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Tracheal Perforation in a Neonate: a Devastating Letters to Editor Tracheal perforation in a size of endotracheal tube, cuff overinflation, cough and vigorous movements of head and neck.[2,3] neonate: A devastating Neonatal tracheal injury is ascribed to factors like complication following traumatic traumatic delivery, weak trachea, congenital tracheal endotracheal intubation stenosis, ring agenesis, metal stylets, rigid endotracheal tube, excessive external laryngeal pressure and [1,4,5] Sir, prolonged ventilation. Tracheal injury in neonates following endotracheal In our case, rigorous attempts at intubation along with intubation represents an uncommon complication excessive hyperextension of head and neck due to altered rarely described in literature but carries high anatomy are likely to have contributed to tracheal injury. morbidity and a mortality rate of 70%.[1] We describe Multiple attempts at intubation are known to result in a [4] a case of neonatal tracheal perforation following false tract and are related to anterior tracheal lesions. multiple attempts at endotracheal intubation due to an Incidentally, our case was an undiagnosed Pierre unanticipated difficulty in an emergency situation in Robins Sequence. A small receding mandible, tongue an undiagnosed case of Pierre Robin Sequence. immobility and cleft palate are identified as independent factors for difficult airway with a risk of upper airway A 4-week-old female baby presented to the emergency obstruction, difficult mask holding, difficult intubation, department with respiratory difficulty. In view of severe leak through the cleft resulting in inadequate ventilation respiratory distress and desaturation (SpO2- 60%) a as well as passage of the endotracheal tube into the decision was made to provide ventilatory support to cleft.[6] Successful airway management in such situation the neonate. Multiple attempts were made at awake entails knowledge of airway, proper airway assessment, intubation by a junior doctor from the emergency adequate training, experience and competent use of department. Post-intubation, baby developed multiple airway devices.[6] subcutaneous emphysema and desaturation. Intercostal drains were inserted bilaterally and patient was shifted In our case, inadequate experience and delay in calling to operation theatre for suspected tracheal injury. experienced colleague for help resulted in improper airway assessment and management. Increased risk Baby was noticed to have a small receding mandible. of iatrogenic tracheal injuries as a consequence of Respiratory movements were not transmitted to emergency intubations in stressful situation has been the breathing bag on connecting to Jackson Rees’ observed, which also holds true in our case.[2,3] circuit. Injection glycopyrrolate and fentanyl were administered intravenously along with infiltration with The diagnosis is based on a high clinical suspicion local anaesthesia at the proposed site of tracheostomy. with appearance of highly suggestive signs of air Neck exploration revealed the tip of the endotracheal leak like subcutaneous emphysema, pneumothorax tube in the subcutaneous plane which was removed. and occasionally pneumoperitoneum. The onset of Anaesthesia was continued with sevoflurane with subcutaneous emphysema is reflected as protective oxygen through face mask, maintaining spontaneous factor as its presence alerts one to the possibility of ventilation. Airway was secured with tracheostomy tracheal rupture, thus accelerating the procedures of [1,2,4,5] and confirmed by end-tidal CO2. Bronchoscopy definitive diagnosis and initiation of treatment. revealed a tracheal perforation on the anterior wall at 12 O’ clock position in subglottic region. Post-operatively, Management includes an approach ranging from micrognathia, glossoptosis and cleft palate lead to a conservative management to tracheostomy. Surgical clinical diagnosis of Pierre Robin sequence. treatment has traditionally been the mainstay of treatment[2-4] as in our patient taking severe respiratory A multi-factorial origin of tracheal injury has been distress and massive subcutaneous emphysema into proposed. Anatomical factors include extremes of ages, consideration. congenital tracheal malformations and weakness of pars membranosa. Mechanical factors include multiple Conservative management includes passing an forced attempts, inexperience, endotracheal tube endotracheal tube beyond the perforation and introducers protruding beyond the tip, inappropriate ventilation, advocated in the presence of small Indian Journal of Anaesthesia | Vol. 57 | Issue 6 | Nov-Dec 2013 623 Letters to Editor perforation with minimal non-progressive symptoms Neuraxial block in a patient with and no air leakage on spontaneous breathing. Important measures include drainage of air, use of low ventilatory dural ectasia pressures, high-frequency ventilation and sedation.