Bronchial rupture after intubation with double lumen endotracheal tube. Case report*
Rotura bronquica después de intubación con tubo de doble lumen. Relato de caso
Roberto Cardoso Bessa Júnior, TSA, M.D.I; Jaci Custódio Jorge, TSA, M.D.II; Agnaldo Ferreira Eisenberg, M.D.III; Wallace Lage Duarte, M.D.IV; Márcio Sérgio Carvalho Silva, M.D.IV
IEspecialista em Terapia
Intensiva pela AMIB e Certificado de Área de Atuação em Dor pela
SBA. Instrutor do CET/IPSEMG. Anestesiologista do Hospital Vera Cruz
IIResponsável pelo CET/IPSEMG. Chefe do Serviço de Anestesiologia do Hospital Vera Cruz
IIICirurgião Torácico do Hospital Vera Cruz e IPSEMG
IVME2 do CET/IPSEMG
BACKGROUND AND OBJECTIVES:
Tracheobronchial tree injuries are uncommon however severe complications after
intubation or bronchoscopy. This report aimed at calling the attention to the
difficult selective intubation, which has led to bronchial rupture associated
to pneumomediastinum and hypertensive pneumothorax, with airway deformation
and death by systemic inflammatory response.
CASE REPORT: Male patient, 50 years old, with bronchopleural fistula secondary to bulla rupture in right lung upper lobe. After anesthetic induction it was difficult to intubate left bronchus. At the third attempt, patient developed hypoxemia, hypotension and extensive subcutaneous emphysema, being submitted to thoracic drainage for hypertensive pneumothorax. Fibrobronchoscopy has revealed left bronchus laceration. Patient evolved with hemoptysis, and left thoracotomy was necessary to suture bronchial laceration. Patient developed postoperative multiple organs dysfunction and evolved to death.
CONCLUSIONS: Selective intubation is a procedure to be carefully performed, being necessary the understanding of some risk factors and the early diagnosis of complications.
Key words: COMPLICATIONS: bronchial rupture; EQUIPMENTS: double lumen endotracheal tube
JUSTIFICATIVA Y OBJETIVOS:
Las lesiones del árbol traqueobronquico son complicaciones raras, sin embargo
después de intubación o broncoscopia pasan a ser graves. El objetivo
de ese relato fue llamar la atención sobre la dificultad de intubación
selectiva que ocasionó rotura bronquica asociada a pneumomediastino y neumotórax
hipertensivo, con deformaciones de las vías aéreas y fallecimiento
por la respuesta inflamatoria sistémica.
RELATO DEL CASO: Paciente del sexo masculino, 50 años, portador de fístula broncopleural secundaria a la rotura de ampolla en el lobo superior de pulmón derecho. Después de la inducción anestésica, hubo dificultad en la intubación endobronquica izquierda. En la tercera tentativa, se desarrolló un cuadro de hipoxemia, hipotensión y enfisema subcutáneo extenso, siendo sometido a drenaje torácico por neumotórax hipertensivo. La fibrobroncoscopia mostró laceración del bronquio izquierdo. Evolucionó con hemoptisis, siendo necesaria toracotomia izquierda para sutura de la laceración bronquica. En el postoperatorio, el paciente desarrolló cuadro de disfunción de múltiples órganos, evolucionando en fallecimiento.
CONCLUSIONES: La intubación selectiva es un procedimiento que debe ser realizado con cautela, siendo necesario el reconocimiento de algunos factores de riesgo y el diagnóstico precoz de las complicaciones.
Single lung ventilation with double lumen endotracheal tube is often performed as part of the anesthetic management for intrathoracic procedures. The ability to isolate and collapse the non-dependent lung is critical for a good surgical exposure. Tracheobronchial lacerations are uncommon, however with high morbidity/mortality risk 1,2. The presence of classic symptoms, such as subcutaneous emphysema and acute respiratory failure, is highly suggestive of those adverse events. Early diagnosis and immediate therapy are critical for a favorable prognosis 3. Early mortality is associated to hypertensive pneumothorax and pneumomediastinum, leading to esophageal collapse and to tracheal lumen compression with signs and symptoms of acute asphyxia. Late mortality is caused by mediastinitis and septic shock 3. Our case describes the rupture of main left bronchus during endobronchial intubation with its early diagnosis and treatment, which have not prevented the fatal outcome.
