Pneumomediastinum due to distal tracheal diverticulum after uneventful tracheal intubation and management of subsequent general anaesthesia
B. Mazul-Sunko,1D. Zdenčar,1J. Špiček-Macan,2 I. Kožul,3 D. Stančić-Rokotov,4N. Hodoba,2N. Osmančević,1N. Chalfe,5I. Gilja,3 D. Tonković1
1 Department of Anaesthesiology and Intensive Care, University Hospital Sveti Duh, Zagreb, Croatia
2 Department of Anaesthesiology and Intensive Care, University Hospital Center Zagreb, Zagreb, Croatia
3 Department of Urology, University Hospital Sveti Duh, Zagreb Croatia
4 Department of Thoracic Surgery Jordanovac, University Hospital Center Zagreb, Zagreb, Croatia
5Departmentof Pulmonary Diseases Jordanovac, University Hospital Center Zagreb, Croatia
Corresponding author : Branka Mazul-Sunko, Department of Anaesthesiology and Intensive Care, University Hospital Sveti Duh, Sveti Duh 64, 10 000 Zagreb, Croatia,
Telephone: ++385 91 3712 438
e-mail:
Financial disclosure: all diagnostic tests and imaging were part of clinical routine and we have received no financial support or additional funding
Body text: 1207 words
Tracheal diverticulum is a rare anatomic anomaly associated with potentially serious complications during general anaesthesia (1). It has been diagnosed several times after difficult tracheal intubation or ventilation (2,3). We report of a patient who developed pneumomediastinum caused by tracheal diverticulum laceration after uneventful tracheal intubation. The clinical course was complicated by necessity of radical cystectomy under general anaesthesia shortly after the occurrence of pneumomediastinum. Additional problem was the location of diverticulum close to tracheal bifurcation so that a standard procedure of bridging it by orotracheal tube would not provide safe bilateral ventilation.
Case report
An 80-year-old female was admitted to the Department of Urology due to macrohematuria. Three days after admittance, the patient underwent an emergent endoscopic surgery due to uncontrolled hematuria. Tracheal intubation was performed without difficulties on first attempt using 7,5 Ch orotracheal tube with guide wireto provide smooth and fast induction for the emergent procedure . Immediately after extubation the patient was eupnoic, hemodynamically stabile and awake. 10 minutes after admittance to the Intensive Care Unit the patient complained of difficult breathing. MSCT (Multisliced Computed Tomography) revealed extensive pneumomediastinum and discontinuity of the posterior tracheal wall in length of 40 mm and 30 mm cranially from the tracheal bifurcation.
Two days after surgery, the patient was transferred to the Department of Thoracic Surgery, where fiberbronchoscopic examinationof the trachea showed a 40 mmlong diverticulum on the membranous wall,30mmcranial from carina. Under fiberbronchoscopic examination,no sign of laceration or communication with mediastinal structures was visible.
(Figure 1).
Therefore we concluded that there did exist a minor lesion of a thinner tracheal diverticulm wall which did not cause clinical problems under spontaneous respiration, but provoked mediastinal air leakage only under positive pressure ventilation. Given the uneventful clinical course, no further major thoraco-surgical procedure was indicated.
In the meanwhile, histological analysis revealed invasive carcinoma of urinary bladder, and radical cystectomy under general anaesthesia had to be planned. Anaesthesiological managment was complicated by the distal position of tracheal diverticulum. It was described to be 30 mm cranial from carina and standard orotracheal tube with the tip position 50 to 70 mm above tracheal bifurcation could not bridge it, but would bend at the level of diverticulum or in the diverticulum itself, causing pneumomomediastinum again. On the other hand, a more distal position of a standard orotracheal tube, would not provide safe bilateral ventilation during the prolonged surgical procedure. Therefore, we decided to intubate the patient using a left-sided Robertshaw tube which has a more distal tube opening and tracheal cuff positioning than standard orotracheal tube and ensured bypassing the tracheal diverticulum in this way.
