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LETTER TO EDITOR
Year : 2014  |  Volume : 8  |  Issue : 4  |  Page : 572-573

Severe barotrauma resulting from subtle migration of tracheal tube: A nightmare


Department of Neuroanaesthesiology, Jai Prakash Narain Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India

Correspondence Address:
Dr. Niraj Kumar
Department of Neuroanesthesiology, Room No. 316, Jai Prakash Narain Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1658-354X.140917

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Date of Web Publication16-Sep-2014
 


How to cite this article:
Bindra A, Chauhan M, Kumar N, Jain V, Chauhan V, Goyal K. Severe barotrauma resulting from subtle migration of tracheal tube: A nightmare. Saudi J Anaesth 2014;8:572-3

How to cite this URL:
Bindra A, Chauhan M, Kumar N, Jain V, Chauhan V, Goyal K. Severe barotrauma resulting from subtle migration of tracheal tube: A nightmare. Saudi J Anaesth [serial online] 2014 [cited 2019 Dec 10];8:572-3. Available from: http://www.saudija.org/text.asp?2014/8/4/572/140917

Sir,

Airway related complications carry significant importance while managing a critical patient. Whereas accidental extubation gets the desired attention of the staff, subtle endobronchial migration of tracheal tube (TT) can be missed. Though subtle migrations are not uncommon entities but such disastrous consequences are rarely seen. We report a case of 6-year-old child who presented to us following road traffic accident. She was intubated with 5.5 mm internal diameter uncuffed TT in view of low Glasgow coma score. Non-contrast computed tomography showed mild cerebral edema. Chest radiograph (CXR) following intubation was normal with correct position of the TT [Figure 1]. Patient was shifted to neurosurgical intensive care unit on transport ventilator. On arrival, the patient had bilateral air entry on chest auscultation. However, after few hours of volume controlled ventilation with a tidal volume 8 ml/kg, respiratory rate 15/min and peak airway pressure around 20 cm H 2 O the child developed subcutaneous emphysema. All possible causes of airway trauma were looked for and CXR was requested simultaneously. On radiograph subcutaneous emphysema, pneumomediastinum alongwith right endobronchial migration of TT was seen [Figure 2]. There was however no collapse of the left lung. Endotracheal tube was repositioned using fiberoptic bronchoscopy. No obvious tracheobronchial injury was seen. Subsequent CXR showed the presence of pneumothorax as well. Right intercostal drain was inserted and mechanical ventilation was continued. No other surgical intervention was advised. The radiologic findings improved over the next 2 days and patient was weaned to T-piece and later tracheostomized for neurorehabilitation. The present case report highlights the disastrous effects of TT migration during patient care. Though vigorous or repeated attempts at intubation particularly in emergency setting, co-existing airway trauma may also cause trancheo-bronchial injuries and lead to pneumomediastinum or pneumothorax, but TT migration played a predominant role in development of complication in present case as gradual improvement was seen with repositioning of TT. [1] A plateau airway pressure of 35 mmHg is associated with risk of barotrauma however in this case airway pressures were normal (20 cm H 2 O). [2] Endobronchial migration of TT along with mechanical ventilation resulted in pulmonary barotrauma, which remained undetected for some time and caused pneumomediastinum, pneumothorax and subcutaneous emphysema. We feel that bilateral air entry and normal airway pressures may be fallacious in pediatric patients. The position of TT after intubation should be documented in the patient notes and reconfirmed after every patient shifting or positioning. The use of excessive adhesive taping should be avoided. CXR and fiberoptic bronchoscopy can make quick diagnosis and should be done at the earliest.
Figure 1: Chest radiograph just after intubation


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Figure 2: Chest radiograph after tracheal tube migration to right main bronchus

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  References Top

1.Fan CM, Ko PC, Tsai KC, Chiang WC, Chang YC, Chen WJ, et al. Tracheal rupture complicating emergent endotracheal intubation. Am J Emerg Med 2004;22:289-93.  Back to cited text no. 1
    
2.Boussarsar M, Thierry G, Jaber S, Roudot-Thoraval F, Lemaire F, Brochard L. Relationship between ventilatory settings and barotrauma in the acute respiratory distress syndrome. Intensive Care Med 2002;28:406-13.  Back to cited text no. 2
    


    Figures

  [Figure 1], [Figure 2]



 

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