Iatrogenic rupture of the trachea caused by double Lumen tube intubation

Abstract

Acute injuries of the tracheobronchial system are rare and life-threatening situations. Tracheal rupture most commonly occurs after blunt trauma to the chest. It is a rare but most concerning immediate complication of intubation. One-lung ventilation is required in lung surgery. Video assisted thoracoscopic procedures are an absolute indication for one-lung intubation. The double-lumen tube is the mainstay of one lung ventilation. Due to their larger size and rigidity, double lumen tubes are more difficult to insert, and complications are more common than with single lumen tubes. Opinions about the need for checking routinely the position of a double lumen tube by fiber optic bronchoscopy directly after intubation are divided. A 69-year-old woman with epidermoid lung carcinoma was scheduled for video assisted thoracoscopic left upper pulmonary lobectomy under general anaesthesia. The patient was prepared for the operation and itubated with the Carlens double lumen tube as usual. On introducing the camera into the thoracic cavity, the surgeon noted that the lungs were not completely collapsed. During blind adjustment the position of the tube the trachea was ruptured. The right-sided thoracotomy was performed and closed the greater part of the tracheal laceration. Only its upper 1.5-cm segment was surgically inaccessible because of the anatomical situation and thus remained unsutured. The patient received antibiotics, continuous airway humidification, analgesia with piritramide, and chest physiotherapy. She had no complications. In the literature, opinions about checking routinely the position of a double lumen tube by fiber optic bronchoscopy are divided.. Possibly, the very serious complication encountered in our patient could have been avoided, had the tube position been checked by bronchoscopy. The treatment strategy for post-intubation tracheal rupture depends on the size and location of the rupture, its clinical presentation, and the overall condition of the patient). Early surgical repair is the treatment of choice for most patients when a transmural tear with a length exceeding 2 cm. In our the combination of surgical and conservative treatment was performed. The uppermost part of the tear could not be sutured because of the anatomical situation, and so about 1.5 cm of the trachea remained open. The case is interesting from many perspectives. It shows that intubation with a Carlens tube is a potentially hazardous procedure, which should be performed only by experienced anaesthesiologists. Furthermore, our case report underscores the importance of checking routinely the position of a double lumen tube by fiber optic bronchoscopy. It provides evidence that minor tracheal lacerations can be successfully managed by conservative measures.