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Pneumopericardium and Pneumomediastinum Complicating Endotracheal Intubation D

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Pneumopericardium and Pneumomediastinum Complicating Endotracheal Intubation D Postgraduate Medical Journal (April 1979) 55, 273-275 Postgrad Med J: first published as 10.1136/pgmj.55.642.273 on 1 April 1979. Downloaded from Pneumopericardium and pneumomediastinum complicating endotracheal intubation D. O'NEILL D. N. K. SYMON M.B., Ch.B., M.R.C.P. B.Sc., M.B., Ch.B., M.R.C.P. Department of Cardiology, Western Infirmary, Glasgow GIl 6NT Summary was promptly inserted by the house physician. This Pneumopericardium and pneumomediastinum have type of tube has a total length of 30 cm with mark- been described as complications of endotracheal ings at 22, 24 and 26 cm. It was not trimmed before intubation and assisted ventilation in neonates and insertion. Copious secretions were aspirated and children. Here the occurrence of these complications intermittent positive pressure ventilation commenced in an adult is described and the possible mechanism using an Ambu bag. It was then noticed that the discussed. left lung was not being inflated and the tube was partially withdrawn. Ventilation with the Ambu bag Introduction was continued for 30 minutes until spontaneous The use of the endotracheal tube during surgery ventilation returned. During this period gastric has become the most widely used and acceptable lavage was carried out after an oro-gastric tube had method of providing an airway and of assisting in been passed without difficulty. Protected by copyright. the ventilation of the patient. Although some On admission to the intensive care unit he was complications do arise, the beneficial aspects of the noted to have a loud pericardial friction rub audible procedure have far outweighed the limitations due to over the entire praecordium. The heart sounds these hazards (Freeman, 1972; McGovern, Fitz- remained normal. There was no rise in jugular Hugh and Edgemon, 1971). Occasional reports of venous pressure and pulsus paradoxus was absent. trauma to the trachea from endotracheal intubation Chest X-ray showed a pneumomediastinum and in adults have appeared in the literature (Thompson pneumopericardium (Fig. 1). The electrocardiogram and Read, 1968) but most have been of children and remained normal throughout his stay in hospital. particularly of newborn infants (Fearon et al., Blood barbiturate level on admission was 310 1966). A combination of surgical emphysema, mmol/l. pneumothorax, pneumomediastinum and pneumo- His subsequent course was uneventful and he peritoneum has been described (Scott and Viner, recovered full consciousness 15 hr after admission. and has been documented The endotracheal tube had been in for 12 hr. 1975) pneumopericardium place http://pmj.bmj.com/ following endotracheal intubation in the neonatal Follow-up was incomplete as the patient discharged period (Moodie et al., 1976). Mansfield et al. (1973) himself from hospital against medical advice 60 hr felt that pneumopericardium occurred almost after admission. However, his friction rub persisted exclusively in pre-term newborn infants with for the duration of his stay in hospital. idiopathic respiratory distress syndrome (IRDS). Six weeks later he presented himself once again at This complication in an adult is now described. the Accident and Emergency Department with a fractured left ankle. At that time he had no cardiac Case report signs nor symptoms and the chest X-ray appearances on September 24, 2021 by guest. A 27-year-old male with a history of frequent had returned to normal. drug overdose was brought to the Accident and Emergency Department of the Western Infirmary, Discussion Glasgow, with a history of ingesting 93 tablets of Pneumopericardium was first described as a phenobarbitone 30 mg and a quantity of alcohol. post-mortem finding by Joseph Lieutaud (1767) but On arrival he was drowsy and within minutes became it was not until 77 years later that the classic deeply comatose and apnoeic. An endotracheal tube* pericardial sound ('Bruit de Moulin') was first described (Bricheteau, 1844). It is a rare but poten- * 'Clearway' cuffed endotracheal tube, 9 mm (J. G. Franklin ially lethal complication of many conditions, and Sons, High Wycombe, Buckinghamshire). and when Correspondence: Dr D. N. K. Symon, Department ofChild tension develops within the pericardium Health, Royal Hospital for Sick Children, Yorkhill, Glasgow the resultant cardiac tamponade necessitates prompt G3 8SJ. decompression (Khan, 1974). 