Lung Laceration After Tracheal Extubation Over a Plastic Tube Changer Luiz G. R. delima,
MD,
and Michael J. Bishop,
MD
Departments of Anesthesiology and Medicine (Division of Pulmonary and Critical Care), Harborview Medical Center, University of Washington, Seattle, Washington
S
tiff plastic, gum bougie, or woven stylets have become popular as introducers in difficult tracheal intubations and for replacement of endotracheal tubes (1).Additionally, they may be left in the trachea during tracheal extubation of patients with abnormal airway anatomy to assist if emergent reintubation is required. The recommended technique for ascertaining tracheobronchial placement of the bougie is the detection of a firm resistance to further passage of the stylet (2,3). We report a case of pneumothorax and lung abscess after extubation of the trachea over a plastic tracheal tube changer (TTC) (JEM 400, TTC; Instrumentation Industries, Bethel Park, Penn.) in which the TTC was advanced until a firm resistance was felt.
Case Report A 38-yr-old man with osteogenesis imperfecta presented for ventriculoperitoneal shunt placement before removal of the odontoid process to relieve brainstem compression. Because of abnormal airway anatomy, sedation and local anesthesia were used to facilitate tracheal intubation over a fiberoptic bronchoscope. The intraoperative course was uneventful. His trachea was extubated in the recovery room but required reintubation because of upper airway obstruction. The reintubation was very difficult. The following day, the patient was alert, cooperative, and all criteria for tracheal extubation were met. With the cuff deflated, there was a large leak around the endotracheal tube (ETT), and the patient could breathe around the tube when the lumen was occluded. After instillation of 4% lidocaine down the E’IT, a TTC was gently inserted down the ETT until slight resistance was met. The ETT was removed over the Accepted for publication May 16, 1991. Address correspondence to Dr. Bishop, Department of Anesthesiology, Harborview Medical Center, 325 Ninth Avenue, ZA-14, Seattle, WA 98104.
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Anesth Analg 1991;73:35&1
TTC. Gas flow through the TTC was evident and breath sounds were clear and equal bilaterally. Oxygen was supplied via a face mask. For the first 10 min the patient was comfortable, able to communicate effectively, and had a clear airway and no dyspnea. Soon thereafter he developed respiratory difficulty, with prolonged and forceful expirations. Agitation and tachycardia were noted but there was no apparent upper airway obstruction. Attempts to thread ETTs over the TTC were unsuccessful, the TTC having softened after having been exposed to body temperature for several minutes. As the patient’s level of consciousness started to deteriorate, complete airway obstruction developed. Performing laryngoscopy with a Macintosh No. 3 blade opened the airway, but no recognizable structures could be visualized. The heart rate decreased to 52 beatdmin and the hollow TTC was connected to oxygen at a flow of 5 L/min, and 1 mg of atropine was given intravenously. Laryngoscopy was unsuccessfully attempted with different blades. Subcutaneous emphysema began to develop. The patient continued to deteriorate and began seizing. Ventilation via a bag and mask and an oral airway was ineffective. Systolic arterial blood pressure decreased to 70 mm Hg with a fraction of inspired oxygen of 1.0. Partial arterial pressure of oxygen was 40 mm Hg, pH, = 7.26, and partial arterial pressure of carbon dioxide was 24 mm Hg. A cricothyrotomy was performed and a 5-mm cuffed ETT was inserted. Breath sounds were not heard over the left side of the chest and chest roentgenogram confirmed a left pneumothorax, which was drained by thoracostomy tube placement. Arterial saturation and arterial blood pressure improved immediately, and the patient recovered consciousness a few hours later. The patient was taken to the operating room to revise the cricothyrotomy and change it to a tracheostomy. A roentgenogram taken in the recovery room after conversion of the cricothyrotomy to a tracheostomy showed a 2 x 4-cm lucency in the midportion of the left lung with the characteristic oval 91991 by the International Anesthesia Research Society 0003-2999/91/$3.50
ANESTH ANALG 1991;73:35&1
Figure 1. Chest roentgenogram taken after reexpansion of the pneumothorax. Note the persistent ovoid lucency in the left mid-lung field (arrow), characteristic of a lung laceration.
shape of a lung laceration (Figure 1). A moderate amount of air was present in the soft tissues of the chest, but there was no evidence of air in the neck or mediastinum. Subsequently, an abscess developed in the superior segment of the left lower lobe where the 2 x 4-cm air lucency had been present. The abscess resolved with antibiotic therapy.