Male patient, 50 years old, 80 kg, 1.68 m, smoker, drinker and with systemic hypertension (SH) under 40 mg/day nifedipine. One year before he presented spontaneous right pneumothorax with the need for thoracic drainage in water seal, with option to conservative treatment. A bulla in the right lung upper lobe was diagnosed.
Patient was again hospitalized with new spontaneous right pneumothorax, being submitted to new thoracic drainage. Chest CT-scan has shown persistence of the right upper lung bulla. Patient evolved with hypoxemia (86% oxygen saturation in room air), major air escape by the thoracic drain, chest pain and dyspnea, which have led to the diagnostic hypothesis of bronchopleural fistula. Chest X-rays have shown the persistence of small pneumothorax however without signs of subcutaneous emphysema. Video-thoracoscopic bullectomy was indicated.
After anesthetic induction, airways were classified at laryngoscopy as Cormack-Lehane level 2 4. Initial intubation technique consisted of the use of the a endotracheal tube with stylet until crossing vocal cords; at this moment the stylet was removed and the tube was rotated 90º counterclockwise and progressed until approximately 28 cm.
The first left endobronchial intubation attempt with left Bronco-Cath® 39 Fr tube (Mallinckrodt Medical) failed with pulmonary auscultation evidencing right endobronchial intubation. The second attempt had the same outcome.
At the third attempt, the endotracheal tube was replaced by a 37 Fr tube and the stylet remained in place throughout the intubation process. During manual ventilation to confirm tube positioning, extensive subcutaneous emphysema involving chest, abdomen, cervical region and face was identified associated to abrupt SpO2 decrease. Double lumen tube was promptly removed and replaced by single lumen tube.
Laryngoscopy has revealed oropharynx deformation by subcutaneous emphysema and bleeding, without visualization of glottis and vocal cords. Patient developed severe hypoxemia (25% SpO2), hypotension (BP 60 x 40 mmHg) and bradycardia (HR 40 bpm), with ineffective manual ventilation by the bag-mask-valve system. When pulmonary auscultation revealed lack of breath sounds in left hemithorax, 200 µg epinephrine was administered. The second left intercostal space was then accessed with peripheral 14G venous catheter at the hemiclavicular line, with release of a large air amount and confirming the suspicion of hypertensive pneumothorax. Then, chest was drained in water seal in the eighth left intercostal space, in medium axillary line.
There has been oxygenation improvement (85% SpO2) in manual ventilation with bag-mask-valve system. Two unsuccessful intubations with fibrobronchoscope were attempted. Patient was then submitted to another conventional laryngoscopy with successful intubation, without vocal cords visualization, and confirmed by pulmonary auscultation, capnography and SpO2 increase to 96%. Single lumen endotracheal tube fibrobronchoscopy has detected endotracheal blood and laceration of approximately 3 cm in the membranous portion of main left bronchus. Invasive monitoring was made difficult by the subcutaneous emphysema, which extended to both limbs.
Patient evolved to severe hemoptysis with hypoxemia (75% SpO2). There has been SpO2 improvement after new firbrobronchoscopy and progression of the single lumen tube to the right bronchus, excluding left pulmonary ventilation. Urgency left thoracotomy was performed in right lateral position to main left bronchus suture and thoracic hematoma drainage. In the supine position, tube was pulled to the trachea with manual ventilation without escape. Due to right-side air escape persistence, we decided to go ahead with the initial treatment plan. Right axillary thoracotomy was performed in the left lateral position for right upper lung bullectomy. Posterior mediastinum was opened due to signs of pneumomediastinum. Patient was referred to intensive care unit with the following hemodynamic parameters: mean blood pressure of 80 mmHg, heart rate of 120 bpm and 98% SpO2.
