Accidental endobronchial intubation

ACCIDENTAL ENDOBROCHIAL INTUBATION 

 

Authors 

Dr. Shafi Ejas T.M; PGY 1, MEM

Dr. Yoga Moorty MS; PGY 1, PGFEM

Dr. Fabith Moideen VM; Attending ER Physician

Dr. Shahul Hameed; Attending ER Physician, Mentor

Dr. Venugopalan P.P; Chief , EM MIMS

 

A 38 year old male presented to the emergency department with fever, generalized weakness and jaundice since past one week, vomiting and altered mental status since past 2 days

 

No h/o known drug allergies in the past

Not on any regular medications

No co - morbid illness like DM, HTN, CAD

He is a c/c alcoholic

 

Air way      - Obstructed

Breathing    - Laboured

Circulation - Pulses + (Feeble)

Disabiltiy    – Responsive to Pain

Exposure     – Nil significant

IV access, Oxygen and Monitors established

.

VITALS:  Heart 110/min, BP 100/90mmHg Rt. arm supine, RR 26/min, SpO2 84 % with 4L Oxygen

Temp 99 (F) GRBS 157 mg/dl

Pallor +++

Examination showed B/L Ronchi and B/L Crepitations.

S1, S2 Normal, Systolic murmur + .No Rub.

Abdomen: Soft, Non tender, No Organomegaly

Extremities: Normal.

He was electively intubated [Rapid sequence intubation] and monitored. Post Intubation air entry was equal bilaterally. NG inserted, bladder catheterized. Patient was shifted to ED ICU and placed in propped up position. Patient began to de saturate. SpO2 levels dropped to 80% with 100% oxygen on ventilator. Air entry markedly decreased on the left side.

Heart rate 103/ min, BP 100/ 70mmHg. 

 

Chest X-ray revealed:

 

 

 

 

What is your diagnosis?

 

ANS: Accidental endobronchial intubation.

 

DISCUSSION.

 

 Airway management is a fundamental aspect of anesthetic practice and of emergency and critical care medicine. Endotracheal Intubation is the most reliable way to ensure a patent airway, provide oxygenation and ventilation, and prevent aspiration. At large patients both unconscious and even conscious may be unable to spontaneously clear the airway of secretions, may require mechanical ventilation, may have aspirated, or lack protective airway reflexes.

 

ENDOBRONCHIAL INTUBATION 

 

It is defined as an incorrect positioning of an endotracheal tube, causing an inadequate delivery of gaseous anesthesia, hyperventilation, hypoxia and cyanosis.1 

Invariably the tube will get placed in the right main bronchus in case of accidental endobronchial intubations. Detection of main stem bronchial intubation is made by clinical examination yielding a unilateral chest expansion on inspection, unequal breath sounds on auscultation and depth of endotracheal tube placement. Inadvertently, a massive unilateral aspiration leading to diminished lung sounds may be misinterpreted as an endobronchial intubation. 

The consequences of an endobronchial intubation include collapse of the intubated lung and hyperinflation of the contra-lateral lung. This produces a shunting of blood through the collapsed lung which in turn leads to the return of deoxygenated blood to the heart without gaseous exchange. On the other hand the hyper - inflated lung produces dead space ventilation. Both these phenomenon produce a gross ventilation perfusion mismatch leading to hypoxia. The physiological response of endobronchial intubations is hypoxic pulmonary vasoconstriction in contra-lateral lung which may help to reduce the hypoxic effects but is a very transient process. Early detection and correction is the critical step in the management.

Emergent endotracheal intubations can result in a significant occurrence of malpositioned endotracheal tubes that are undetected by clinical evaluation. Malposition is not detected by routine clinical assessment, but only by a chest radiograph. Women are at a greater risk than men for endotracheal tube malposition after emergent intubations as the tube is more likely to be positioned very close to the carina. 

 

A chest radiograph for confirmation of endotracheal tube position after emergent intubations should remain the standard of practice. Management include reposition by withdrawing the tube carefully till get a bilateral chest movements and breath sounds.

 

CONFIRMATION OF ENDOTRACHEAL TUBE PLACEMENT

 

1)Direct visualization of tube passing through the vocal cords

2)Bilateral Chest rise on ventilation

3)Clinical assessment - chest and epigastric auscultation

4)ET CO2 detectors

5)Esophageal detection devices

6)Chest radiography

7)Fibro- optic bronchoscopy

 

POOR BI LATERAL BREATH SOUNDS AFTER INTUBATION & DESATURATION

 

ALWAYS THINK OF ‘DOPE’!

 

DISPLACEMENT [ESOPHAGEAL/ ENDOBRONCHIAL]

OBSTRUCTION (KINKED OR BITTEN TUBE, SECRETIONS)

PNEUMOTHORAX (BAROTRAUMA)

EQIUPMENT FAILURES

 

 It is critical to RE - ASSESS the position of the tube after securing the tube and after any physical movement of the patient.

 

CONCLUSION:

 

Tube displacement is a common complication especially after transport, and failure to detect this complication will lead to increase in morbidity and mortality. The clinician should be extremely vigilant for the cause and should keep a high index of suspicion. Ideally the tube should be secured using a commercially available endotracheal tube holder.

 

 

REFERENCES: 

 

  1] Saunders Comprehensive Veterinary Dictionary, 3 ed. © 2007 Elsevier, Inc

  2] Rosen textbook of emergency medicine

  3] Tintinally textbook of emergency medicine