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The dangers of playing with sharp sticks Cheryl Pirozzi, MD Pulmonary Grand Rounds October 13, 2011.

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Presentation on theme: "The dangers of playing with sharp sticks Cheryl Pirozzi, MD Pulmonary Grand Rounds October 13, 2011."— Presentation transcript:

1 The dangers of playing with sharp sticks Cheryl Pirozzi, MD Pulmonary Grand Rounds October 13, 2011

2 Case 43 yo woman presented to OSH with SOB, productive cough with hemoptysis, and weakness

3 PMH CVID with ↓ IgG and IgM, treated with monthly IVIG Multiple recent hospitalizations (x7 in 2011), mult for pneumonia, most recent 8/8-9/2011 Adrenal insufficiency due to chronic steroids: unclear why Chronic hypoxemia: 3LPM Asthma  PFTs 12/10: mildly reduced FEV1, nl DLCO Chronic pain, narcotic abuse Psych issues: bipolar d/o, borderline personality d/o, prior overdoses on narcotics, tricyclics, atarax Papillary thyroid Ca, s/p thyroidectomy VRE skin and UTI infections DM2 ? Crohns disease – negative biopsy

4 PMH PSH: gastric bypass, CCY, tonsillectomy, sinus surgeries x2, hiatal hernia repair, PFO closure SH: on disability, married. Denies EtOH, tobacco, IDU

5 Meds Prednisone 20 mg qd Lortab 10 q4 hrs Tapentadol 100 mg q4h Albuterol Budesonide Lasix Atarax Synthroid cytomel IVIG 30 g q mo Nexium Lunesta Seroquel 800 mg qHS Metoprolol Zofran Cymbalta

6 Case PE  T 38.5, p116, 85/40 → 111/56, R 18, 84%/3L  Ill-appearing, alert but tangental  Bilateral crackles and rhonchi Labs:  WBC 16, 20% bands, hgb 11, plt 266  Lactate 3.7, BUN 22, Cr 0.8

7 Initial CXR OSH 8/30/11

8 Hospital Course Initially treated for HCAP with Zosyn, Levaquin, and Vancomycin Stress dose steroids IVIG

9 CXR 8/31/11

10 9/1/11 Reportedly, patient’s husband sneaks her extra antihistamine, dramamine, seroquel and tapentadol, and she has an aspiration event Acute hypoxic respiratory failure Emergent intubation

11 CXR 9/1/11

12 9/1/11 Soon after intubation, patient has bronch with BAL  “proximal airways were normal in appearance”  BAL grows MRSA A few hours later, she is noted to acutely decompensate and “blow up”

13 9/1/11

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15 9/4/11 Patient again decompensates, with increased hypoxia and subcutaneous emphysema, and transfer to IMC is requested

16 9/4/11 transfer to IMC T 38.1, p123, 122/87, R 24 FiO2 100%, PEEP 11, Vt 6 ml/kg Diffuse subcutaneous emphysema, crackles, edema

17 What would you do next?

18 CT 9/4/11

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23 What is going on?

24 Bronch 9/8/11

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26 CT 9/8/11

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28 Hospital Course Recurrent infectious complications and intermittent septic shock:  Acromobacter PNA  Persistent MRSA tracheobronchitis  C.diff colitis  VRE UTI  Treated with Vanc, linezolid, zosyn, ceftaroline, flagyl Severe ARDS Self extubation with emergent re-intubation on 9/13 Eventually stabilizes, but unable to wean from vent

29 Bronch 9/24/11

30 Hospital Course Trach on 9/27/11

31 Bronch 9/28/11

32 Tracheal injury associated with endotracheal intubation Clinical presentation How often does this happen? What are the risk factors? How do we avoid it? What is the treatment?

33 Tracheal injury/rupture Rare condition with high morbidity and mortality Most common cause is head and neck injury Most common iatrogenic cause is orotracheal intubation; also can occur with tracheostomy, bronchoscopy, placement of stents, esophagectomy Usually longitudinal rupture in distal third of membranous trachea Miñambres et al. European Journal of Cardio-thoracic Surgery 35 (2009) 1056—1062

34 Tracheal injury associated with endotracheal intubation Clinical presentation:  Most common: subcutaneous emphysema, pneumomediastinum, pneumothorax, respiratory distress  dyspnea, dysphonia, cough, hemoptysis, and pneumoperitoneum  signs often develop immediately or soon after intubation, but can take several days to appear Miñambres et al. European Journal of Cardio-thoracic Surgery 35 (2009) 1056—1062

35 Diagnosis Requires high clinical suspicion based on clinical s/sx Confirmed by direct visualization of lesion with bronchoscopy CT

