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| LETTER TO EDITOR |
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| Year : 2019 | Volume
: 6
| Issue : 4 | Page : 270-271 |
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Subcutaneous emphysema after emergency endotracheal intubation
Niraj Kumar Keyal1, Niru Nepal2, Manish Nakarmi3, Sanam Karki3
1 Department of Critical Care and Emergency Medicine, B and C Medical College Teaching Hospital and Research Centre, Birtamode, Nepal
2 Department of Anaesthesia and Critical Care, B and C Medical College Teaching Hospital and Research Centre, Birtamode, Nepal
3 Department of Critical Care Medicine, B and C Medical College Teaching Hospital and Research Centre, Birtamode, Nepal
| Date of Submission | 14-May-2019 |
| Date of Decision | 07-Jul-2019 |
| Date of Acceptance | 08-Sep-2019 |
| Date of Web Publication | 21-Nov-2019 |
Correspondence Address:
Niraj Kumar Keyal
Department of Critical Care and Emergency Medicine, B and C Medical College Teaching Hospital and Research Centre, Birtamode
Nepal
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/cjhr.cjhr_51_19
How to cite this article:
Keyal NK, Nepal N, Nakarmi M, Karki S. Subcutaneous emphysema after emergency endotracheal intubation. CHRISMED J Health Res 2019;6:270-1 |
How to cite this URL:
Keyal NK, Nepal N, Nakarmi M, Karki S. Subcutaneous emphysema after emergency endotracheal intubation. CHRISMED J Health Res [serial online] 2019 [cited 2021 Mar 3];6:270-1. Available from: https://www.cjhr.org/text.asp?2019/6/4/270/271334 |
Sir,
Tracheal injury is a life-threatening condition that occurs in 15%[1] of patients after blunt trauma to neck and chest, but tracheal injury following endotracheal intubation is rare with an approximate incidence of 0.005%.[1]
A 64-year-old male weighing 80 kg, with a history of diabetes and hypertension under regular medication, presented to the emergency department with headache and altered level of consciousness for 1 day. At presentation, his Glasgow coma scale (GCS) was 9/15, pulse rate 130 beats/min, blood pressure 160/70 mmHg, respiratory rate 11 breaths/min, oxygen saturation 96% on 10 L of oxygen, and pupil bilateral round, regular, and reactive. Other systemic examination was normal. The patient was diagnosed as sagittal venous sinus thrombosis and started infusion of unfractionated heparin. The patient was shifted to the intensive care unit (ICU), and GCS dropped to 7/15 so intubated and was put on intermittent positive pressure ventilation. Difficult intubation was anticipated as MACOCHA score was 8. Orotracheal intubation was done with a 7-mm single-lumen tube in the third attempt after using bougie and applying external laryngeal pressure. The patient developed drop in saturation, swelling of the neck, and palpable crepitus on the neck and upper chest after 3 h of intubation. Chest X-ray [Figure 1] showed the presence of air in the subcutaneous planes of neck. Computed tomography (CT) of the chest and neck [Figure 2] showed small defect at posterior tracheal membrane and emphysema at neck and pneumomediastinum. Bronchoscopy was not done as it was not available at our center. Mode of mechanism was changed to spontaneous mode after development of emphysema. The patient was extubated on the 2nd day. The patient was managed conservatively with broad-spectrum antibiotics and high flow oxygen, and at 4th day, emphysema of the neck was almost resolved. He had an uneventful recovery. | Figure 1: Chest x-ray showing subcutaneoos emphysema and pneumomediastinum
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The complication related to endotracheal intubation in the ICU is more than an operating room;[2] therefore, the MACOCHA score is used that considers patient-, physiological-, and operator-related factors to identify difficult intubation.[3]
Tracheal injury mostly occurs in female in the distal third of trachea and the main bronchi posteriorly at cartilage and membranous junction, but it occurs in the proximal trachea due to cuff overinflation.[4] The major mechanisms for injury are inappropriate tube size, cuff overinflation, multiple unsuccessful attempts, and inappropriate repositioning without complete emptying of the cuff. The reason for injury in our patient may be difficult airway that leads to multiple attempts.
It usually presents as subcutaneous emphysema of the chest and neck, pneumomediastinum, and pneumothorax, which was present in our patient, and diagnosis is suspected by chest and neck X-ray and confirmed by CT scan which has sensitivity of 85% and fiberoptic bronchoscopy.[5] Tracheal injury is treated by conservative or surgery. Our patient was treated conservatively as it was diagnosed early and had no evidence of mediastinitis and ventilatory instability.
To conclude, tracheal injury is a life-threatening injury that can be prevented by early anticipation of difficult airway, intubation by an experienced doctor, deflating cuff during manipulation, and appropriate pressure in cuff, and mortality can be decreased by early recognition and treatment.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
| 1. | Ghosh I, Behera P, Das B, Gerber CJ. Subcutaneous emphysema after endotracheal intubation: A case report. Saudi J Anaesth 2018;12:348-9.  |
| 2. | Lapinsky SE. Endotracheal intubation in the ICU. Crit Care 2015;19:258. |
| 3. | Myatra SN, Ahmed SM, Kundra P, Garg R, Ramkumar V, Patwa A, et al. The all India difficult airway association 2016 guidelines for tracheal intubation in the intensive care unit. Indian J Anaesth 2016;60:922-30. [ PUBMED] [Full text] |
| 4. | 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 2009;35:809-13. |
| 5. | Boonsarngsuk V, Suwatanapongched T, Korrungruang P, Raweelert P. A patient with subcutaneous emphysema following endotracheal intubation. Respir Care 2012;57:1191-4. |
[Figure 1], [Figure 2]
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