Case
A 55 year old female, no previous medical history, underwent out-of-hospital cardiac arrest. Advanced cardiac life support (ACLS) was initiated, with return of spontaneous circulation after 30’ of conventional resuscitation efforts. At first hospital arrival coronary angiography and successful percutaneous transluminal angioplasty were performed to treat right coronary artery stenosis.
Incidentally, lung computed tomography (CT) revealed signs of aspiration pneumonia (Figure 1). Moreover, as a result of improper out-of-hospital endotracheal tube (ETT) positioning (ID 7.5/OD 10.7 mm) during ACLS, the patient suffered iatrogenic airway injury, as confirmed by bronchoscopy (12 x 19 mm respectively sagittal and longitudinal axis, Figures 1 and 2).
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Figure 1.: Tracheal injury (white arrow) and aspiration pneumonia at CT scan performed at hospital admission: distal end of the endotracheal tube in the main right bronchus (white arrow); retrocarinal pneumomediastinum (black arrow); evidence of basal consolidation in the left lung. CT, computed tomography.
Figure 2.: Evolution of tracheal injury (white arrows) at fiberoptic bronchoscopy. A: day 1 large tear in the pars membranacea (posterior wall) of the trachea, extended to the emergence of the main right bronchus (white arrow), with hyperemic peripheral area; (B) day 7: partial re-epithelialization of the posterior wall, and decreased mucosal hyperemia; (C) day 24 evidence of resolution of the injury, with a residual linear scar. ECMO, extracorporeal membrane oxygenation; LMB, left main bronchus; RMB, right main bronchus.
Pneumonia worsened rapidly to acute respiratory distress syndrome (ARDS) over subsequent days, and the presence of tracheal injury complicated mechanical ventilation management, so femoro-femoral veno-venous extracorporeal membrane oxygenation (V-V ECMO) was initiated in referring hospital (details in online supplement, Supplemental Digital Content 1, https://links.lww.com/ASAIO/A876). After cannulation the patient was transferred to referral center.
For the first 2 days deep sedation and neuromuscular blockade were deemed necessary to provide lung protective ventilation (settings detailed in online supplement, Supplemental Digital Content 1, https://links.lww.com/ASAIO/A876). Due to the location of the distal end of the ETT cuff tube, the intracuff pressure was strictly monitored and maintained at 20 mm Hg.
On minimal ECMO support gas exchange rapidly improved. To improve tracheal tear healing the patient was extubated on third day of ECMO, and high flow nasal oxygen (HFNO) initiated. After 8 days successful weaning trial was attempted, and decannulation performed.
Follow up CTs demonstrated progressive resolution of lung disease and airway injury, with reabsorption of pneumodediastinum.
Since ECMO weaning the patient remained eupneic; she was discharged home with almost complete lung recovery and intact tracheal wall (evolution of injury and clinical course are depicted in supplementary figures 1 and 2, Supplemental Digital Content 1, https://links.lww.com/ASAIO/A876). Full neurologic recovery was achieved, with no signs of physical impairment.
References
1. Fitzgerald JC, Topjian AA, McInnes AD, et al.: Bi-caval dual lumen venovenous extracorporeal membrane oxygenation and high-frequency percussive ventilatory support for postintubation tracheal injury and acute respiratory distress syndrome. J Pediatr Surg 46: e11–e15, 2011.
2. Antonacci F, De Tisi C, Donadoni I, et al.: Veno-venous ECMO during surgical repair of tracheal perforation: A case report. Int J Surg Case Rep 42: 64–66, 2018.
3. Jeng EI, Piovesana G, Taylor J, Machuca TN: Extracorporeal membrane oxygenation to facilitate tracheal healing after oesophagogastric catastrophe. Eur J Cardiothorac Surg 53: 288–289, 2018.
4. Langer T, Santini A, Bottino N, et al.: “Awake” extracorporeal membrane oxygenation (ECMO): pathophysiology, technical considerations, and clinical pioneering. Crit Care 20: 150, 2016.
5. Gurnani PK, Michalak LA, Tabachnick D, Kotwas M, Tatooles AJ: Outcomes of extubated COVID and Non-COVID patients receiving awake venovenous extracorporeal membrane oxygenation. ASAIO J 68: 478–485, 2022.
