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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 8  |  Issue : 2  |  Page : 293-295

Airway exchange catheter inducing pneumothorax during reintubation: A rare complication


1 Department of Anaesthesiology, Military Hospital, Kirkee, India
2 Department of Anaesthesiology and Critical Care, Armed Forces Medical College, Pune, Maharashtra, India

Date of Submission18-Aug-2020
Date of Decision24-Nov-2020
Date of Acceptance25-Nov-2020
Date of Web Publication23-Dec-2020

Correspondence Address:
Dr. Debashish Paul
Department of Anaesthesiology and Critical Care, Armed Forces Medical College, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/amhs.amhs_217_20

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  Abstract 


Airway exchange catheters (AECs) are a safe option for exchanging an endotracheal tube (ETT) or in the trial to extubate a patient from ventilation in the intensive care unit (ICU). The complication with AEC is underreported. Pneumothorax is a known complication for instrumentation by AEC in the airway. However, having a pneumothorax complication while placing the AEC in expert hands and with all safety precautions is very rare. We report a case of developing pneumothorax while exchanging an ETT in the ICU. Early clinical diagnosis and remedial measures helped us to save the patient. It is interesting as we did not encounter any difficulties while placing the AEC with no significant change in ventilation settings. We feel that highlighting this case will help the physician in the emergency and in the ICU to have a strong suspicion of pneumothorax while using AEC.

Keywords: Airway exchange catheters, complications, pneumothorax


How to cite this article:
Khanna S, Bhan S, Kaur KB, Paul D. Airway exchange catheter inducing pneumothorax during reintubation: A rare complication. Arch Med Health Sci 2020;8:293-5

How to cite this URL:
Khanna S, Bhan S, Kaur KB, Paul D. Airway exchange catheter inducing pneumothorax during reintubation: A rare complication. Arch Med Health Sci [serial online] 2020 [cited 2021 Jun 22];8:293-5. Available from: https://www.amhsjournal.org/text.asp?2020/8/2/293/304716




  Introduction Top


Pneumothorax is a rare complication following routine intubation (0.1%).[1] It is mostly reported in cases of bougie-guided difficult endotracheal intubation, double-lumen tube placement, and high-pressure jet ventilation (HPJV) or sometimes following feeding tube placement.[2] We want to share a rare pneumothorax case following re-intubation aided by airway exchange catheter (AEC) and its urgent management by surgical decompression.


  Case Report Top


A 59-year-old male, body mass index of 23.8 kg/m2, known case of diabetes mellitus Type II and dilated cardiomyopathy with moderate left ventricular dysfunction, nonsmoker with no history of obstructive lung disease, intubated given sudden unconsciousness with low Glasgow Coma Scale, and low blood sugar (40 mg/dl) was transferred into our center with a diagnosis of hypoglycemic encephalopathy for further management.

The patient was intubated with a smaller size endotracheal tube (ETT) (5.5 mm internal diameter [ID]) with a high peak inspiratory pressure (PIP) of 32 mmHg. We decided to change the tube. Injection propofol 50 mg intravenous (IV) and injection fentanyl l100 μg IV were administered along with muscle-relaxant injection rocuronium 40 mg IV. AEC was used anticipating a difficult airway over which the tube was exchanged with a cuffed, polyvinylchloride tube of 8.5 mm ID. Bilateral air entry was confirmed. The patient was placed on synchronized intermittent mandatory ventilation with settings of tidal volume (TV) of 450 ml, respiratory rate of 18/min, and positive end-expiratory pressure of 5 with FiO2 1.0. Sedation was initiated with an infusion of fentanyl 40 μg/h and midazolam 2 mg/h.

The patient soon had desaturation to 80%–85%, followed by inadequate delivery of TV and raised PIP to 42 mmHg. The patient had a blood pressure of 78/52 mmHg with a heart rate of 116–120 bpm. Manual ventilation was done with Bain's circuit to rule out machine failure followed by volume control mode, which recorded increased plateau pressure (Pplat of 30 mmHg) and decreased static compliance (18 mL/cm H2O). Saturation further dropped to 75%. On auscultation, reduced air entry on the right infraclavicular, mammary, and infra-mammary areas along with little chest rise on the same side was observed. Quick bedside lung ultrasonography (USG) scan revealed the presence of “bar code” sign and loss of “comet tail artifacts” with the absence of lung sliding phenomenon demonstrating right-sided pneumothorax. On reaching a radioclinical diagnosis of pneumothorax, needle thoracostomy was done immediately in the fifth intercostal space at the midaxillary line with an IV cannula without delay. It was connected to an underwater seal; air bubbles entering the bottle were observed. The patient's saturation improved but remained hypotensive, with no significant improvement in Pplat and compliance. Bedside chest X-ray was done in the intensive care unit (ICU) with the ICU's portable X-ray machine, which revealed a significant pneumothorax on the right side in anteroposterior view [Figure 1]. Intercostal chest drain (ICD) was placed at the thoracostomy site, following which oxygen saturation increased to 96%–98%, and bilateral air entry improved. Peak pressure started reducing gradually. We suspected the cause of pneumothorax to be iatrogenic due to a small mucosal tear in the tracheobronchial tree during intubation; however, the same could not be endorsed by bronchoscopy after stabilization of the patient. In our opinion, the size of mucosal tear might be small enough not to be detected in bronchoscopy. ICD was removed on the 3rd day as pneumothorax got resolved entirely. Subsequently, the patient was tracheostomized, given the required elective ventilation, and shifted out of the ICU to the high-dependency unit.
Figure 1: Anteroposterior view of the chest X-ray showing right-sided pneumothorax.jpg

