|LEARNING CASE REPORT
|Year : 2014 | Volume
| Issue : 1 | Page : 36-38
Bilateral pneumothorax: Perils of emergency tracheostomy
Shraddha Jain1, Sunil Kumar2, Prasad Deshmukh1, Sagar Gaurkar1
1 Departments of Otorhinolaryngology and Head and Neck Surgery, Jawahar Lal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Sawangi, Wardha, Maharashtra, India
2 Department of Medicine, Jawahar Lal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Sawangi, Wardha, Maharashtra, India
|Date of Web Publication||22-Sep-2014|
Department of Otorhinolaryngology and Head and Neck Surgery, Jawahar Lal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Sawangi, Wardha, Maharashtra - 442 004
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Tracheostomy is a life-saving procedure performed in both emergency and elective setting. Development of bilateral pneumothorax in adults following tracheostomy is a rare complication. We report a case of bilateral iatrogenic pneumothorax in 33-year-old woman from rural Maharashtra in central India, immediately following emergency mid-level tracheostomy done for post- radiotherapy fibrosis with laryngeal perichondritis and retropharyngeal infection associated with prolonged dyspnea. No pleural injury or posterior tracheal wall injury had occurred. Sudden left-sided chest pain with immediate reoccurrence of dyspnea prompted us to do urgent chest X-ray. Bilateral pneumothorax was identified, more on the left side. The patient was treated with tube thoracostomy. The case is being reported to highlight the possibility of occurrence of this rare life-threatening complication due to the underlying mechanism in any case of emergency tracheostomy.
Keywords: Complications, pneumothorax, tracheostomy
|How to cite this article:|
Jain S, Kumar S, Deshmukh P, Gaurkar S. Bilateral pneumothorax: Perils of emergency tracheostomy
. J Laryngol Voice 2014;4:36-8
| Introduction|| |
Tracheostomy is a very common procedure mostly performed in an elective setting nowadays. Occasionally, does it have to be done as an emergency procedure for severe airway compromise? There are basically two approaches to tracheostomy: Open surgical tracheostomy (ST) and percutaneous dilational tracheostomy (PDT). Iatrogenic pneumothorax is a known complication of tracheostomy, slightly more common with the former technique.  It is believed to be more common in low tracheostomy due to injury to pleura.  But on the basis of autopsy evidence, few reports mention this to be a very rare cause of pneumothorax and to almost exclude pleural injury as a cause when the pneumothorax is accompanied by mediastinal emphysema.  This complication is more common in children. Prevalence of severe degrees of respiratory obstruction and loose areolar tissue in children has been listed as possible causes.  Most believe it to be due to high pleural dome in children. Bilateral pneumothorax following tracheostomy in adults is rare and herein we report such an occurrence immediately following emergency tracheostomy. The case is being reported to highlight the possibility of occurrence of this rare life threatening complication in any case of emergency tracheostomy due to the underlying mechanism, which has not received much attention.
| Case report|| |
A 33-year-old woman presented to the otolaryngology emergency department of this hospital with difficulty in swallowing, breathing difficulty, change in voice, and pain over left side of neck. She had been operated for alveolar malignancy with segmental mandibulectomy and received radiotherapy 6 months back. The patient had tenderness over larynx, intermittent inspiratory stridor, trismus, ankyloglossia, and restricted neck movements due to radiation fibrosis. Her laryngoscopic examination revealed bilateral edematous aryepiglottic folds, with bulge of posterior pharyngeal wall and slough in post-cricoid region. X-ray of neck - lateral view showed retropharyngeal widening with straightening of cervical spine and A-P view showed narrowing of airway. CT-Scan showed edematous laryngeal and pharyngeal tissues. Chest X-ray did not reveal any pathology. The patient was diagnosed as post-radiotherapy laryngeal perichondritis with retropharyngeal space infection. She was treated with broad-spectrum antibiotics along with steroids. Her retropharyngeal space infection and laryngeal edema subsided with treatment, but due to severe radiation fibrosis, her glottic chink remained narrow with impaired mobility of left vocal cord. Repeat CT scan did not show any collection or mass and biopsy of larynx was negative for malignancy. Her dysphagia, trismus, ankyloglossia and pain improved but she continued to have waxing- waning type of stridor. Patient was initially not giving consent for tracheostomy. One day, her stridor increased suddenly and patient did not improve with steroids and nebulization. As difficult intubation was contemplated due to radiation fibrosis of airway leading to a narrow glottis chink, emergency tracheostomy was planned. Tracheal rings were nicely visualized and pleura did not come anywhere in the field as mid-level tracheostomy was done. As soon as the tracheal rings were excised, she had a single sudden bout of coughing with initial transient improvement in her dyspnea followed immediately by shortness of breath with left-sided chest pain. She was not able to cough out her secretions. The chest wall movements appeared diminished and there was decreased air entry on auscultation. There was no surgical emphysema till then. Blood gas analysis was pH. 7.32, PaO 2: 85, and PaCO 2: 57. An immediate chest X-ray revealed bilateral pneumothorax, which was managed by left-side tube thoracostomies with under water seal [Figure 1]. In the follow-up, chest tubes were removed on the fifth day after full chest expansion.