36 Radiographic signs Subcutaneous emphysema Pneumomediastinum Overdistended ETT cuff On CT tracheal defect/perforation Am J Emerg Med 2004;22:

37 J Bras Pneumol. 2009;35(8):

38 Tracheal injury associated with endotracheal intubation How often does this happen?  Case reports, several case series and reviews  Incidence estimates from 0.005% % of intubations, more common with double lumen tubes Miñambres et al. European Journal of Cardio-thoracic Surgery 35 (2009) 1056—1062 Medina et al. J Bras Pneumol. 2009;35(8):

39 Tracheal injury associated with endotracheal intubation Miñambres et al. Tracheal rupture after endotracheal intubation. Eur J Cardiothorac Surg. 2009;35(6): cases of postintubation tracheal rupture. mortality 22% 86% women Intubations: 14% “difficult”, 27% emergent Increased mortality associated with age ( p = 0.015) and emergency intubation (RR = 3.11; p = 0.001)

40 Miñambres et al. European Journal of Cardio-thoracic Surgery 35 (2009) 1056—1062

41 Variables associated with mortality Miñambres et al. European Journal of Cardio-thoracic Surgery 35 (2009) 1056—1062

42 Risk factors / mechanism for tracheal rupture with intubation Am J Emerg Med 2004;22:

43 Risk factors for tracheal injury with intubation Why women?  Shorter, with use of improperly long tubes  Smaller tracheal diameters- more vulnerable to cuff overinflation Anesth Analg 2001;93:1270–1

44 How do I avoid tracheal injury with emergent intubation? Recommendations for emergent intubation:  Select the proper size of endotracheal tube  Check all equipment before intubation  Check position of stylet (tip not beyond murphy’s eye)  Intubate gently and use RSI when necessary  Retract the stylet when balloon cuff passes through vocal cords  Inflate the cuff slowly with proper volume and pressure  Fix ETT tightly to reduce the possibility of tube movement  Deflate the cuff first when repositioning the tube Am J Emerg Med 2004;22:

45 Management of tracheal laceration or rupture Traditionally early surgical repair was mainstay Now many recommend conservative treatment if rupture < 2 cm, and if minimal non-progressive sxs and no air leak If > 2 cm, surgical vs conservative is debated. In Miñambres et al. meta-analysis, surgical repair was associated with a 2x increased mortality Meyer et al. case series: surgical repair in critically ill pts is high risk, mortality up to 71%. Miñambres et al. European Journal of Cardio-thoracic Surgery 35 (2009) 1056—1062 Meyer M. Thorac Cardiovasc Surg 2001;49:115—9.

46 Management of tracheal laceration or rupture Most recent studies recommend conservative management if  stable pt, no air leakage, no esophageal damage, minimal mediastinal collections, no clinical progression, no sign of infection Conservative management = intubation with cuff distal to lesion, continuous tracheal aspiration, pleural drain, empiric abx Surgical repair if unstable, large defect (>4cm), any evidence of mediastinitis Miñambres et al. European Journal of Cardio-thoracic Surgery 35 (2009) 1056—1062 Medina et al. J Bras Pneumol Aug;35(8):809-13

47 Management of tracheal laceration or rupture Am J Emerg Med 2004;22:

48 Management of tracheal laceration or rupture Am J Emerg Med 2004;22:

49 In retrospect, had we known what was going on, would probably have at least evaluated for surgical repair earlier. Small rupture, but distal to ETT and with demonstrated clinical deterioration

50 Questions/comments?

51 References Sternfeld D, Wright S. Tracheal rupture and the creation of a false passage after emergency intubation. Ann Emerg Med Jul;42(1): Miñambres E, Burón J, Ballesteros MA, Llorca J, Muñoz P, González-Castro A. Tracheal rupture after endotracheal intubation: a literature systematic review. Eur J Cardiothorac Surg Jun;35(6): Fan CM, Ko PC, Tsai KC, Chiang WC, Chang YC, Chen WJ, Yuan A. Tracheal rupture complicating emergent endotracheal intubation. Am J Emerg Med Jul;22(4): Chen EH, Logman ZM, Glass PS, Bilfinger TV. A case of tracheal injury after emergent endotracheal intubation: a review of the literature and causalities. Anesth Analg Nov;93(5): Medina CR, Camargo Jde J, Felicetti JC, Machuca TN, Gomes Bde M, Melo IA. Post-intubation tracheal injury: report of three cases and literature review. J Bras Pneumol Aug;35(8): Meyer M. Iatrogenic tracheobronchial lesions—a report on 13 cases. Thorac Cardiovasc Surg 2001;49:115—9.


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