Pneumothorax Caused by Delayed Tracheal Rupture in a Pediatric Patient with Acute Respiratory Distress Syndrome

Minyoung Jung; Jong Ho Cho; Ah Young Choi; Minji Kim; Joongbum Cho

doi:10.4266/acc.2018.00234

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Image in Critical Care Pulmonary Pneumothorax caused by delayed tracheal rupture in a pediatric patient with acute respiratory distress syndrome: Minyoung Jung^1,2, Jong Ho Cho³, Ah Young Choi², Minji Kim⁴, Joongbum Cho²; Acute and Critical Care 2019;34(2):170-171.
DOI: https://doi.org/10.4266/acc.2018.00234
Published online: February 7, 2019

¹Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

²Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

³Department of Thoracic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

⁴Department of Pediatrics, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea

Corresponding author Joongbum Cho Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea Tel: +82-2-3410-6399 Fax: +82-2-2148-7088 E-mail: joongbum.cho@gmail.com

• Received: July 10, 2018 • Revised: September 5, 2018 • Accepted: January 15, 2019

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Tracheal rupture is a potentially lethal complication of endotracheal intubation [1-3] and usually occurs shortly after intubation [4]. Such rupture presents as a linear tear and is caused by movement of an over-inflated cuff or stylet [5]. Herein, we describe a case of pneumothorax caused by tracheal rupture after 30 days of intubation. A previously healthy 8-year-old boy was admitted to the pediatric intensive care unit for severe acute respiratory distress syndrome. The patient was treated with mechanical ventilation and extracorporeal membrane oxygenation. Cuff pressure was managed between 20 to 30 cmH₂O, and the endotracheal tube was not changed before extubation. On hospital day 30, extubation was perfomred, and spontaneous breathing was noted. On the same day, massive pneumothorax was developed and was not controlled by chest tubes. Computed tomography showed a new lesion on the trachea (Figure 1), and bronchoscopy showed an oval ischemic lesion surrounded by a C-shaped tear (Figure 2). Since the position and size of the ischemic lesion were similar to those of the cuff, we suspected that prolonged cuff pressure created ischemia, and active breathing tore the weak margin. Managing cuff pressure in children requires high caution, and suspicion of tracheal rupture should be considered as a cause of pneumothorax.

NOTES

CONFLICT OF INTEREST No potential conflict of interest relevant to this article was reported.

AUTHOR CONTRIBUTIONS

Conceptualization: MJ, JHC, AYC, MK, JC. Data curation: MJ, JHC. Writing original draft: MJ, AYC. Writing-review & editing: MK, JHC, JC.

Figure 1.

Chest computed tomography with post-contrast views. (A) A black arrow marks a 4-mm tracheal tear at the level of T3-4. Air collection is also presented on sagittal view. (B) Tracheal rupture appears above the carina on the right side.

Figure 2.

Bronchoscopic findings. A C-shaped tracheal rupture (white arrowheads) around the oval ischemic lesion at the posterior membrane of the lower third of the trachea.

References

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3. Minambres E, Buron J, Ballesteros MA, Llorca J, Munoz P, Gonzalez-Castro A. Tracheal rupture after endotracheal intubation: a literature systematic review. Eur J Cardiothorac Surg 2009;35:1056-62.Article PubMed PDF
4. Jabre P, Avenel A, Combes X, Kulstad E, Mazariegos I, Bertrand L, et al. Morbidity related to emergency endotracheal intubation: a substudy of the KETAmine SEDation trial. Resuscitation 2011;82:517-22.Article PubMed
5. Lim H, Kim JH, Kim D, Lee J, Son JS, Kim DC, et al. Tracheal rupture after endotracheal intubation: a report of three cases. Korean J Anesthesiol 2012;62:277-80.Article PubMed PMC

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