The dangers of playing with sharp sticks

Cheryl Pirozzi, MD Pulmonary Grand Rounds October 13, 2011

Case  43 yo woman presented to OSH with SOB, productive cough with hemoptysis, and weakness

PMH            CVID with ↓ IgG and IgM, treated with monthly IVIG Multiple recent hospitalizations (x7 in 2011), mult for pneumonia, most recent 8/8-9/2011 Adrenal insufficiency due to chronic steroids: unclear why Chronic hypoxemia: 3LPM Asthma  PFTs 12/10: mildly reduced FEV1, nl DLCO Chronic pain, narcotic abuse Psych issues: bipolar d/o, borderline personality d/o, prior overdoses on narcotics, tricyclics, atarax Papillary thyroid Ca, s/p thyroidectomy VRE skin and UTI infections DM2 ? Crohns disease – negative biopsy

PMH  PSH: gastric bypass, CCY, tonsillectomy, sinus surgeries x2, hiatal hernia repair, PFO closure  SH: on disability, married. Denies EtOH, tobacco, IDU

Meds                 Prednisone 20 mg qd Lortab 10 q4 hrs Tapentadol 100 mg q4h Albuterol Budesonide Lasix Atarax Synthroid cytomel IVIG 30 g q mo Nexium Lunesta Seroquel 800 mg qHS Metoprolol Zofran Cymbalta

Case  PE  T 38.5, p116, 85/40 → 111/56, R 18, 84%/3L  Ill-appearing, alert but tangental  Bilateral crackles and rhonchi  Labs:  WBC 16, 20% bands, hgb 11, plt 266  Lactate 3.7, BUN 22, Cr 0.8

Initial CXR OSH 8/30/11

Hospital Course  Initially treated for HCAP with Zosyn, Levaquin, and Vancomycin  Stress dose steroids  IVIG

CXR 8/31/11

9/1/11

 Reportedly, patient’s husband sneaks her extra antihistamine, dramamine, seroquel and tapentadol, and she has an aspiration event  Acute hypoxic respiratory failure  Emergent intubation

CXR 9/1/11

9/1/11

 Soon after intubation, patient has bronch with BAL  “proximal airways were normal in appearance”  BAL grows MRSA  A few hours later, she is noted to acutely decompensate and “blow up”

9/1/11

9/1/11

9/4/11

 Patient again decompensates, with increased hypoxia and subcutaneous emphysema, and transfer to IMC is requested

9/4/11 transfer to IMC

  T 38.1, p123, 122/87, R 24 FiO2 100%, PEEP 11, Vt 6 ml/kg Diffuse subcutaneous emphysema, crackles, edema

What would you do next?

CT 9/4/11

CT 9/4/11

CT 9/4/11

CT 9/4/11

CT 9/4/11

What is going on?

Bronch 9/8/11

Bronch 9/8/11

CT 9/8/11

CT 9/8/11

Hospital Course  Recurrent infectious complications and intermittent septic shock:  Acromobacter PNA     Persistent MRSA tracheobronchitis C.diff colitis VRE UTI Treated with Vanc, linezolid, zosyn, ceftaroline, flagyl    Severe ARDS Self extubation with emergent re-intubation on 9/13 Eventually stabilizes, but unable to wean from vent

Bronch 9/24/11

Hospital Course  Trach on 9/27/11

Bronch 9/28/11

Tracheal injury associated with endotracheal intubation  Clinical presentation  How often does this happen?

 What are the risk factors? How do we avoid it?

 What is the treatment?

Tracheal injury/rupture

 Rare condition with high morbidity and mortality  Most common cause is head and neck injury  Most common iatrogenic cause is orotracheal intubation; also can occur with tracheostomy, bronchoscopy, placement of stents, esophagectomy  Usually longitudinal rupture in distal third of membranous trachea Miñambres et al. European Journal of Cardio-thoracic Surgery 35 (2009) 1056—1062

Tracheal injury associated with endotracheal intubation  Clinical presentation:  Most common: subcutaneous emphysema, pneumomediastinum, pneumothorax, respiratory distress  dyspnea, dysphonia, cough, hemoptysis, and pneumoperitoneum  signs often develop immediately or soon after intubation, but can take several days to appear Miñambres et al. European Journal of Cardio-thoracic Surgery 35 (2009) 1056—1062

Diagnosis

 Requires high clinical suspicion based on clinical s/sx  Confirmed by direct visualization of lesion with bronchoscopy  CT

Radiographic signs

    Subcutaneous emphysema Pneumomediastinum Overdistended ETT cuff On CT tracheal defect/perforation

Am J Emerg Med 2004;22:289-293.

