Case Study Explores Maintaining Tracheal Injuries

How often do tracheal injuries following intubation occur during surgery?

These injuries are extremely rare, and are estimated to occur in one in 20,000 intubation attempts, with rates of injury higher if the intubation is an emergency procedure, but usually require surgical repair.

The journal Seminars in Cardiothoracic and Vascular Anesthesia published a case study and review ahead-of-print that explores this issue. In the unlikely event that a post-intubation injury occurs, the clinical team needs to be prepared and respond appropriately.

Endotracheal intubation may lead to iatrogenic tracheobronchial laceration and rupture. Usually, the injury is longitudinal, running along the posterior membranous wall of the trachea.

In the typical situation, the clinician inserts an intubating stylet or overinflates the endotracheal tube cuff. Laceration and rupture are possible if the tip of the endotracheal tube catches in a fold of membranous tissue.

Risk factors include female sex, age greater than 50 years, incorrect endotracheal tube size, steroid use, and preexisting tracheomalacia.

The first sign of iatrogenic tracheal injury may appear soon after extubation, but it may not be apparent until many hours or a few days after the procedure. The healthcare team will need to employ flexible bronchoscopy to determine the type and extent of injury.

If the surgical team decided that surgical repair was necessary, the next-step would be to decide how to maintain the airway, with the patient’s stability as the guiding factor.

Adequate means of ventilation may be at odds with surgical access to the trachea, creating the need for careful selection of an airway device. Among the options are a double lumen endotracheal tube, a single lumen tube positioned in the left mainstem bronchus, a bronchial blocker delivered via single lumen tube, and jet ventilation.

The authors also described appropriate ways to maintain removed endotrachial tubes after repair, including using medication to ensure a smooth process.