Patient was extubated 10 hours later in the ICU without neurological deficit. In the following hours, patient evolved with progressive respiratory and hemodynamic worsening; chest X-rays revealed diffuse and bilateral pulmonary infiltrate, compatible with acute pulmonary injury. The patient needed endotracheal intubation and norepinephrine continuous infusion in progressively higher doses. In the following hours he developed multiple organs and systems dysfunction syndrome (renal failure, acute respiratory distress syndrome and refractory shock). Patient died 48 hours after admission to the intensive care unit.
Tracheobronchial ruptures have been probably under-reported. A recent review has identified 33 cases between 1972 and 1998 5. Estimated incidence is approximately 0.2% in historical series with Carlens tubes 6. Most common sites are distal trachea and posterior membranous wall of main bronchi, resulting in air escape to mediastinum, pleural spaces or subcutaneous tissues 7. With the advent of PVC tubes (polyvinylchloride) in the early 1980s, it was thought that they would be safer as compared to red rubber tubes. However, medical reports on airway injuries started to appear soon after 8.
Factors leading to injury are multiple handling errors (several intubation attempts, inexperienced physicians, inadequate use of stylet, rapid inflation with high cuff volume, inadequate tube size, tube malpositioning, use of nitrous oxide, abrupt movements during intubation, presence of cough) and anatomic factors (steroid-induced wall weakness, chronic obstructive pulmonary disease, tracheomalacia, anatomic bronchial distortion). According to the literature, most affected patients are women above 50 years of age, in general with injuries in the membranous portion of the left bronchus (due to higher number of left bronchus intubations regardless of thoracotomy site). This observation is probably a consequence of inadequate equipment selection and higher vulnerability to cuff inflation due to higher brittleness of the membranous portion of tracheobronchial wall in women 2,3,9,10.
In our case, some factors were probably responsible for the rupture: several attempts, use of stylet and bronchial distortion. Brodksky et al. 10 in a report on experience with double lumen endotracheal tube left intubation in 1,116 patients, have observed 75.9% intubation success in the first attempt (847 out of 1,116). With the maneuver of head rotation to the right, in which the right ear is bent to the right shoulder, there has been success in 208 out of 269 patients, with maximum three attempts. From the 61 remaining patients, fiber bronchoscopic assistance was successful in 43 and 18 could not be selectively intubated to the left. Lieberman et al. 11 have shown, in a small study with 30 patients, 100% success rate in the first left selective intubation attempt when bronchial stylet was maintained throughout the intubation, as compared to 77% success when the stylet was removed after tracheal penetration, being the safety of this method just limited to this small study.
Abrupt subcutaneous emphysema and hypoxemia have alerted to the presence of hypertensive pneumothorax and pneumomediastinum, suggestive of tracheobronchial laceration. Tube was removed without the placement of a guide to help the reinsertion of another tube due to fear of the laceration extension 12, action of high risk due to subsequent deformation of airways and their difficult control through manual ventilation and intubation. Patient died after systemic inflammatory response and multiple organs dysfunction.
Some recommendations for the safety of endobronchial intubation procedures are the adequate selection of tube size through chest X-rays (tracheal diameter at the carina multiplied by 0.68); limitation of bronchial cuff inflation volume to no more than 3 mL with slow inflation; preference to PVC tubes, avoid tubes with carineal hook; at the minor sign of resistance do not advance the tube, do not introduce it deeply (distance between incisives of 28 to 29 cm for a 1,70 m adult with approximately 1 cm variation for each 10 cm change in height); maximum cuff pressure of 32 mmHg due to risk of mucosal ischemia; judicious use of the stylet; cuff deflation during lateral positioning for thoracotomy; avoid nitrous oxide 1,3,10.
As conclusion, in spite of early diagnosis through clinical signs of hypertensive pneumothorax and pneumome- diastinum indicating airway rupture, there has been no prognostic improvement. It is possible that the permanence of the stylet throughout the intubation process was related to the severe complications.
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Dr. Roberto Cardoso Bessa Júnior
Address: Rua Itamonte, 35/602 Bairro Floresta
ZIP: 31110-220 City: Belo Horizonte, MG
Submitted for publication
January 26, 2005
Accepted for publication September 2, 2005
* Received from Hospital Vera Cruz, Belo Horizonte, MG