Conservative treatment of spontaneous tracheal rupture

[Traumatic Tracheobronchial Injuries - Recommendation of the Interdisciplinary Working Group of the DGT and DGU to Establish a Uniform Classification for Diagnostics and Therapy]

Traumatic tracheobronchial injuries are extremely rare. In comparison, iatrogenic injuries are somewhat more common. A literature search revealed that there is a large number of case reports and small case series for this clinical entity. There are hardly any reviews and they usually have a low level of evidence. One reason for this is the lack of a classification to allow comparison of the individual cases with each other. There is only one classification for iatrogenic injuries of the posterior tracheal wall, which the authors modified and expanded with regard to traumatic tracheobronchial injuries. This classification was extended by the authors to also include traumatic injuries. A three-digit classification is presented here. The grading of the injury covers the entire spectrum of injury patterns, from peribronchial emphysema to wall injuries of different depths to subtotal and complete rupture of the bronchus. In addition, the anatomical location and the cause of the injury were added to the classification. The levels of injury in the tracheobronchial tree are distinguished anatomically. The third digit distinguishes traumatic, iatrogenic and spontaneous injuries. On the basis of the three-digit classification resulting from these parameters, it is possible to group individual cases together and to develop recommendations for diagnostics and therapy.

Spontaneous rupture of trachea treated conservatively: A case report

Introduction and importance

Spontaneous rupture of the trachea is a rare, life-threatening condition. Spontaneous rupture associated with corticosteroid use has been rarely reported in the literature.

Case presentation

We report a case of a 17-year-old male, a known case of nephrotic syndrome managed by corticosteroid treatment, who presented with diffuse neck and chest swelling after forceful coughing resulting in a spontaneous rupture of the trachea. The diagnosis was established using radiological imaging. The patient was managed conservatively with significant improvement and was discharged shortly.

Clinical discussion

Prolonged use of corticosteroids may lead to spontaneous rupture of the trachea due to tracheal wall weakness. Radiological imaging followed by bronchoscopy can be used to confirm the diagnosis. Management can either be conservative or surgical, depending on the case.

Conclusion

Conservative treatment by pain relief, intravenous fluids, and antibiotics should be considered an alternative to surgery in selected patients.

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Spontaneous rupture of the trachea is a rare and life-threatening condition.

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Spontaneous rupture of the trachea can be predisposed by prolonged corticosteroid use.

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The prompt diagnosis and appropriate management of patients with tracheal rupture are crucial.

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Diagnostic measures for spontaneous tracheal rupture include radiological imaging with the possible need for bronchoscopy.

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Tracheal rupture should be suspected in the presence of pneumomediastinum and cervical emphysema without pneumothorax.

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Tracheal rupture can be managed either conservatively or surgically depending on the patient’s whole clinical picture.

Spontaneous pneumomediastinum in accidental chlorine gas inhalational injury: case report and review of literature

A young man presented in emergency department with shortness of breath and cough after accidental inhalation of chlorine gas. Initial presentation was unremarkable; therefore, he was kept under observation for 8 hours and was later discharged. After 5 hours, the patient presented again in emergency department with sudden-onset shortness of breath and chest discomfort. On examination, subcutaneous crepitation around the neck and chest was found. Chest and neck X-ray revealed subcutaneous emphysema and pneumomediastinum. CT neck and chest was done, which revealed subcutaneous emphysema and pneumomediastinum and a linear air density in close approximation to right posterolateral wall of trachea at the level of superior margin of sternum was reported. These findings raised the possibility of tracheal injury which was later confirmed by fiberoptic laryngoscopy. The patient was intubated due to hypercapnic respiratory failure resulting from hypoventilation and respiratory distress. Bilateral chest tube insertion was done due to worsening subcutaneous emphysema, high ventilator parameters and prevention of progression to pneumothorax. He was extubated after 5 days; bilateral chest tubes were removed before discharge and underwent uneventful recovery.

