Iatrogenic Tracheal Diverticula as a Cause of Subcutaneous Emphysema after Double-Lumen Tube Insertion

To the Editor,

A 59-year-old female, with a six-month history of cough with expectoration, underwent right upper lobectomy for a hydatid cyst. Under general anesthesia, an initial attempt with 35 Fr left double-lumen tube (DLT) (patient height 163 cm) was taken which did not pass beyond the vocal cords. She was eventually intubated with 32 Fr left DLT under video-laryngoscope and bronchoscope guidance. At the end of the surgery, the DLT was exchanged with a 7.0 mm cuffed single-lumen tube. Within a few hours into postoperative intensive care unit, she gradually developed grade 4 subcutaneous emphysema. The patient did not have an air leak, was hemodynamically stable, and was extubated to prevent the worsening of emphysema with positive pressure ventilation. Computed tomography of neck and thorax to evaluate the etiology showed two separate tracheal diverticula in upper and lower paratracheal regions without any signs of lacerations [Figure 1a and b]. These diverticula were not seen in the preoperative images [Figure 1c and d]. The subcutaneous emphysema resolved in the next two days, and the patient discharged home. She has been under regular outpatient follow-up and is doing well.

Figure 1.

Axial images of high-resolution computed tomography of cervical-thoracic segments showing: Air-filled tracheal diverticula located in left upper paratracheal area (red arrow) in post-intubation images (a); sagittal reformatted images of chest showing air-filled tracheal diverticula in the upper thoracic second vertebrae level (red arrow) and lower thoracic fourth vertebrae level (yellow arrow) paratracheal region in post-intubation (b); axial image of high-resolution computed tomography of cervical-thoracic segments showing the absence of diverticula in preoperative images (c); sagittal reformatted images of chest showing the absence of diverticula in preoperative images (d)

Tracheal diverticulum can be either congenital or acquired. An acquired diverticulum can form in patients with chronic cough, where the membranous portion of posterior trachea becomes lax and prone to herniation.[1] A tracheal diverticulum may cause difficulty in endotracheal intubation and airway lacerations.[2] However, in our case the patient preoperatively did not have any diverticulum. We used a 35 Fr DLT which could have been an inappropriate size based on the studies on the Indian population.[3] It appears that our attempts at intubating with a larger DLT could have caused the diverticula.[4] The air leak occurred only during the postoperative period where a smaller-sized endotracheal tube was placed. The treatment is usually conservative, unless the patient is symptomatic.[5] Our case highlights the possibility of iatrogenic tracheal diverticula creation during a difficult intubation as one of the causes of subcutaneous emphysema in a postoperative patient. The future anesthesia considerations for this patient will be to rule out secondary infections along the diverticula, spontaneous ventilation, bronchoscopy guided intubation if in need of a positive pressure ventilation and low inspiratory pressure ventilation with endotracheal tube cuff pressures less than 30 cm H2O.

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

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Conflicts of interest

There are no conflicts of interest.