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The Diagnosis and Management of Patient with Delayed Symptoms from a Tracheal Tear

Greilich, Nancy B. MD; Gasanova, Irina MD, PhD; Farrell, Brian CRNA; Joshi, Girish P. MD, FFARCSI

doi: 10.1213/XAA.0000000000000289
Case Reports: Clinical Care

Development of subcutaneous emphysema after gastrointestinal endoscopy with general anesthesia presents a diagnostic conundrum. We discuss the management of a patient who experienced significant vomiting followed by neck and facial swelling with crepitus and shortness of breath after the endoscopic retrograde cholangiopancreatography. The presence of respiratory distress usually suggests that head and neck subcutaneous emphysema is most likely associated with pneumothorax and/or pneumomediastinum. We discuss the prevention, differential diagnosis, and current management of tracheal tears including subcutaneous emphysema.

From the *Department of Anesthesiology and Pain Management, University of Texas Medical Center, Dallas, Texas; and Department of Anesthesiology, Parkland Health and Hospital System, Dallas, Texas.

Accepted for publication October 22, 2015.

Funding: Departmental.

Girish P. Joshi has received honoraria from Baxter, Mallinckrodt, and Pacira Pharmaceuticals.

Address correspondence to Irina Gasanova, MD, PhD, Department of Anesthesiology and Pain Management, University of Texas Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390. Address e-mail to

Subcutaneous emphysema after a gastrointestinal endoscopy performed under general anesthesia is rare, but it can present a diagnostic conundrum. Delays in diagnosis and treatment can lead to an adverse outcome.1,2 We present a case of a tracheal tear that presented as delayed facial subcutaneous emphysema combined with pneumothorax and pneumomediastinum after endoscopic retrograde cholangiopancreatography (ERCP) under general anesthesia. The prevention, differential diagnosis, and current management of a tracheal tear are discussed.

We have made multiple attempts to contact the patient but have not been successful. Thus, we sought approval for publication of this report from our local IRB that determined that this report does not meet the definition of human subject research as 45 CFR 46.102.

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A middle-aged, small-in-stature woman with persistent nausea and vomiting presented to the emergency department with signs and symptoms of biliary obstruction. She was scheduled for ERCP in the prone position for removal of biliary stones and sphincterotomy under general anesthesia. Her medical history was unremarkable. Her surgical history included surgeries for cesarean delivery, bilateral tubal ligation, and laparoscopic cholecystectomy, which were uneventful. Physical examination, including airway examination, was unremarkable. The intraprocedure anesthetic course was uneventful. The tracheal tube was placed until the upper edge of the cuff was just below the vocal cords at approximately 19 to 20 cm at the lip. However, the ERCP procedure was technically difficult, and extravasation of contrast around the bowel was noted on fluoroscopy suggestive of a gastrointestinal perforation. The gastroenterologist placed a biliary stent and determined that the patient should be observed after the procedure. After the procedure, the patient was transferred to the postanesthesia care unit (PACU). While in the PACU, she was stable, and the gastroenterologist examined the patient on 2 occasions. She was subsequently transferred to the floor 45 minutes after admission in the PACU.

While being transported to the floor, the patient had an episode of forceful retching. On arrival to her room, the patient experienced shortness of breath, and the nurse noticed facial swelling. Her vital signs (heart rate, arterial blood pressure, and oxygen saturation) were within normal limits. The gastroenterologist was notified, and the rapid assessment team was activated and attributed her symptoms to an allergic response to contrast, which was treated with diphenhydramine, methylprednisolone, and low-dose epinephrine. Because of intraprocedure contrast extravasation, an esophageal tear was suspected, and an urgent chest computerized tomography scan was performed. Imaging studies revealed a 2-cm tracheal tear approximately 3 cm above the carina associated with pneumomediastinum and bilateral pneumothoraces (left >> right). No esophageal injury was observed (Fig. 1).

Figure 1

Figure 1

Figure 2

Figure 2

The surgical team was consulted, and urgent intensive care unit admission and chest tube placement were planned. On arrival in the intensive care unit approximately an hour after the inciting event, she developed respiratory compromise requiring emergent tracheal intubation. General anesthesia was induced, and tracheal intubation was performed uneventfully using a videolaryngoscope. Of note, although a fiberoptic tracheal intubation was planned, the severity of respiratory compromise prevented this approach. After intubation, her arterial oxygen saturation continued to decline, and there was a high resistance to mechanical ventilation. Emergent chest tube placement and repositioning the tracheal tube, which included placement of the tracheal tube cuff distal to the injury, resulted in an improvement in lung compliance and oxygen arterial saturation. Bronchoscopic examination confirmed the presence of a tear in the posterior tracheal wall. An emergent surgical repair of the tracheal tear (stent placement with intercostal muscle flap) was performed uneventfully 4 hours later (Fig. 2). Although the intraoperative course was uneventful, the postoperative course was complicated by difficulty weaning from the ventilator, acute kidney injury, and infection. She was discharged home 3 weeks later.

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The first indication of concern in our patient was the occurrence of facial swelling with crepitus accompanied by respiratory distress. The presence of crepitus is suggestive of subcutaneous emphysema. Differentiation between the causes of subcutaneous emphysema in the head and neck regions can be clinically challenging. Because there is a continuum of fascial planes, subcutaneous emphysema in the head and neck region could extend into the thorax or vice versa.3,4 The possible causes of head/neck subcutaneous emphysema are presented in Table 1.