Pediatric tracheal trauma

Tracheal trauma is an uncommon but potentially serious cause of airway injury in children. Presentation may be acute in cases of blunt or penetrating trauma, or delayed in cases of chronic irritation or indwelling endotracheal tubes. Symptoms include dyspnea, progressive respiratory distress, neck and chest swelling and ecchymosis, and dysphonia. Workup is pursued as allowed by the patient's clinical status and may include plain radiography, computed tomography, and endoscopy. Accuracy and efficiency of diagnosis is paramount for those at risk of rapid decompensation. Treatment may include observation, elective and strategic intubation, or primary surgical repair.

Postintubation Tracheal Perforation While on Long-Term Steroid Therapy: A Case Report

BACKGROUND

Endotracheal intubation is an essential basic skill for emergency physicians. The procedure can cause complications that should be recognized. Awareness and early identification of complications are needed to allow early intervention to optimize outcomes. The risk factors for tracheal perforation during intubation are typically related to the physician skill and experience and to the patient's comorbidities, including body habitus and chronic use of certain medications.

CASE REPORT

We report a case of a 45-year-old man with renal transplant on tacrolimus and prednisolone for 16 years. He presented with decreased level of consciousness due to an acute intracranial hemorrhage and was intubated for airway protection. Post intubation, a significant subcutaneous emphysema was noted on the patient's neck and chest, which was subsequently determined to be caused by a tracheal perforation. The management of tracheal injury depends on the size and location of the tear, as well as the patient's clinical status and comorbidities. In this case, the tracheal perforation was treated conservatively and was successful. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case has been reported to increase awareness about this rare and potentially life-threatening event. The prevention of this rare injury can be difficult but use of a slightly smaller endotracheal tube in a high-risk patient can be of benefit. In addition, early consideration of this complication when there is an acute change in physiologic status will allow for rapid facilitated management.

Tracheal rupture as a result of coughing

Tracheal rupture is mostly traumatic or iatrogenic. A few cases of spontaneous tracheal rupture have been reported in literatüre and all of them have been described posterior membraneous wall which is the weakest portion of trachea. In most of such cases, predisposing factors that weaken the tracheal structure were present. We presented the first case of spontaneous anterolateral tracheal rupture as a result of coughing that caused no respiratory distress and that spontaneously recovered without any complications. A 24 year old male presented to the emergency department with sore throat. After eating chicken shawarma, the patient felt a lump in his throat and coughed. After coughing, a tearing like and severe pain developed at his neck's front region radiating to his shoulders and back. On past medical history, the patient had no known diseases and had no history of use of medications. Physical examination findings were unremarkable except for neck tenderness. Pneumomediastinum, free air within the cervical fascias and a 4mm tracheal mural defect on the left anterolateral side at the level superior to the manubrium was observed in computerised tomography scan of neck and chest. The patient had no shortness of breath and therefore urgent surgery was not considered. Increase in free air was not seen in the control x-rays 6 hours later. The patient with a foriegn nationality left the emergency at his own will. He was contacted one month later via telephone. The patient said that his neck pain subsided and had no other complaints.

A 4-year-old child presenting morning onset of spontaneous tracheal rupture due to bronchial mucous plug occlusion during the nighttime sleep: a case report

Background

Coughing is the most efficient mechanism for clearing mucus and fluid secretions from the airways and its reflex can be suppressed by sleep. Spontaneous tracheal ruptures are believed to result from raised intratracheal pressure against a closed glottis, such as for severe coughing. This is the first reported case of tracheal rupture presented on morning awakening after bronchial mucous plug formation during the nighttime sleep because of an ineffective cough reflex.

Case presentation

An otherwise healthy white 4-year-old child presented morning onset of dyspnea, chest pain and diffuse swelling of the neck. His history was significant only for nonsevere coughing episodes before his nighttime rest; the child’s parents denied any recent fever, weight loss, pains, trauma, bronchial asthma, and sick contacts. A chest X-ray and computed tomography scan revealed pneumomediastinum, obstructive atelectasis of the lower lobe of his left lung, and a small tracheal laceration confirmed by an emergency bronchoscopy. After endoscopic removal of a mucous plug and secretions, the child’s pulmonary gas exchange and respiratory rate improved, so our patient was managed conservatively.

