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Iatrogenic Tension Pneumothorax After Surgical Tracheostomy in a Child with Idiopathic Subglottic Stenosis - Case Report

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Iatrogenic Tension Pneumothorax After Surgical Tracheostomy in a Child with Idiopathic Subglottic Stenosis - Case Report Kosin Medical Journal 2019;34:161-167. https://doi.org/10.7180/kmj.2019.34.2.161 &D VH 5HSRUWV Iatrogenic Tension Pneumothorax after Surgical Tracheostomy in a Child with Idiopathic Subglottic Stenosis - case report Sang Yoong Park, Woo jae Yim, Joon Ho Jeong, Jeongho Kim, Seung-Cheol Lee, So Ron Choi, Jong-Hwan Lee, Chan Jong Chung Department of Anesthesiology and Pain Medicine, Dong-A University College of Medicine, Busan, Korea Tracheostomy is increasingly performed in children for upper airway anomalies. Here, an 18-month-old child (height 84.1 cm, weight 12.5 kg) presented to the emergency department with dyspnea, stridor, and chest retraction. However, exploration of the airways using a bronchoscope failed due to subglottic stenosis. Therefore, a surgical tracheostomy was successfully performed with manual mask ventilation. However, pneumomediastinum was found in the postoperative chest radiograph. Although an oxygen saturation of 99% was initially maintained, oxygen saturation levels dropped, due to sudden dyspnea, after 3 hours. A chest radiograph taken at this time revealed a left tension pneumothorax and small right pneumothorax. Despite a needle thoracostomy, the pneumothorax was aggravated, and cardiac arrest occurred. Car - diopulmonary-cerebral resuscitation was performed, but the patient was declared dead 30 minutes later. This study high - lights the fatal complications that can occur in children during tracheostomy. Therefore, close monitoring, immediate suspicion, recognition, and aggressive management may avoid fatal outcomes. Key Words : Pediatrics, Pneumomediastinum, Tension pneumothorax, Tracheostomy, Thoracostomy Tracheostomy is increasingly being performed swallowing problems, some of which can be in children, leading to improvements in neonatal life-threatening in children. 1 Here, we report a and pediatric ICU care; it is frequently per - case of a fatal bilateral pneumothorax compli - formed in children with upper-airway anom - cation with surgical tracheostomy in an 18- alies. However, there are several complications month-old child. associated with tracheostomy. Some early com - plications include air leaks, injury to surround - ing tissues, pulmonary edema, respiratory arrest, CASE airway obstruction, and injury caused by tube placement. Delayed complications include air - An 18-month-old child (height 84.1 cm, weight way obstruction, tracheoesophageal fistula, and 12.5 kg) presented to the emergency department Corresponding Author : Jeongho Kim, Department of Anesthesiology and Pain Medicine, Dong-A University Receive d: Sep. 03, 2019 College of Medicine, 26, Daesingongwon-ro, Seo-gu, Busan 49201, Korea Revise d: Oct. 15, 2019 Tel: +82-51-240-5390 Fax: +82-51-247-7819 E-mail: [email protected] Accepted : Oct. 30, 2019 161 Kosin Medical Journal 2019;34:161-167. with dyspnea, stridor, and chest retraction. with 25 mg of ketamine and 5 mg of rocuronium, Symptoms aggravated despite treatment with a the otolaryngologist attempted to insert a rigid nebulizer and steroid. Computed tomography bronchoscope (Karl Storz, Tuttlingen, Germany) was performed after admission where no foreign with an outer diameter of 4.0 mm. However, in - bodies were found. A flexible bronchoscope was sertion failed beyond the subglottic stenosis. The used for exploration of the airways by the pedi - patient displayed a Cormack-Lehane classifica - atric resident. However, the presence of subglot - tion grade of 1, and intubation was attempted tic stenosis made advancing the scope into the using a wire-reinforced endotracheal tube trachea, via the vocal cord, difficult (Fig. 1). The (Mallinckrodt ReinforcedTM, Covidien, Dublin, severity of the patient’s dyspnea increased. Ireland) with an inner diameter of 3.5 and 4.0 Therefore, we decided to use a rigid ventilating mm. However, the endotracheal tube failed to bronchoscope for exploration and to perform tra - pass the vocal cord. We did not make an addi - cheostomy with controlled ventilation under gen - tional attempt due to the surrounding tissue eral anesthesia. edema and risk of complete airway obstruction. When the patient was admitted to an operation We therefore decided to perform a tracheostomy room, initial vital signs showed a blood pressure with manual mask ventilation for the manage - of 115/72 mm Hg, a heart rate of 114 beats/min, ment of dyspnea. Anesthesia was maintained a respiratory rate of 32/min, and an oxygen sat - with inhalational sevoflurane. Surgical tra - uration of 92%. After induction of anesthesia cheostomy was performed with manual mask Fig. 1. Bronchoscopic view of subglottic stenosis 162 