Discussion This patient had no prior history of lung disease yet a tension pneumothorax developed after placement of the TTC and removal of the ETT. Localized air collection in the central area of the left lung also developed, consistent with lung laceration. Pneumothorax, pneumomediastinum, hydrothorax, bronchopleural fistula, subcutaneous emphysema, and lung abscess have been ascribed to stylets, small-bore feeding tubes, polyvinyl feeding tubes, and other relatively stiff objects introduced into the airway (4,5). Roubenoff and Rovick (6) presented four cases of pneumothorax caused by intrapulmonary placement of small-bore nasogastric feeding tubes, and their review of the literature revealed 106 cases of similar complications. The senior author (M.B.) has seen two
CASE REPORTS
351
other cases of pneumothoraces after tracheal tube changes over woven stylets (Eschmann gum-elastic bougie). However, in these two cases, underlying lung disease and mechanical ventilation raised questions about a causal relationship. Given the numerous reports of lung trauma with insertion of plastic gastric tubes, it is not surprising that occasional trauma will occur with blunt tracheal tube changers. Kidd et al. (2) found that firm resistance to passage of a gum elastic bougie was felt between 24 and 40 cm during 100 attempted tracheal intubations. They assumed that the resistance occurred when the bougie reached the small bronchi. We disagree with the recommendation that the bougie or TTC be inserted until there is a firm resistance and suggest that measurement and use of markings to limit the depth of insertion are warranted. A distance of 40 cm from the lips seems potentially hazardous, as a study of 59 subjects found that incisor-carina distances ranged from 23.0 to 31.5 cm (7). Thus, 40 cm could easily result in very peripheral placement of such a stylet. In changing a tube, a distance of no more than 23 cm from the lips should result in good intratracheal position in most patients (8). In our patient, grossly abnormal anatomy created a very short distance from the lips to the carina and undoubtedly contributed to overly deep insertion of the TTC with consequent laceration of the lung.
References 1. Tomlinson AA. Difficult tracheal intubation (letter). Anaesthesia 1985;4049&7. 2. Kidd JF, Dyson A, Latto IP. Successful difficult intubation. Use of the gum elastic bougie. Anaesthesia 1988;43:4374. 3. Sellers WFS, Jones GW. Difficult tracheal intubation (letter). Anaesthesia 1986;41:93. 4. Dorsch JA, Dorsch SE. Understanding anesthesia equipment. 2nd ed. Baltimore: Williams & Wilkins, 1984:388-9. 5 . Flemming DC. Hazards of tracheal intubation. In: Orkin FK, Cooperman LH, eds. Complications in anesthesiology. Philadelphia: JB Lippincott, 1983:165-72. 6. Roubenoff R, Rovick WJ. Pneumothorax due to nasogastric feeding tubes. Arch Intern Med 1989;149:18&8. 7. Schellinger RR. The length of the airway to the bifurcation of the trachea. Anesthesiology 1964;25:169-72. 8. Owen RL, Cheney FW. Endobroncial intubation: a preventable complication. Anesthesiology 1987;67:255-7.
MD,
and Michael J. Bishop,
MD
Departments of Anesthesiology and Medicine (Division of Pulmonary and Critical Care), Harborview Medical Center, University of Washington, Seattle, Washington
S
tiff plastic, gum bougie, or woven stylets have become popular as introducers in difficult tracheal intubations and for replacement of endotracheal tubes (1).Additionally, they may be left in the trachea during tracheal extubation of patients with abnormal airway anatomy to assist if emergent reintubation is required. The recommended technique for ascertaining tracheobronchial placement of the bougie is the detection of a firm resistance to further passage of the stylet (2,3). We report a case of pneumothorax and lung abscess after extubation of the trachea over a plastic tracheal tube changer (TTC) (JEM 400, TTC; Instrumentation Industries, Bethel Park, Penn.) in which the TTC was advanced until a firm resistance was felt.
Case Report A 38-yr-old man with osteogenesis imperfecta presented for ventriculoperitoneal shunt placement before removal of the odontoid process to relieve brainstem compression. Because of abnormal airway anatomy, sedation and local anesthesia were used to facilitate tracheal intubation over a fiberoptic bronchoscope. The intraoperative course was uneventful. His trachea was extubated in the recovery room but required reintubation because of upper airway obstruction. The reintubation was very difficult. The following day, the patient was alert, cooperative, and all criteria for tracheal extubation were met. With the cuff deflated, there was a large leak around the endotracheal tube (ETT), and the patient could breathe around the tube when the lumen was occluded. After instillation of 4% lidocaine down the E’IT, a TTC was gently inserted down the ETT until slight resistance was met. The ETT was removed over the Accepted for publication May 16, 1991. Address correspondence to Dr. Bishop, Department of Anesthesiology, Harborview Medical Center, 325 Ninth Avenue, ZA-14, Seattle, WA 98104.
