Massive Subcutaneous Emphysema Following Percutaneous Tracheostomy David M. Kaylie, MD, and Mark K. Wax, MD Background: Bronchoscopic subcutaneous dilatational tracheostomy is fast becoming the method of choice for securing an airway in chronic ventilated patients in an intensive care setting. Many studies have demonstrated that it is a cost-effective and safe procedure in experienced hands. Complications appear to be equivalent to those encountered in open tracheostomy. Subcutaneous emphysema following tracheostomy is a rare occurrence. Only 3 cases have been described following percutaneous dilatational tracheostomy. Management can be quite complex. Material and Methods: Retrospective review with case report of a patient with massive subcutaneous emphysema following percutaneous tracheostomy. Conclusion: Massive subcutaneous emphysema following percutaneous tracheostomy is a major complication that is rarely encountered. When due to a posterior tracheal wall tear, management consists of bypassing the laceration and allowing it to heal secondarily. (Am J Otolaryngol 2002;23:300-302. Copyright 2002, Elsevier Science (USA). All rights reserved.) (Editorial Comment: As physicians continue to debate the safety of percutaneous tracheotomy, the authors particularly describe the serious complications and the intensive care required to manage the entry to the tracheal wall. This is important information to surgeons certainly performing percutaneous tracheotomy and for those contemplating doing it in the future.)
Sheldon and Pudenz1 first described percutaneous tracheostomy (PT) in 1957. Several modifications of different techniques have since been developed.1,2 The percutaneous technique was developed in an effort to lower the morbidity seen with standard open surgical tracheostomies carried out in the operating room and to eliminate the need to transport severely ill patients. Because PT avoided anesthesia and operating room charges, significant cost savings were realized. However, percutaneous tracheostomies are not without
From the Oregon Health & Science University Portland, Oregon. Presented at American Academy of Otolaryngology– Head and Neck Surgery 2000, Washington DC, September, 2000. Address reprint requests to Mark K. Wax, MD, Department of Otolaryngology–Head and Neck Surgery Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, PV-01, Portland, OR 97201-3098. E-mail:
[email protected]. Copyright 2002, Elsevier Science (USA). All rights reserved. 0196-0709/02/2305-0010$35.00/0 doi:10.1053/ajot.2002.124192 300
complications. Powell et al3 reviewed the world literature and described the gamut of complications seen with PT. These included peritracheal insertion, hemorrhage, wound infections, pneumothorax, and death. No significant difference was found in the rates of these complications between PT and open surgical tracheostomy.3 Massive subcutaneous emphysema is a rare complication of any form of tracheostomy. It has been described 3 times in association with percutaneous tracheostomy, each time with significant morbidity. The purpose of this report is to discuss a case of massive subcutaneous emphysema following a percutaneous tracheostomy. The etiology and management of this rare problem are discussed. CASE REPORT A 67-year-old woman with severe chronic obstructive pulmonary disease was admitted through the emergency department for respiratory distress. She was emergently intubated upon arrival and transferred to the intensive care unit. Once there, she was started on bronchodilators and steroids. After 3 days, it was felt she had improved enough to be extubated. Unfortunately, the patient developed respiratory distress and required reintubation. Her past medical history was significant in that she had required intubation for exacerbations
American Journal of Otolaryngology, Vol 23, No 5 (September-October), 2002: pp 300-302
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of her disease 2 other times within the previous 12 months. After being intubated for 6 days, an otolaryngology consultation was obtained for placement of a tracheostomy. A Simms percutaneous tracheostomy kit (Portex, Keene, NH) was used. The procedure was complicated by a difficult tube insertion secondary to the patient’s extremely large neck. Even though bronchoscopic visualization was used, multiple attempts were required. At the end of the procedure, the tube was felt to be in a good position. Several hours following the procedure, the patient developed massive subcutaneous emphysema encompassing her entire body. A chest radiograph was obtained. The tracheostomy tube was still felt to be in a good position. No pneumothorax was seen, although massive subcutaneous emphysema was apparent (Fig 1). The patient was taken to the operating room for a direct laryngoscopy and bronchoscopy. A 1.5 cm laceration was found in the membranous trachea at the distal end of the tube. Positive ventilation through the defect was determined to be the cause of the patient’s subcutaneous emphysema. A custom Bivona tracheostomy tube (Bivona Medical Technologies, Gary, IN) was placed with the tip distal to the laceration. Her subcutaneous emphysema began to subside. On the evening of postoperative day one, the subcutaneous emphysema increased. She was returned to
Fig 1. Chest radiograph revealing subcutaneous emphysema.