Complications after tracheostomy in children ventilation at set adjustable pressure-limiting again and oxygen saturation dropped to 92%. A pressure levels of 10 cmH2O, and a 4.5-mm tra - blood clot was found in the tracheostomy tube. cheostomy tube was inserted by an otolaryngol - Thus, the clot was removed. However, suction ogist. The duration of the surgery was 55 catheter insertion was not easy even after remov - minutes, and no hypoxic events occurred during ing the clot, and the tracheostomy tube was anesthesia. changed. The 4.5-mm tracheostomy tube was re - At the post-anesthesia care unit following sur - moved due to concerns regarding tracheal wall gery, oxygen was supplied via a T-piece at about narrowing, and a 4.0-mm tracheostomy tube was 2 L/min and an oxygen saturation of 100% was inserted by an otolaryngology resident. A chest maintained. The patient was spontaneously radiograph taken at this time revealed a left ten - breathing, with improved symptoms of dyspnea. sion pneumothorax and small right pneumotho - However, a pneumomediastinum was found in rax (Fig. 3). Needle thoracostomy was performed the postoperative chest radiograph (Fig. 2). At by a pediatric resident using a 20-gauge angio - the ward, an oxygen saturation of 99% was main - catheter needle, and 200 cc of air was aspirated. tained with oxygen supply via T-piece about 2 The following chest radiograph showed the ex - L/min for 3 hours. However, sudden dyspnea oc - isting left pneumothorax, but an aggravated right curred and oxygen saturation levels dropped to pneumothorax (Fig. 4). During tube thoracos - 88%. After manual ventilation, oxygen saturation tomy, which was performed by a thoracic sur - rose to 99% temporarily, dyspnea occurred once geon, the pulse rate decreased to 70 beats/min, Fig. 2. A chest radiograph showing the pneumomediastinum(arrows) after tracheostomy 163 Kosin Medical Journal 2019;34:161-167. Fig. 3. A chest radiograph showing the pneumomediastinum(arrow heads), the right pneumothorax and left tension pneumothorax(black arrows) Fig. 4. A chest radiograph showing the pneumomediastinum(arrow heads) and the bilateral pneumothorax (black arrows) 164 Complications after tracheostomy in children with an oxygen desaturation of up to 45~55%. the risk of developing pneumothorax involves CPCR was performed. Epinephrine 120 mcg was maintaining the peak inspiratory pressures low. 5 injected every 5 min, and 10 mEq of sodium bi - In this situation, a fiberoptic bronchoscopic as - carbonate was injected thrice. But the patient was sessment is recommended to identify the site and declared dead 30 minutes later. severity of the injury. While a small tracheal in - jury can be managed conservatively, a larger tear of over 1 cm requires surgical repair. 6 Addition - DISCUSSION ally, using the fiberoptic bronchoscope as a guide, prevents the tracheostomy catheter being Many complications can arise from tra - inserted into a false cavity. This procedure can cheostomy being performed in children. For ex - also prevent tracheal wall injury caused by the ample, pneumomediastinum can occur in tracheostomy tube. 7 Therefore, tracheostomy children who have undergone tracheostomy, guided by a fiberoptic bronchoscope is recom - through dissection of air between the deep and mended in pediatric patients. superficial cervical fascia. In order to prevent In our case, the pneumothorax was thought to pneumomediastinum, minimizing the pretracheal develop from pneumomediastinum, and was ex - and paratracheal dissection is essential. 1 In the acerbated by manual ventilation after desatura - absence of associated comorbidities, sponta - tion. Moreover, the blood clot in the neous pneumomediastinum can be managed with tracheostomy tube could have cause airway ob - observation without the need for further struction and aggravated the pneumothorax. Ten - imaging. 2 In our case, we failed to consider the sion pneumothorax occurs when a one-way valve possibility of tracheal injury despite the presence is created between the lung and pleura. Air accu - of pneumomediastinum in the postoperative mulates in the pleural cavity with every breath, chest radiography. Therefore, we overlooked the and intrapleural pressure is elevated. This leads fact that the pneumomediastinum could be wors - to a shrinkage in the ipsilateral lung, and the me - ened by continuous manual ventilation. Pneu - diastinum is pushed to the opposite side. This re - mothorax most commonly occurs due to an duces venous return, resulting in a cardiac arrest. increase in the pressure gradient between the me - During tension pneumothorax, chest radiological diastinum and pleural space. Presence of pneu - findings show a hemi-diapragmatic depression, momediastinum allows gas to rupture the increased rib separation, increased thoracic vol - mediastinal pleura, causing it to enter the pleural ume, ipsilateral flattening at the heart border,
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