|Figure 1: Chest X-ray shows the tracheostomy cannula and bilateral pneumothoraces with lung collapse|
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| Discussion|| |
Pneumothorax is classified as spontaneous and acquired. Acquired pneumothorax is subdivided into iatrogenic, barotraumatic, and traumatic.  Iatrogenic pneumothoraces result from medical interventions. Simultaneous bilateral pneumothorax has been reported following transtracheal aspiration.  There are few reports of its occurrence following surgical tracheostomy (ST). ,,,,, Cases have also been reported following PDT. 
The mechanism for its occurrence after tracheotomies, as suggested by Padovan and coworkers, involves the entry of air through the cervical incision and its downward passage peritracheally into the mediastinum during inspiration, presumably due to the drop in pleural pressure which accompanies inspiration. When significant pressure exists within these mediastinal air pockets, (which may be hastened by extrinsic factors like Intermittent Positive Pressure Ventilation IPPV), rupture into both pleural spaces is possible with resultant bilateral pneumothorax. , Padovan's experiments with cats suggested that hyperextension of the neck applies mechanical tension to the mediastinal pleura and favors bleb rupture with escape of air into the pleural space. 
In the setting of upper airway obstruction, another contributory factor is the powerful inspiratory efforts which generate a marked negative intrathoracic pressure. This negative pressure 'sucks' air rapidly from the atmosphere into the mediastinum through the edges of the tracheostomy wound and on reaching sufficient pressure ruptures through the pleura.  So, the resulting bilateral pneumothorax can occur as a sudden catastrophe immediately following emergency tracheostomy or acute tracheal obstruction. ,,, In our patient long-standing airway obstruction with marked negative intra-thoracic pressure, fibrosis of the neck tissues with difficult dissection to expose trachea and extension of neck may have led to this complication. Negative pressure pulmonary edema can also occur with forced inspiration against a closed or obstructed airway. So, the other differential diagnosis of sudden increase in respiratory distress following tracheostomy could be interstitial edema due to sudden tracheal obstruction. 
Other less common causes of a pneumothorax in patients needing tracheostomy include spontaneous rupture of a pulmonary bleb, iatrogenic trauma (pleural injury, posterior tracheal wall injury) or barotrauma in patients on ventilators.  The possibility of pulmonary bleb rupture was excluded in our case on preoperative chest X-ray and CT of the thorax. The IPPV treatment after tracheostomy or even needle puncture of the cricothyroid membrane may contribute to air passage into the mediastinum with subsequent development of bilateral pneumothorax.
The preventive measures at the time of tracheostomy include meticulous surgical technique with minimal separation of cervical fascia and limiting the time interval between dividing the cervical fascia and inserting the tracheostomy tube. Prior intubation will prevent extreme diaphragmatic contractions during the operation. The head of the patient should not be overextended so as to prevent overextension of the tracheobronchial tree. Modification of surgical technique, known as starplasty has been proposed to minimize the possibility of pneumothorax in children. 
The diagnosis of pneumothorax in tracheostomized patient is made by symptoms of persistence or recurrence of dyspnoea and chest pain.  We found decreased cough reflex following tracheostomy another suspicious feature.
| Conclusions|| |
The pathophysiology of bilateral pneumothorax following tracheostomy lies in the negative intra-thoracic pressure in cases of upper airway obstruction or IPPV after tracheostomy or other procedures which may lead to air leak into mediastinum. This complication should be borne in mind in case of any emergency tracheostomy even when no pleural injury is contemplated. Heightened vigilance for this potential cause of hypoxia following tracheostomy may help avoid fatality.
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