Near total transection of the trachea

W.K.A. KEDJANYI and D. GUPTA Department of Otolaryngology, Head and Neck Surgery, Royal Devon and Exeter Hospital (Wonford), Barrack Road, Exeter EX2 5DW, UK

Introduction

Case Report

Discussion

References

The bedside procedure of percutaneous dilatational tracheostomy (PDT) in the intensive care unit continues to gain popularity. Percutaneous dilatational tracheostomy is recommended as simple, safe and cost-effective. The procedure can be associated with serious life-threatening complications. We report a case of near total transection of the trachea following PDT.

The bedside procedure of percutaneous dilatational tracheostomy (PDT) is now widely accepted as a safe and cost effective alternative to formal surgical tracheostomy.1 There have been several reports of the complications associated with percutaneous dilatational tracheostomy. 2-5

We report a case of near total transection of the tracheal ring following PDT with satisfactory recovery after surgical exploration and repair.

A 67-year-old man was admitted to hospital as an emergency with a leaking abdominal aortic aneurysm. At laparotomy, the ruptured aneurysm was repaired with a Dacron per thousand graft. Post-operatively the patient was ventilated on the intensive care unit (ICU). During the post-operative period, the patient accidentally self-extubated and was maintained on spontaneous intermittent mandatory ventilation (SIMV).

A week later, the patient had PDT performed in the ICU by an experienced anaesthetist. The anaesthetist was initially unable to insert the portex tracheostomy tube using the Rapitrac technique and so converted to the Ciaglia Cook system with graded dilators. A chest radiograph, immediately afterwards, was noted to have a marked opacity on the left side.

The patient was found to have subcutaneous emphysema of the neck, which, after 8 hours, was worse extending from the nipples into both arms, the neck and face. The patient also required unacceptably high tracheostomy tube cuff inflation pressures to maintain respiratory minute volume. An opinion was sought from an ear, nose and throat surgeon and open tracheostomy was performed.

Exploration of the tracheostomy site revealed an extensive transverse laceration between the 1st and 2nd tracheal rings involving almost 75% of the circumference. Repair of the laceration was carried out and a tracheostomy created involving the 2nd and 3rd tracheal rings. A post-operative chest radiograph showed the tracheostomy tube in place and absence of any pneumothorax. The patient made a slow recovery and was eventually decannulated a month later. At review, 3 months post-operatively, he remained well with no respiratory difficulty.

Ciaglia et al (1985), reported the first PDT technique, which used no cutting other than for the small skin incision and the use of progressive hollow plastic tracheal dilators over a guide wire. ^2,6 In 1989, Schachner et al reported a new method of PDT where the dilatation device, the metal tracheostome, was passed over the guide wire into the trachea to dilate the track fully in one step.⁷

Complications associated with both PDT techniques vary and have been widely reported in the medical literature. ^3,4,8 Careful patient selection is important in avoiding some of the complications associated with PDT. Contraindications to PDT include a large goitre, a short thick neck, aberrant jugular veins and a coagulopathy.²

The risk of injury to the posterior tracheal wall and paratracheal placement of the tracheostomy tube with associated subcutaneous emphysema and pneumothorax has been reduced with the use of flexible bronchoscopic guidance.^9,10 Frosh etal (1997) presented a case of asymptomatic rupture and herniation of tracheal rings into the lumen of the trachea following PDT that was noticed as an incidental finding during bronchoscopy. ¹¹Osborne et al (1999) reported a symptomatic case of anterior tracheal ring herniation after PDT that was not noticed at the time of the tracheostomy despite flexible bronchoscopy.⁵ These tracheal ring complications were anteriorly located. Hutchinson and Mitchell (1991) reported a vertical tear in the posterior wall of the trachea following Rapitrac PDT with severe subcutaneous emphysema, bilateral tension pneumothoraces, and pneumoperitoneum.³