Conclusions

This report illustrates an unusual presentation of lung obstructive atelectasis due to a mucous plug manifested by tracheal rupture. This report also highlights the importance of the coughing reflex as one of several defensive mechanisms protecting the airways from the potentially damaging effects of aspirate and accumulated secretions.

Spontaneous tracheal rupture: a case report

BACKGROUND

Upper-airway disruption is a rare but potentially life-threatening phenomenon. It can occur spontaneously, be due to trauma, or be iatrogenically induced. Even more rare are such events reported in the pediatric population.

OBJECTIVE

This article discusses the presentation, diagnostic difficulties, and management of spontaneous tracheal rupture in a child.

CASE REPORT

A 3-year-old boy was brought by emergency medical services to our emergency department with a presumptive diagnosis of anaphylaxis. With progressive swelling and respiratory distress, the patient quickly deteriorated. He received i.v. epinephrine, chest compressions, and bag-valve mask ventilation. He was intubated without difficulty and with no noted airway edema. Concomitant bilateral needle thoracostomies were performed and subsequent bilateral tube thoracostomies were placed. Immediately after intubation and chest tube placements, the patient's oxygen saturations and heart rate improved. Bronchoscopy failed to demonstrate any evident pathology. However, computed tomography scan revealed a defect in the posterior wall of the trachea proximal to the termination of the endotracheal tube. Cardiothoracic surgery was consulted and performed a primary repair of the tracheal defect. The patient was extubated soon after surgery, and he was discharged home neurologically intact.

CONCLUSIONS

The initial presentation of spontaneous tracheal rupture can be misleading and difficult to diagnose. After resuscitation, stabilization, and diagnosis, both surgical repair and nonoperative management have been reported as successful treatment measures for tracheal disruption.

Iatrogenic tracheal rupture in a child: case study and review of literature

Tracheal rupture is rare in childhood, and optimal treatment is not clear. A 14-year-old boy was admitted to a local hospital after sudden loss of consciousness. He underwent endotracheal intubation and was referred to our hospital. The patient's history revealed that he had voluntarily inhaled butane gas. The physical examination was consistent with coma and cardiogenic shock, and the chest radiograph showed pulmonary edema. The patient was admitted to the intensive care unit, and diuretic and inotropic therapy was started. In the third hour of monitoring of the patient under mechanical ventilation, subcutaneous emphysema and pneumothorax at the right hemithorax were observed without deterioration of the vital functions. Thoracic computed tomography scan findings were consistent with tracheal rupture. The patient was monitored conservatively without surgery. On the fifth day of hospitalization, his tube was removed, and he was discharged on the 12th day with a positive prognosis. In this study, a tracheal rupture case after endotracheal intubation is presented in which the patient recovered completely with conservative therapy.

Spontaneous tracheal rupture caused by vomiting

OBJECTIVES

To present a pediatric case of spontaneous tracheal rupture caused solely by vomiting and to discuss its diagnosis and management.

STUDY DESIGN

Case presentation and literature review.

RESULTS

A 14-year-old girl with a new diagnosis of type 1 diabetes mellitus presented with respiratory distress. History was significant only for 4 days of violent vomiting, and she was diagnosed with diabetic ketoacidosis. Examination revealed tachypnea and considerable subcutaneous air overlying the upper chest and neck; chest x-ray showed pneumomediastinum. A swallow study showed no evidence of an esophageal tear. Computed tomography of the chest showed a posterior tracheal tear 4.5 cm distal to the cricoid cartilage. The patient's ketoacidosis was controlled, and supplemental oxygen was administered temporarily to promote absorption of the extravasated air. Serial chest x-rays showed complete resolution within 5 days and intubation was not required.

CONCLUSIONS

To our knowledge, this is the first reported pediatric case of tracheal rupture secondary to vomiting. Previous reports of spontaneous tracheal rupture have been related to paroxysmal coughing. In similar cases of subcutaneous emphysema and pneumomediastinum after retching, an esophageal rupture should be ruled out. Conservative management was successful in this case.