10 days after the first surgery for transurethral tumor resection general anaesthesia for radical cystectomy was planned. Before intubation epidural catheter at T9-T10 level was introduced.Anaesthesia was induced The trachea was intubated using left sided Robertshaw tube 7,5 Ch. Correct position was bronchoscopically checked. Anaesthesia was maintained administering isoflurane 0,7-1,2 MAC, continuous epidural anaesthesia and vecuronuim for muscle paralysis. The lungs were ventilated without difficulties and there were no signs of hemodynamic instability throughout the procedure . The patient was extubated in the operating theatre. Postoperative recovery went uneventful and the patient left hospital 10 days after surgery.
Discussion
Tracheal diverticulum is a benign and rare entity with prevalence of 1 % in autopsy series (4, 5). It is characterized by a single or multiple invaginations of tracheal wall. Most cases are asymptomatic or symptoms are nonspecific. They can be congenital or acquired. It is possible that chronic cough caused by mild obstructive changes in our patient could cause increased intraluminal pressure to provoke herniation of themucosal membrane throughthe tracheal wall (6).
There are several reports of complications caused by tracheal diverticulum in the context of orotracheal intubation and positive pressure ventilation (1,2,3,7).In these reports, complications caused by tracheal diverticulum injury are associated with difficult intubation or ventilation. Our report points out that tracheal diverticulum remains an important option in the differential diagnosis of pneumomediastinum after intubation and positive-pressure ventilation, even whenendotracheal intubation was uneventful. A clinical course indicative of a lesion which could not be confirmed bronchoscopically has been reported before (8). In both cases the events could reasonably be ascribed todiverticulum lesions or opening too narrow to be open under conditions of spontaneous respiration.
The possible contributing factors might be those found to predispose to tracheal lesion, like older age, female gender and cancer (9), which were all present in our patient,precipitated by the use of a guide wire by the anaesthesiologist.
Another specific aspect of our report is management of subsequent general anaesthesia shortly after tracheal diverticulum lesion occurred. Bilateral ventilation using endobronchial tube after distal tracheal diverticulum injury has not been previously reported to our knowledge, although similar management was described in distal tracheal lesions in the absence of a diverticulum (10). Our experience confirms that distal tracheal diverticulum lesions can be safely treated in the same way.
References:
- Moller GM),Tenberge, EJFM, Stasen CM. Traceocoele – a rare cause of difficult endotracheal intubation and subsequent pneumomediastinum. Eur Resp J 1994; 7(7): 1376-1377.
2.Davies R: Difficult tracheal intubation secondary to tracheal diverticulum and 90 degree deviation in the trachea. Anaesthesia 2000; 55 (9 ) 923-925.
3. Dinner M, Ward R, Yun E. Ventialtion difficultiy secondary to a trachealdiverticulum. Anesthesiology 1992; 77(3):586-587.
- MacKinnon D. Tracheal diverticula. J Path Bacteriol 1953; 65(2): 513-517
- Soto-Hurtado EJ, Penuela – Ruiz L, Rivera-Sanchez I, Torres-Jimenez J. Tracheal diverticulum: A review of the literature. Lung 2006; 184(6): 303-307
- Frenkiel S, Assimes IK, Rosales JK. Congenital tracheal diverticulum - a case report. Ann Otol Rhinol Lyringol 1980; 89(5): 406-408
- Kaslow O, Holak EJ, Owen HLP, Tisol WB, Pagel PS. Anterior Chest Discomfort and Right Neck Pain in a Young Woman 2 Days After an Appendectomy. J Cardioth Vasc Anesth 2010; 24(3): 519-522
, 8. Djamouri F, Barthes FL , Pheulpin G, Grignet JP, Carnot F, Riquet M. Air-filled paratracheal bronchogenic cysts: origin and prevalence. Rev Mal Respir 2002; 19(4): 523-526
- Hofmann HS, Rettig G, Radke G, Neef H, Silber RE. Iatrogenic ruptures of tracheobronchial tree. Eur J Cardiothorac Surg 2002; 21(4): 649-652.
- Conti M, Pougeoise M, Wurtz A, Porte H, Fourrier F, Ramon P, Marquette Ch. Management of postintubation tracheobronchial ruptures . Chest2006; 130( 2): 412-418