Table 1

Table 1

In our patient, it was initially assumed that the cause of subcutaneous emphysema was esophageal injury because of procedural difficulties and intraprocedure contrast extravasation. However, the most likely cause of the symptoms was tracheal injury that occurred during tracheal intubation for ERCP. This initial tracheal injury may have been incomplete (i.e., mucosal, submucosal, or muscular). Therefore, no signs or symptoms were observed in the intraoperative or immediate postoperative periods. In fact, the patient was stable in the immediate postoperative period including the 45-minute stay in the recovery room. It is likely that the vigorous retching that occurred while the patient was being transferred to the floor resulted in complete laceration of the posterior tracheal wall and subsequent development of symptoms of injury (i.e., facial subcutaneous emphysema and respiratory distress). Alternatively, forceful vomiting could have caused spontaneous tracheal injury. Spontaneous tracheal tear has been reported after forceful vomiting.7

The risk factors for tracheal tear are presented in Table 2. Like in this case, tracheal tears are more common in short women, most likely caused by inappropriate positioning of the tracheal tube.8 Tracheal injury typically occurs in the membranous trachea just above the carina as evidenced in this patient.5,9 The American Society of Anesthesiologists closed claims analysis of airway injuries identified 39 cases with tracheal injuries, 13 of which involved actual perforations. Of these, 70% were deemed routine intubations and only 5 (of 13) were diagnosed intraoperatively.10 Five of the 6 deaths in the tracheal perforation group were thought to have included iatrogenic trauma as a major contributing factor.10 Thus, iatrogenic tracheal injuries, although rare, are frequently of a much higher acuity than other causes.11–15 Therefore, prevention of tracheal tear in patients at high risk is critical. Appropriate positioning of the tracheal tube, avoidance of overinflation of the tracheal cuff, and avoidance of routine use of a tracheal introducer, which is common, are basic steps necessary to prevent this devastating complication. The increase in use of videolaryngoscopes should reduce the number of attempts and deep tracheal intubation, but it is necessary to be cognizant that the rigid stylet (introducer) used with this technique may increase the risk of tracheal damage.

Table 2

Table 2

Early diagnosis and management of tracheal tears are critical in preventing adverse outcomes. Failure to diagnose tracheal injury may delay treatment, which may have fatal consequences. Therefore, a high index of suspicion, particularly in the patient at risk, is necessary. The symptoms of tracheobronchial injury include shortness of breath and hemoptysis, and the signs include subcutaneous emphysema, pneumothorax, pneumomediastium, and blood in the trachea. In patients with head or neck subcutaneous emphysema, a chest radiograph should be obtained urgently to exclude pneumothorax and/or pneumomediastinum. A computerized tomography scan of the thorax should further elucidate the diagnosis and treatment. A fiberoptic bronchoscopy is the best approach to confirm the diagnosis and determine the location and extent of tracheal injury.

The management of tracheal tears depends on the severity of the symptoms and the degree of injury. Superficial lesions are usually managed conservatively. It is recommended that level 1 injury (mucosal or submucosal lesion without mediastinal emphysema and without esophageal injury) and level 2 injury (muscular wall lesion with subcutaneous or mediastinal emphysema without esophageal injury or mediastinitis) can be safely managed conservatively with endoscopic instillation of fibrin glue over the tracheal lesions.17 Patients with level 3A injury (complete laceration of the tracheal wall with esophageal or mediastinal soft tissue hernia but without esophageal injury or mediastinitis) may be managed conservatively if the respiratory function is stable. However, patients with level 3B injury (any laceration of the tracheal wall with esophageal injury or mediastinitis) require surgical intervention.

Anesthetic management of tracheal tears involves patients who have significant respiratory compromise from complications (e.g., pneumothorax) or patients scheduled for tracheal repair, similar to our case. General anesthesia with tracheal intubation, facilitated by muscle relaxants, is necessary for this surgical procedure. It is necessary to obtain the information regarding the size and site of the injury. Tracheal intubation should be performed with great care so as not to increase the injury. If time permits, it is best to place the tracheal tube under direct vision using a fiberscope. If this is not possible, the placement of a tracheal tube using a videolaryngoscope is the next best approach. Also, a fiberscope could be used as a bougie to guide the tracheal tube instead of the commonly used rigid stylet and to confirm the proper tube placement. The tracheal tube cuff should be placed distal to the injury. Thus, endobronchial intubation may sometimes be necessary depending on the site of injury. Mechanical ventilation should include low tidal volume without positive end-expiratory pressure to minimize peak airway pressures and avoid further damage. A recent systematic review assessing lung-protective mechanical ventilation concluded that low tidal volumes without positive end-expiratory pressure may be appropriate for improving postoperative pulmonary outcomes.18 Also, the acceptance of mild-to-moderate hypercapnia may be appropriate,19,20 which should further reduce airway pressures, because it reduces the need to hyperventilate. After completion of the repair, the tracheal tube is withdrawn with the tip just above the repair. This is followed by testing the integrity of the repair using higher peak airway pressures and returning to the protective ventilation technique when the test is complete. Early smooth tracheal extubation, preferably at the end of surgery, is encouraged.

In summary, the development of subcutaneous emphysema in the head and neck regions after an ERCP with general anesthesia presents a diagnostic conundrum. The presence of respiratory distress usually suggests that the head and neck subcutaneous emphysema is most likely associated with pneumothorax and/or pneumomediastinum. The high index of suspicion should prompt an early chest radiograph and imaging for diagnosis and intervention. If tracheal intubation is necessary after suspected tracheal tear, it should be performed ideally using a fiberscope, and lung protective ventilation should be used to prevent further tracheal injury.

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