The Science Journal of the American Association for Respiratory Care

2009 OPEN FORUM Abstracts

TREATMENT OF A BRONCHIAL LACERATION BY SELECTIVE FIBEROPTICGUIDED LEFT MAINSTEM INTUBATION IN A 480 GRAM NEONATE

Steven Sittig, Cody Koch, Shelley Ahrens, Charlotte Van Dorn, Dana Thompson, William Carey; mayo clinic, Rochester, MN

INTRODUCTION: Laceration of the tracheobronchial tree is a rare cause of pulmonary air leak in neonates. Often resultant from traumatic intubation, causative factors include multiple attempts at intubation or inappropriately deep placement of the endotracheal tube. These injuries often present with subcutaneous emphysema, mediastinal emphysema and pneumothorax. For the smallest patients, premature newborns weighing <1 kg, conservative, non-surgical management is the standard of care, despite the high mortality rate associated with this condition. CASE REPORT: Our patient was born at 24 weeks gestation, estimated weight of 600 grams. Multiple intubation attempts were made both during the initial resuscitation and over the first three days of life. After several of these intubations there was radiographic evidence of right mainstem intubation. On the third day of life the patient developed a right pneumothorax. Placement of a thoracostomy tube initially relieved the intrapleural air, but within 12 hours the air reaccumulated. On the fourth day of life the patient was transported to our facility for further management of her persistent air leak. Despite the use of high frequency ventilation, replacement of a thoracostomy tube and patient positioning maneuvers, the pneumothorax did not resolve, leaking continuously until day of life 11. The otolaryngology service then was consulted, and on rigid bronchoscopy a laceration was identified at the take-off of the right upper lobe bronchus. As surgery would have been challenging in a patient of this size (480 gm on that day), the left mainstem bronchus was selectively intubated with fiberoptic guidance. The endotracheal tube was left in this position for the next 24 hours with the patient placed in the right lateral decubitus position. After this time, the ETT was withdrawn to a midtracheal position and the pneumothorax did not reaccumulate. Conclusion: In this case, traumatic intubation led to a bronchial laceration that was complicated by a life-threatening bronchopleural fistula. Making a diagnosis was challenging, given the absence of subcutaneous or mediastinal emphysema. Rigid bronchoscopy enabled us to make the correct diagnosis, and fiberoptic-guided left mainstem intubation allowed us to treat this tiny infant rapidly and effectively. To our knowledge, this is the first case of tracheobronchial laceration so treated in a patient weighing <500 grams. Sponsored Research - None

Rt Mainstem bronchial laceration. Arrow denotes laceration

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