J Bras Pneumol. 2009;35(8):809-813

Tracheal injury associated with endotracheal intubation  How often does this happen?

 Case reports, several case series and reviews  Incidence estimates from 0.005% - 0.37% of intubations, more common with double lumen tubes Medina et al. J Bras Pneumol. 2009;35(8):809-813 Miñambres et al. European Journal of Cardio-thoracic Surgery 35 (2009) 1056—1062

Tracheal injury associated with endotracheal intubation  Miñambres et al. Tracheal rupture after endotracheal intubation. Eur J Cardiothorac Surg. 2009;35(6):1056-62  182 cases of postintubation tracheal rupture.  mortality 22%   86% women Intubations: 14% “difficult”, 27% emergent  Increased mortality associated with age ( p = 0.015) and emergency intubation (RR = 3.11; p = 0.001)

Miñambres et al. European Journal of Cardio-thoracic Surgery 35 (2009) 1056—1062

Variables associated with mortality Miñambres et al. European Journal of Cardio-thoracic Surgery 35 (2009) 1056—1062

Risk factors / mechanism for tracheal rupture with intubation

Am J Emerg Med 2004;22:289-293.

Risk factors for tracheal injury with intubation  Why women?

 Shorter, with use of improperly long tubes  Smaller tracheal diameters- more vulnerable to cuff overinflation Anesth Analg 2001;93:1270 –1

How do I avoid tracheal injury with emergent intubation?

 Recommendations for emergent intubation:         Select the proper size of endotracheal tube Check all equipment before intubation Check position of stylet (tip not beyond murphy’s eye) Intubate gently and use RSI when necessary Retract the stylet when balloon cuff passes through vocal cords Inflate the cuff slowly with proper volume and pressure Fix ETT tightly to reduce the possibility of tube movement Deflate the cuff first when repositioning the tube

Am J Emerg Med 2004;22:289-293.

Management of tracheal laceration or rupture  Traditionally early surgical repair was mainstay  Now many recommend conservative treatment if rupture < 2 cm, and if minimal non-progressive sxs and no air leak   If > 2 cm, surgical vs conservative is debated.

In Mi ñambres et al. meta-analysis, surgical repair was associated with a 2x increased mortality  Meyer et al. case series: surgical repair in critically ill pts is high risk, mortality up to 71%. Miñambres et al. European Journal of Cardio-thoracic Surgery 35 (2009) 1056—1062 Meyer M. Thorac Cardiovasc Surg 2001;49:115 —9.

Management of tracheal laceration or rupture  Most recent studies recommend conservative management if  stable pt, no air leakage, no esophageal damage, minimal mediastinal collections, no clinical progression, no sign of infection  Conservative management = intubation with cuff distal to lesion, continuous tracheal aspiration, pleural drain, empiric abx  Surgical repair if unstable, large defect (>4cm), any evidence of mediastinitis Medina et al. J Bras Pneumol. 2009 Aug;35(8):809-13 Miñambres et al. European Journal of Cardio-thoracic Surgery 35 (2009) 1056—1062

Management of tracheal laceration or rupture

Am J Emerg Med 2004;22:289-293.

Management of tracheal laceration or rupture

Am J Emerg Med 2004;22:289-293.

 In retrospect, had we known what was going on, would probably have at least evaluated for surgical repair earlier.  Small rupture, but distal to ETT and with demonstrated clinical deterioration

Questions/comments?

References       Sternfeld D, Wright S. Tracheal rupture and the creation of a false passage after emergency intubation. Ann Emerg Med. 2003 Jul;42(1):88-92.

Miñambres E, Burón J, Ballesteros MA, Llorca J, Muñoz P, González-Castro A. Tracheal rupture after endotracheal intubation: a literature systematic review. Eur J Cardiothorac Surg. 2009 Jun;35(6):1056-62. Fan CM, Ko PC, Tsai KC, Chiang WC, Chang YC, Chen WJ, Yuan A. Tracheal rupture complicating emergent endotracheal intubation. Am J Emerg Med. 2004 Jul;22(4):289-93 Chen EH, Logman ZM, Glass PS, Bilfinger TV. A case of tracheal injury after emergent endotracheal intubation: a review of the literature and causalities. Anesth Analg. 2001 Nov;93(5):1270-1 Medina CR, Camargo Jde J, Felicetti JC, Machuca TN, Gomes Bde M, Melo IA. Post-intubation tracheal injury: report of three cases and literature review. J Bras Pneumol. 2009 Aug;35(8):809-13.

Meyer M. Iatrogenic tracheobronchial lesions —a report on 13 cases. Thorac Cardiovasc Surg 2001;49:115 —9.