Severe tracheal tear due to endotracheal intubation: a case report

Abstract

Background: Tracheobronchial injury is a life-threatening condition with a considerable missed diagnosis rate. The larger the tracheal lesion the more difficult it is to heal. Both conservative and non-conservative treatments are used to treat tracheal injury. This article reports a clinical scenario in which conservative treatment was successfully used to manage a severe tracheal tear.

Case description: We present the case of a 63-year-old male with a cough for over a year who suffered from a 4-cm tracheobronchial injury (level IIIA, Cardillo classification) after endotracheal intubation for right lower bilobectomy. This injury showed full-layer tissue tearing of the tracheal wall, without esophageal injury or mediastinitis. The tracheal tear was discovered during the bronchoscopy examination on postoperative day one. The patient's vital signs were almost stable, including body temperature, blood pressure, heart rate, and oxygen saturation. We adopted a conservative treatment approach, including oxygen administration, painkillers, broad-spectrum antibiotics therapy, and nutritional support. Using this treatment, the 4-cm long tracheal rupture healed within four weeks. No tracheal tear was found in the bronchoscopy re-examination. The computed tomography scan showed that the mediastinal and subcutaneous emphysema had disappeared entirely. The patient fully recovered well without any complaints of discomfort.

Conclusions: Conservative treatment provides a valuable strategy for treating patients with massive tracheal lesions, representing an effective approach, especially in older patients with underlying diseases whose conditions are not suitable for operative treatments.

Keywords: Tracheal tear; case report; conservative management.

Figure 1

Postoperative day 1: a massive tracheal tear on the membranous part is confirmed by bronchoscopic evaluation (A) following a chest X-ray examination describing a highly suspicious mediastinal emphysema (B). The red arrows indicated subcutaneous emphysema and mediastinal emphysema. The mediastinum becomes wider.

Figure 2

Postoperative day 10: the ongoing healing is showed by bronchoscopy monitoring, with clear signs of re-epithelialization of the membranous wall tear.

Video 1

The chest CT scan was used to investigate mediastinal emphysema on postoperative day 10, showing a concrete improvement of the radiological scenario.

Figure 3

Postoperative day 28: a residual scar on the membranous part of the tracheal wall confirms the full recovery of the postintubation injury. The mediastinal and subcutaneous emphysema had almost disappeared in the computed tomography scan (Video 2).

Video 2

After 28 days post-surgery, the chest CT scan showed the full absorption of mediastinal emphysema.

Figure 4

Case timeline. A tracheal lesion occurred during anesthesia intubation. No rupture was found during the intraoperative bronchoscopy examination. On the first day after extubating, an extensive emphysema occurred. Tracheobronchoscopy confirmed a 4-cm tracheal tear. The patient’s vital signs remained stable. A conservative treatment was primarily chosen. After re-examination on the 10th and 28th day after surgery, the patient’s symptoms gradually improved, and the tracheal injury gradually healed as confirmed by bronchoscopy evaluations. Finally, the patient was discharged smoothly on the 28th day after surgery. CT, computed tomography.

Video S1

The patient had a history of tuberculosis. The preoperative CT scan revealed atelectasis in the middle and lower lobes of the right lung. No obvious abnormalities were found in other lung lobes.