Case:

A patient suffered tracheal injury secondary to difficult placement of a double lumen tube. Bronchoscopy revealed defectin the left bronchus + injury to the distal trachea.

Following MDT - patient put on VV ECMO, and the injury repaired. The patient is recovering on intensive care unit, still awaiting surgery for lung cancer.

Commentary

This content has been developed for SALG by the Association for Cardiothoracic Anaesthesia and Critical Care

Tracheal injury is a known rare but life threatening risk from double lumen tube (DLT) insertion, thought to occur in 1 in 20,000 cases¹. A systematic review suggested common possible contributors include stylet use, cuff over-inflation, multiple attempts to adjust the DLT position, difficult intubation, and using an oversized DLT².  Mortality of patients with airway rupture by DLTs was 8.8%². Overinflating tracheal and bronchial cuffs of the DLT can transmit high pressure to the mucosa, leading to mucosal erosion and inflammation which can potentially lead to scar formation and airway stenosis³.

In this case it appears the defect was likely during actual insertion. The bronchial injury was noticed immediately and appropriate management implemented to allow surgical correction of the defect. Showing the importance of bronchoscopic visualisation of the airway after insertion of the DLT.

References

1. Minambres, E., Buron, J., Ballesteros, M.A., et al. Tracheal rupture after endotracheal intubation: a literature systematic review. Eur J Cardiothorac Surg. 2009; 35: p 1056-62.

2. Liu, S., Mao, Y., Qiu, P. et al. Airway Rupture Caused by Double-Lumen Tubes: A Review of 187 Cases. Anesthesia & Analgesia. 2020; 131(5): p 1485-1490.

3. Patel, M., Wilson, A. and Ong, C. Double-lumen tubes and bronchial blockers. BJA Education. 2023; 23(11): p 416 – 424.