[1,2,5] Sir, Mechanical ventilation for 8-10 days ensures adequate healing of the injured area.[4] We would like to present an interesting case regarding dural ectasia and regional anaesthesia. Dural ectasia is Preventive measures like avoidance of forceful attempts an enlargement of the dural sac and the spinal canal and at intubation, avoidance of hyperextension of the head, sometimes with enlarged nerve sleeves. Dural ectasia use of a satin-slip stylet, following difficult airway can affect the spinal canal in any plane, but the most guidelines, availability of specialised equipment common sites are the lumbosacral region. Therefore, and adequate training of staff need to be practiced the most common clinical symptoms are low back to minimise the incidence of iatrogenic tracheal pain, headache, weakness and loss of sensation above trauma.[5] Awareness about clinical presentation with and below the affected limb, occasional rectal pain subcutaneous emphysema should alert the physician and pain in the genital area.[1] about possibility of tracheal perforation ensuring prompt detection and management. Most of the documented cases of dural ectasia have been in patients with Marfan syndrome.[2] A recent Jui Y Lagoo, Jiby Jose, Kshma A Kilpadi survey of a 10 year follow-up in patients with Marfan Department of Anaesthesia, St. John’s Medical College Hospital, syndrome having dural ectasia concluded that it was Bengaluru, Karnataka, India not associated with a significant increase in dural Address for correspondence: ectasia size or with the development/progression of Dr. Jui Y Lagoo, spondylolisthesis or spondylolysis.[3] The aim of this th Elita Promenade, B7-1101, JP Nagar, 7 Phase, Opposite RBI Water article was to highlight the significance of dural ectasia Tank, Bengaluru ‑ 560 078, Karnataka, India. E‑mail: [email protected] in our anaesthetic practise. REFERENCES A 33-year-old primi gravida with a gestation of 39 weeks presented for elective caesarean section. 1. Doherty KM, Tabaee A, Castillo M, Cherukupally SR. Neonatal tracheal rupture complicating endotracheal intubation: A case She had a background history of a cerebro vascular report and indications for conservative management. Int J accident with the left internal carotid artery dissection Pediatr Otorhinolaryngol 2005;69:111-6. 2. Miñambres E, Burón J, Ballesteros MA, Llorca J, Muñoz P, 3 years back with mild right side hemiparesis and also González-Castro A. Tracheal rupture after endotracheal had aortic root dilatation. Her carotid dissection was intubation: A literature systematic review. Eur J Cardiothorac believed to be due to a connective tissue disorder. There Surg 2009;35:1056-62. 3. Parga B, Castro MC, Martinez GM, Martinez R. Tracheal was no family history of connective tissue disorders. rupture after endotracheal intubation-A retrospective audit Her height was 177 cm and she weighed 76 kg. This from 2003-2009. Eur J Anaesthesiol 2010;27:273. was extensively investigated with genetic testing for 4. Ammari AN, Jen A, Towers H, Haddad J Jr, Wung JT, Berdon WE. Subcutaneous emphysema and pneumomediastinum as Ehlers-Danlos, Marfans and Loeys-Dietz syndrome presenting manifestations of neonatal tracheal injury. all which were negative. Magnetic resonance imaging J Perinatol 2002;22:499-501. 5. Méndez R, Pensado A, Tellado M, Somoza I, Liras J, Pais E, et al. showed dural ectasia in lumbar region with dural sac Management of massive air leak following intubation injury in measuring 0.6 cm at L2, 0.5 cm at L3 and 0.6 cm at L4. a very low birth weight infant. Br J Anaesth 2002;88:722-4. The indication for C section in this case was the history 6. Marston AP, Lander TA, Tibesar RJ, Sidman JD. Airway management for intubation in newborns with Pierre Robin of cerebro vascular accident in the past with carotid sequence. Laryngoscope 2012;122:1401-4. dissection and aortic root dilatation. In view of this, the consultant obstetrician decided on an elective C section Access this article online as it was thought that the stress of delivery may further Quick response code Website: increase the risk of dissection. Subarachnoid block was www.ijaweb.org performed at L3-L4 level using a 25G whitacre needle with good cerebrospinal fluid (CSF) flow. 11.5 mg of DOI: hyperbaric bupivacaine, 15 mcg fentanyl and 100 mcg 10.4103/0019-5049.123343 of preservative free morphine were injected. CSF was aspirated at the end of the injection to confirm the 624 Indian Journal of Anaesthesia | Vol. 57 | Issue 6 | Nov-Dec 2013 Copyright of Indian Journal of Anaesthesia is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use..
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