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the operating room, where it was seen that the tube had migrated caudad. The tip was again embedded in the laceration. The tracheostomy tube was changed to an armored endotracheal tube and positioned approximately 2 cm above the carina. A subcutaneous chest tube was placed to help evacuate the subcutaneous air. Daily flexible bronchoscopy was carried out for 2 weeks to ensure proper tube placement. The patient’s subcutaneous emphysema eventually resolved, and she was changed to a regular cuffed Shiley tube (Mallinckrodt, Inc., St. Louis, MO). Ultimately, she developed a massive gastrointestinal bleed and became profoundly hypotensive; support was withdrawn. DISCUSSION Massive subcutaneous emphysema following percutaneous tracheostomy has only been reported in the literature 3 times. Douglas and Flabouris4 reported 2 cases of subcutaneous emphysema. Both patients in their report had posterior tracheal wall tears at the level of the tracheostomy tube. The investigators concluded that the tip of the tracheostomy tube introducer caused the injury. This conclusion is supported by Fish et al,5 who determined that the Portex (Portex, Inc.) percutaneous guide wire dilational forceps (PGWDF) was more likely to cause an injury to the posterior tracheal wall than the standard Portex obturator or the Cook kit (Cook, Inc., Bloomington, IN). The Simms kit used in this procedure utilizes a guide wire percutaneous dilational system. This system is felt to have less of a learning curve than the PGWDF. Bronchoscopic visualization has also been recommended as a way of lowering complications during PT.4 A bronchoscope was used in the procedure described in this report. However, in retrospect, the force required to insert the tracheostomy tube led to a number of problems. First, the force used compressed the trachea and obscured visualization. Second, it undoubtedly contributed to the edge of the tracheostomy tube lacerating the posterior tracheal wall. A further contributing factor was the patient’s thick neck. The loss of normal landmarks meant that the surgeon did not have the feel that is usually present. Thus, the
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force applied was directed too far posterior and contributed to the posterior tracheal laceration. Management of this complication consists of several therapeutic interventions.4 First, the injury needs to be assessed. This can be done with a fiberoptic bronchoscope at the bedside, but ideally the patient should be evaluated in the operating room under controlled conditions. The complete trachea is evaluated, as is the esophagus. Although massive subcutaneous emphysema is most likely to be secondary to an isolated posterior tracheal wall tear, an injury to the esophagus must be ruled out. Once the lesion is identified, its location with respect to the carina is important to document. Management is complex. Simply bypassing the laceration by placing the endotracheal tube so that the tip is distal to the tear may sound simple but is technically difficult. In our patient, the tear was relatively close to the carina. A review of the literature confirms that these tears occur distal to the insertion point of the tracheostomy, and movement of the endotracheal tube will often place its tip into the tear. This makes the subcutaneous emphysema worse. We found that an armored endotracheal tube sutured in place and monitored on a daily basis with fiberoptic endoscopy ensures proper placement at a suitable level above the carina. Radiologic evaluation is inconclusive.
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Maintenance of this form of ventilation for a period of 2 weeks allows healing of the perforation. Acute management of the surgical emphysema can be done by releasing the gaseous tension in the soft tissue. This can be done with an 18-gauge needle or, when severe, with placement of chest tubes in the subcutaneous tissue of the chest. This allows decompression of the soft tissue and for the natural process of absorption to take place. Intravenous antibiotics are continued for the 2-week period. CONCLUSION Massive subcutaneous emphysema following percutaneous dilatational tracheostomy is an unusual but morbid condition. Prompt recognition, evaluation in the operating room, and placement of the endotracheal tube distal to the tear will result in the resolution of this problem. REFERENCES 1. Sheldon C, Pudenz R: Percutaneous tracheotomy. JAMA 165:2068-2070, 1957 2. Toye F, Weinstein J: A percutaneous tracheostomy device. Surgery 65:384-389, 1969 3. Powell DM, Price PD, Forrest LA: Review of percutaneous tracheostomy. Laryngoscope 108:170-177, 1998 4. Douglas W, Flabouris A: Surgical emphysema following percutaneous tracheostomy. Anaesth Intensive Care 27:69-72, 1999 5. Fish W, Bohiemer N, Cadle D, et al: A life threatening complication following percutaneous tracheostomy. Clin Intensive Care 7:206-208, 1996