350
Anesth Analg 1991;73:35&1
TTC. Gas flow through the TTC was evident and breath sounds were clear and equal bilaterally. Oxygen was supplied via a face mask. For the first 10 min the patient was comfortable, able to communicate effectively, and had a clear airway and no dyspnea. Soon thereafter he developed respiratory difficulty, with prolonged and forceful expirations. Agitation and tachycardia were noted but there was no apparent upper airway obstruction. Attempts to thread ETTs over the TTC were unsuccessful, the TTC having softened after having been exposed to body temperature for several minutes. As the patient’s level of consciousness started to deteriorate, complete airway obstruction developed. Performing laryngoscopy with a Macintosh No. 3 blade opened the airway, but no recognizable structures could be visualized. The heart rate decreased to 52 beatdmin and the hollow TTC was connected to oxygen at a flow of 5 L/min, and 1 mg of atropine was given intravenously. Laryngoscopy was unsuccessfully attempted with different blades. Subcutaneous emphysema began to develop. The patient continued to deteriorate and began seizing. Ventilation via a bag and mask and an oral airway was ineffective. Systolic arterial blood pressure decreased to 70 mm Hg with a fraction of inspired oxygen of 1.0. Partial arterial pressure of oxygen was 40 mm Hg, pH, = 7.26, and partial arterial pressure of carbon dioxide was 24 mm Hg. A cricothyrotomy was performed and a 5-mm cuffed ETT was inserted. Breath sounds were not heard over the left side of the chest and chest roentgenogram confirmed a left pneumothorax, which was drained by thoracostomy tube placement. Arterial saturation and arterial blood pressure improved immediately, and the patient recovered consciousness a few hours later. The patient was taken to the operating room to revise the cricothyrotomy and change it to a tracheostomy. A roentgenogram taken in the recovery room after conversion of the cricothyrotomy to a tracheostomy showed a 2 x 4-cm lucency in the midportion of the left lung with the characteristic oval 91991 by the International Anesthesia Research Society 0003-2999/91/$3.50
ANESTH ANALG 1991;73:35&1
Figure 1. Chest roentgenogram taken after reexpansion of the pneumothorax. Note the persistent ovoid lucency in the left mid-lung field (arrow), characteristic of a lung laceration.
shape of a lung laceration (Figure 1). A moderate amount of air was present in the soft tissues of the chest, but there was no evidence of air in the neck or mediastinum. Subsequently, an abscess developed in the superior segment of the left lower lobe where the 2 x 4-cm air lucency had been present. The abscess resolved with antibiotic therapy.
Discussion This patient had no prior history of lung disease yet a tension pneumothorax developed after placement of the TTC and removal of the ETT. Localized air collection in the central area of the left lung also developed, consistent with lung laceration. Pneumothorax, pneumomediastinum, hydrothorax, bronchopleural fistula, subcutaneous emphysema, and lung abscess have been ascribed to stylets, small-bore feeding tubes, polyvinyl feeding tubes, and other relatively stiff objects introduced into the airway (4,5). Roubenoff and Rovick (6) presented four cases of pneumothorax caused by intrapulmonary placement of small-bore nasogastric feeding tubes, and their review of the literature revealed 106 cases of similar complications. The senior author (M.B.) has seen two
CASE REPORTS
351
other cases of pneumothoraces after tracheal tube changes over woven stylets (Eschmann gum-elastic bougie). However, in these two cases, underlying lung disease and mechanical ventilation raised questions about a causal relationship. Given the numerous reports of lung trauma with insertion of plastic gastric tubes, it is not surprising that occasional trauma will occur with blunt tracheal tube changers. Kidd et al. (2) found that firm resistance to passage of a gum elastic bougie was felt between 24 and 40 cm during 100 attempted tracheal intubations. They assumed that the resistance occurred when the bougie reached the small bronchi. We disagree with the recommendation that the bougie or TTC be inserted until there is a firm resistance and suggest that measurement and use of markings to limit the depth of insertion are warranted. A distance of 40 cm from the lips seems potentially hazardous, as a study of 59 subjects found that incisor-carina distances ranged from 23.0 to 31.5 cm (7). Thus, 40 cm could easily result in very peripheral placement of such a stylet. In changing a tube, a distance of no more than 23 cm from the lips should result in good intratracheal position in most patients (8). In our patient, grossly abnormal anatomy created a very short distance from the lips to the carina and undoubtedly contributed to overly deep insertion of the TTC with consequent laceration of the lung.
References 1. Tomlinson AA. Difficult tracheal intubation (letter). Anaesthesia 1985;4049&7. 2. Kidd JF, Dyson A, Latto IP. Successful difficult intubation. Use of the gum elastic bougie. Anaesthesia 1988;43:4374. 3. Sellers WFS, Jones GW. Difficult tracheal intubation (letter). Anaesthesia 1986;41:93. 4. Dorsch JA, Dorsch SE. Understanding anesthesia equipment. 2nd ed. Baltimore: Williams & Wilkins, 1984:388-9. 5 . Flemming DC. Hazards of tracheal intubation. In: Orkin FK, Cooperman LH, eds. Complications in anesthesiology. Philadelphia: JB Lippincott, 1983:165-72. 6. Roubenoff R, Rovick WJ. Pneumothorax due to nasogastric feeding tubes. Arch Intern Med 1989;149:18&8. 7. Schellinger RR. The length of the airway to the bifurcation of the trachea. Anesthesiology 1964;25:169-72. 8. Owen RL, Cheney FW. Endobroncial intubation: a preventable complication. Anesthesiology 1987;67:255-7.