In our case, the tracheal ring rupture involved almost 75 % of the circumference of the trachea with the narrow segment attached posteriorly. This serious but rare complication of PDT has so far never been reported. Our patient had two different methods of PDT techniques employed before the tracheostomy tube could be inserted.⁴The initial tracheal damage may have been from the failed Rapitrac PDT while the subsequent Cooks’ PDT might have created a new tracheal puncture site. The additional factor which may have converted an initial small tracheal rupture anteriorly into the major rupture found could be the unacceptably high cuff pressure in the tracheostomy cuff, likely to be seated between the split ends of the trachea. This will act as a splint allowing further tracheal ring damage and also the extensive sub-cutaneous emphysema noted. The PDT was not performed under endoscopic guidance, which might have identified the initial problems of the tracheostomy site and tracheostomy tube placement.

This patient is at risk from the long-term complication of tracheal stenosis and will be followed up for a considerable length of time. ^12,13 This case highlights the potential for serious complications with PDT. Care in patient selection, willingness to revert to open tracheostomy in case of difficulty and endoscopic guidance would avoid a lot of the potential complications of PDT.

1. Hazard P, Jones C, Benitone J. Comparative trial of standard operative tracheostomy with percutaneous tracheostomy. Critical Care Medicine 1991; 19: 1018-23
2. Ciagla P, Graniero KD. Percutaneous dilatational tracheostomy. Results and long-term follow-up. Chest 1992; 101: 464-7
3. Hutchinson RC, Mitchell RD. Life-threatening complications from percutaneous dilational tracheostomy. Crit Care Med 1991; 19: 118-20
4. Leinhardt DJ, Mughal M, Bowles B, Glew R, Kishen R, MacBeth J, Irwing M. Appraisal of percutaneous tracheostomy. Br J Surg 1992; 79: 225-58
5. Osborne JE, Osman EZ, Cuddihy P, Ranta M. Traceal ring herniation following percutaneous dilatational tracheostomy and its resection under endoscopic control. J Laryngol Otol 1999; 113: 1116-8
6. Ciagla P, Firsching R, Syniec C. Elective precutaneous dilatational tracheostomy. A new simple bedside procedure; preliminary report. Chest 1985; 87: 715-9
7. Schachner A, Ovil Y, Sidi j, Rogev M, Heilbronn Y, Levy MJ. Crit Care Med 1989; 17: 1052-6
8. Toursarkissian B, Zweng TN, Kearney PA, Pofahl WE, Johnson SB. Percutaneous dilational tracheostomy: report of 141 cases. (Review). Ann Thor Surg 1994; 57: 862-7
9. Marelli D, Paul A, Manolidis S, Walsh G, Odim JNK, Burdon TA, Shennib H, Vestweber KH, Fleiszer DM, Mulder DS. Endoscopic guided percutaneous tracheostomy: early results of a consecutive trial. J Trauma 1990; 30: 433-5
10. Winkler WB, Karnik R, Seelmann O, Havecik J. Bedside percutaneous dilational tracheostomy with endoscopic guidance: experience with 71 ICU patients. Intensive Care Med 1994; 27: 476-9
11. Frosh A, Thomas ML, Weinbren J, Djazaeri B, Richards A. Trachael ring rupture and herniation during percutaneous dilatational tracheostomy identified by fibreoptic bronchoscopy. Revue de Laryngologie Otologie Rhinologie 1997; 118: 179-80
12. McFarlane C, Denholm SW, Sudlow CLM, Moralee SJ, Grant IS, Lee A. Laryngotracheal stenosis: a serious complication of percutaneous tracheostomy. Anaesthesia 1994; 49: 38-40
13. Fischler MP, Kuhn M, Cantieni R, Frutiger A. Late out-come of percutaneous dilatational tracheostony in intensive care patients. Intensive Care Med 1995; 21: 475-81

Copyright date: 27th January 2001
Correspondence: Mr WKA Kedjanyi, Department of Otolaryngology, Head and Neck Surgery, Royal Devon and Exeter Hospital (Wonford), Barrack Road, Exeter EX2 5DW, UK

Near total transection of the trachea following percutaneous dilatational tracheostomy