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.
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.
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
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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