0032-5473/79/0400-0273 $02.00 ©) 1979 The Fellowship of Postgraduate Medicine Postgrad Med J: first published as 10.1136/pgmj.55.642.273 on 1 April 1979. Downloaded from 274 Case reports Protected by copyright. FIG. 1. Chest X-ray on admission to the intensive therapy unit showing pneumomediastinum and pneumopericardium. Shackelford (1931) while reviewing 76 cases site of potential weakness where the parietal peri- occurring in the previous century noted that more cardium is reflected on to visceral pericar- than 66% had a fatal outcome. Many of these were dium near the ostia of the pulmonary veins http://pmj.bmj.com/ the result of penetrating injuries or of tuberculosis. (Mansfield et al., 1973). The pericardial collagenous Since then, other cases have been described of tissue is not continuous around the point of re- complicating conditions such as hiatus hernia flection but tends to pass peripherally, contributing (Monro et al., 1974), oesophagitis (Curry and to the perivascular sheath. Air dissecting through Anderson, 1974), lung abscess (Netto, 1944) the appropriate layer of the perivascular sheaths and even dental extraction (Sandler, Libshitz and could enter the pericardial sac with relative ease at Marks, 1975). There is in the literature one instance the site of since the obstacles would reflection, only on September 24, 2021 by guest. of pneumopericardium following endotracheal in- be thin layers of mesothelium and areolar tissue. tubation for anaesthesia in a 3-5-month-old boy In the present patient it seems likely that the mechan- (Loftis et al., 1962). However, most cases of pneumo- ism was through direct damage to the trachea pericardium occur in newborn infants (Moodie (Thompson and Read, 1968) or right main bronchus, et al., 1976), particularly those treated with continu- with the air then tracking down to the pericardial ous positive airways pressure (CPAP) or inter- sheath. mittent positive pressure ventilation with positive This case illustrates that endotracheal intubation end-expiratory pressure (PEEP) for IRDS is a procedure which continues to have a morbidity (Mansfield et al., 1973; Matthieu et al., 1970). in adults as well as in children, and insertion of The mechanism causing pneumopericardium is endotracheal tubes must be undertaken with extreme probably related to the rise in intra-bronchial air care and, where possible, by an experienced person. pressure (Johannides and Tsoulos, 1930), brought about by the CPAP or PEEP. Acknowledgments Histological preparations have demonstrated a We would like to thank Dr R. T. S. Gunn for permission to Case reports 275 Postgrad Med J: first published as 10.1136/pgmj.55.642.273 on 1 April 1979. Downloaded from describe his patient, and Professor F. Cockburn for his helpful MCGOVERN, F.H., FITZ-HUGH, G.S. & EDGEMON, J.L. (1971) advice. We also thank Miss Fiona Paton for typing the The hazards of endotracheal intubation. Annals ofOtology, manuscript. Rhinology and Laryngology, 80, 556. MANSFIELD, P.B., GRAHAM, C.B., BECKWITH, J.B., HALL, D.G. & SAUVAGE, L.R. (1973) Pneumopericardium and References pneumomediastinum in infants and children. Journal of BRICHETEAU, M. (1844) Observation d'hydro-pneumo- Pediatric Surgery, 8, 691. pericarde, accompagn6 d'un bruit de fluctuation per- MATTHIEU, J., NUSSLE, D., TORRADO, A. & SADEGHI, H. ceptible a l'oreille. Archives GLnirales de Me'decine, 4, (1970). Pneumopericardium in the newborn. Pediatrics, 334. 46, 117. CURRY, N. & ANDERSON, R.S. (1974) Pneumopericardium MONRO, J.L., NICHOLLS, R.J., HATELY, W., MURRAY, R.S. and esophago-pericardial fistula following chronic & FLAVELL, G. (1974) Gastropericardial fistula-a esophagitis presenting as acute respiratory distress. Chest, complication of hiatus hernia. British Journal of Surgery, 66, 731. FEARON, B., MACDONALD, R.E., SMITH, C. & MITCHELL, D. 61, 445. (1966) Airway problems in children following prolonged MOODIE, D.S., KLEINBERG, F., HATTERY, R.R. & FELDT, R.H. endotracheal intubation. Annals of Otology, Rhinology and (1976) Neonatal pneumopericardium. Proceedings. Mayo Laryngology, 75, 975. Clinic, 51, 101. FREEMAN, G.R. (1972) A comparative analysis of endo- NETTO, D.J.L. (1944) Pneumopericardium in a forty-two day tracheal intubation in neonates, children and adults: old infant. American Journal of Diseases of Children, 67, complications, prevention and treatment. Laryngoscope, 288. 82, 1385. SANDLER, C.M., LIBSHITZ, H.l. & MARKS, G. (1975) Pneu- JOHANNIDES, M. & TsoULOS, G.D. (1930) The etiology of moperitoneum, pneumomediastinuni and pneumoperi- interstitial and mediastinal emphysema. Archives of cardium following dental extraction. Radiology, 115, Surgery, 21, 333. 539. KHAN, R.M.A. (1974) Air tamponade and tension pneumo- SCOTT, J.K. & VINER, J. (1975) Surgical emphysema, bilatera, pericardium. An unusual complication of subtotal peri- pneumothorax, pneumomediastinum and pneumoperi- cardiectomy. iournal of Thoracic and Cardiovascular toneum complicating intubation for anaesthesia. Post- Surgery, 68, 328. graduate Medical Journal, 51, 654. Protected by copyright. LIEUTAUD, J. (1767) Historia anatomica-medica sistens numerosissima cadaverum humanorum extispicia. Tomus SHACKELFORD, R.T. (1931) Hydropneumopericardium. Secundus, p. 71. Vincent, Paris. Journal of the American Medical Association, 96, 187. LOFTIS, J.W., SUSEN, A.F., MARCY, J.H. & SHERMAN, F.E. THOMPSON, D.S. & READ, R.C. (1968) Rupture of the trachea (1962) Pneumopericardium in Infancy. American Journal following endotracheal intubation. Journal ofthe American of Diseases of Children, 103, 61. Medical Association, 204, 995. http://pmj.bmj.com/ on September 24, 2021 by guest..
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