Tracheal Injury After Intubation

Tracheal injury after intubation is a mucosal tear, laceration or full thickness rupture of the trachea (usually the posterior membranous wall), caused by the tube, stylet, bougie, cuff over inflation or repeated attempts.

Epidemiology. Rare (about 1 in 20,000 to 1 in 75,000 intubations). More frequent in women, older adults, emergency intubation, double lumen tubes and difficult airways. Mortality in major rupture reaches about 20%.

Risk factors. Female sex, age over 60 years, short stature, steroid use, chronic obstructive pulmonary disease, tracheal abnormality, double lumen tube, cuff over inflation, nitrous oxide diffusing into the cuff, repeated attempts, stylet protrusion and percutaneous tracheostomy.

Pathophysiology.

Mechanical force or sudden pressure rise tears the weaker membranous wall. Air tracks into the mediastinum, neck and pleural space.

Subcutaneous emphysema (neck and chest), air leak around the cuff, haemoptysis, dyspnoea, cough, pneumothorax, pneumomediastinum, difficulty in ventilation, and tube cuff visible in the surgical field.

Red flags.

• Rapidly spreading subcutaneous emphysema.
• Tension pneumothorax.
• Persistent air leak after chest drain.
• Hypoxaemia with difficulty ventilating.
• Mediastinitis (fever, chest pain).

Flexible bronchoscopy is the definitive test, and shows the site and depth of injury. Chest radiograph or CT shows pneumomediastinum, pneumothorax and subcutaneous air. Place the bronchoscope just over the carina and avoid bringing the tube over the injury.

Differential diagnosis.

• Oesophageal perforation.
• Barotrauma.
• Pneumothorax from other causes.
• Bronchial rupture.
• Cuff leak without injury.

Conservative management suits small tears (under 2 cm), stable patients and spontaneous breathing or low airway pressures. Place the tube cuff beyond the injury under bronchoscopic vision, keep pressures low, extubate early, and treat infection.

• Piperacillin-tazobactam (if contaminated or mediastinitis): 4.5 g IV every 6 hours for 7 to 14 days; maximum 18 g daily; monitor renal function and counts; reduce for creatinine clearance under 40 mL/min.

Surgical repair is needed for tears over 2 cm, full thickness injury, mediastinitis, oesophageal involvement, failed ventilation or progressive emphysema. Approach by thoracotomy or cervical incision depending on location.

Insert a chest drain for pneumothorax. One lung ventilation of the opposite side may protect repair.

Prevention. Measure cuff pressure (20 to 30 cmH2O), avoid nitrous oxide diffusion by checking pressure, use the correct size, keep the stylet recessed, and handle double lumen tubes with care.

Monitoring. Subcutaneous air extent, saturation, chest radiograph and temperature.

Referral and escalation. Urgent thoracic surgery, anaesthetic and critical care review. Bronchoscopy within hours of suspicion.

Special groups. Women, older adults and patients on steroids need extra care with double lumen tubes.