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Pulmonary
Pneumothorax caused by delayed tracheal rupture in a pediatric patient with acute respiratory distress syndrome
Minyoung Jung1,2orcid, Jong Ho Cho3orcid, Ah Young Choi2orcid, Minji Kim4orcid, Joongbum Cho2orcid
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

Copyright © 2019 The Korean Society of Critical Care Medicine

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.

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.
acc-2018-00234f1.jpg
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.
acc-2018-00234f2.jpg
  • 1. Hofmann HS, Rettig G, Radke J, Neef H, Silber RE. Iatrogenic ruptures of the tracheobronchial tree. Eur J Cardiothorac Surg 2002;21:649-52.ArticlePubMedPDF
  • 2. Schneider T, Storz K, Dienemann H, Hoffmann H. Management of iatrogenic tracheobronchial injuries: a retrospective analysis of 29 cases. Ann Thorac Surg 2007;83:1960-4.ArticlePubMed
  • 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.ArticlePubMedPDF
  • 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.ArticlePubMed
  • 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.ArticlePubMedPMC

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