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  Discussion Top


AECs are commonly existing airway adjuncts for providing a conduit within the trachea that allows for emergent securing or re-securing of an airway and, on occasions, to ventilate during extubation or exchange of an airway device. The overall concept of these devices is that of a long, thin, flexible, sometimes hollow tube with a blunt end that can accomplish the above objectives with minimal dangers to the patient. However, sufficient data reveal that these products can have a high rate of dangerous complications as high as 60%[3],[4],[5] and the patient's risk of airway loss. The most threatening of these complications is pneumothorax, which is up to 11%.[6]

Pneumothorax in a critically ill or anesthetized patient is suspected when tachycardia, tachypnea, hypotension, or desaturation happen along with respiratory mechanics changes. Although clinically well appreciated, diagnosis is usually confirmed on chest radiograph and/or improvement after therapeutic decompression. In our case scenario, we did a lung USG that helped us in establishing our clinical diagnosis. Bedside diagnosis USG obviates the need for patient transport in unstable situations eliminating the risk of radiation exposure. It is quicker to perform and is immediately interpreted at the bedside without unnecessary delays in ICU and operation theaters (OTs).[7] Dwivedi et al., in their case report, had used lung USG to diagnose bilateral pneumothorax and manage it quickly in OT with a favorable outcome.[8]

One of the mechanisms for developing pneumothorax with AEC is trauma to the tracheobronchial tree by the device itself. Although the AECs have blunt tips, case reports of tracheobronchial tree tear by the blunt tip are there, which leads to a fatal pneumothorax, the risk of which is increased with smaller AECs.[6] While pneumothorax is a known complication of HPJV as a result of barotraumas, auto-PEEP, and dynamic hyperinflation, it has been reported with the use of AECs without HPJV.[9] Strong clinical suspicion or use of a bronchoscope is required to safely use an AEC to rapidly identify and manage pneumothorax, even with indistinct clinical and diagnostic data. A case report by Harris et al. has questioned the safety of the use of AEC bidding for high complication rates with their use.[10]

Therefore, proper technique is essential in AEC placement with intense monitoring for airway pressures, adequate chest movement, and ample time for exhalation. The gravity of these complications has led to the investigation of other options for using AECs and considering the risks and benefits in selecting these devices for an anesthetic plan.


  Conclusion Top


AECs are not devoid of risk to the airway. The clinicians should have a high suspicion of pneumothorax with its use in the event of a cardiovascular or pulmonary collapse.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Martin LD, Mhyre JM, Shanks AM, Tremper KK, Kheterpal S. 3,423 emergency tracheal intubat?ions at a university hospital: Airway outcomes and complications. Anesthesiology 2011;114:42-8.  Back to cited text no. 1
    
2.
Hensel M, Marnitz R. Pneumothorax following nasogastric feeding tube insertion: Case report and review of the literature. Anaesthesist 2010;59:229-32.  Back to cited text no. 2
    
3.
Benumof JL. Airway exchange catheters: Simple concept, potentially great danger. Anesthesiology 1999;91:342-4.  Back to cited text no. 3
    
4.
Baraka AS. Tension pneumothorax complicating jet ventilation via a cook airway exchange catheter. Anesthesiology 1999;91:557-8.  Back to cited text no. 4
    
5.
Mort TC. Continuous airway access for the difficult extubation: The efficacy of the airway exchange catheter. Anesth Analg 2007;105:1357-62.  Back to cited text no. 5
    
6.
Duggan LV, Law JA, Murphy MF. Brief review: Supplementing oxygen through an airway exchange catheter: Efficacy, complications, and recommendations. Can J Anaesth 2011;58:560-8.  Back to cited text no. 6
    
7.
Husain LF, Hagopian L, Wayman D, Baker WE, Carmody KA. Sonographic diagnosis of pneumothorax. J Emerg Trauma Shock 2012;5:76-81.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Dwivedi D, Sud S, Singh S, Kumar M. Postoperative pneumomediastinum with bilateral pneumothorax following percutaneous nephrolithotomy. Indian J Respir Care 2020;9:113-5.  Back to cited text no. 8
  [Full text]  
9.
Rashid A, Williams C, Noble J, Rashid O, Takabe K, Anand R. Pneumothorax, an underappreciated complication with an airway exchange catheter. J Thorac Dis 2012;4:659-62.  Back to cited text no. 9
    
10.
Harris K, Chalhoub M, Maroun R, Elsayegh D. Endotracheal tube exchangers: Should we look for safer alternatives? Heart Lung 2012;41:67-9.  Back to cited text no. 10
    


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