Delayed Recognition of a Cuff-Level Tracheal Rupture After Double-Lumen Endotracheal Tube Intubation for Thoracic Surgery: A Case Report

Abstract

Background

Double-lumen endotracheal tubes (DLTs) are widely used to facilitate one-lung ventilation during thoracic surgery and are generally considered safe. However, tracheobronchial rupture is a rare but potentially life-threatening complication. Injuries occurring at the tracheal cuff level may initially remain clinically occult because the inflated cuff can obscure the injured area during bronchoscopic examination.

Case Presentation

An 81-year-old man underwent left upper lobectomy for lung adenocarcinoma using a left-sided DLT. The procedure was converted from VATS to an anterolateral mini-thoracotomy because of persistent diffuse oozing. Ten hours postoperatively, he required emergent reoperation for intrathoracic bleeding. Persistent air leakage, left lung atelectasis, and progressive subcutaneous emphysema subsequently developed. Bronchoscopy on postoperative day (POD) 6 demonstrated a posterolateral tracheal wall defect at the membranous–cartilaginous junction, estimated to measure at least 1–1.5 cm. Exact measurement was limited by oxygen desaturation. Initial conservative management was undertaken; however, the air leak and failure of lung re-expansion persisted. Repeat bronchoscopy on POD12 showed no appreciable improvement in the defect and confirmed that the defect was located approximately 5 cm above the carina. Definitive surgical repair was performed through a left thoracotomy on POD13. The defect was primarily closed using 4–0 Prolene sutures, and intraoperative bronchoscopy and air-leak testing confirmed closure.

Conclusion

Tracheal cuff injuries after DLT intubation may initially remain undetected. Persistent postoperative air leakage, subcutaneous emphysema, or failure of lung re-expansion should prompt early bronchoscopic evaluation, with careful inspection of the tracheal cuff level.

Introduction

Double-lumen endotracheal tubes (DLTs) are commonly used to achieve one-lung ventilation during thoracic surgery. Although generally safe, DLT use is associated with rare but serious complications, including tracheobronchial rupture.¹ In a review of 187 reported cases of DLT-associated airway rupture, Liu et al reported a mortality rate of 8.8%.²

DLT-associated airway injury may result from direct mechanical trauma during intubation or tube manipulation, as well as pressure-related injury from the tracheal cuff.^2,3 Several risk factors have been proposed, including advanced age, female sex, small stature, difficult or repeated intubation, inappropriate tube size, use of a stylet, and excessive cuff inflation.^2,3 Tracheobronchial rupture most commonly involves the membranous portion of the distal trachea or main bronchus and may present with subcutaneous emphysema, pneumomediastinum, pneumothorax, persistent air leakage, or respiratory compromise.^2,4 Bronchoscopy remains the primary diagnostic modality for determining the location and extent of airway injury.^4,5

The Cardillo morphological classification provides a framework for assessing post-intubation tracheal injuries and guiding conservative vs surgical management.⁵ The present case is noteworthy for a cuff-level tracheal defect that was not initially recognized and persisted despite conservative management, ultimately requiring surgical repair. We report the clinical course of an elderly patient who developed a cuff-level tracheal defect following DLT intubation for thoracic surgery and discuss the diagnostic challenges, possible contributing mechanisms, and considerations for early recognition and management.

Case Presentation

An 81-year-old man (163 cm, 56 kg) was scheduled for left upper lobectomy via video-assisted thoracic surgery (VATS) for a 1.6-cm left upper lobe adenocarcinoma. He had a history of myocardial infarction treated with percutaneous coronary intervention and coronary stent implantation and was receiving aspirin 100 mg daily as single antiplatelet therapy. Preoperative cardiology consultation recommended continuation of single antiplatelet therapy if feasible; however, the exact timing of perioperative aspirin interruption was not documented. He had no history of smoking or significant pulmonary disease. Preoperative examination, laboratory testing, and pulmonary function were unremarkable, with a hemoglobin level of 14.5 g/dL.

General anesthesia was induced with propofol and remifentanil using target-controlled infusion, followed by intubation with a 37-Fr left-sided DLT. Correct tube positioning was confirmed by fiberoptic bronchoscopy immediately after intubation and again after right lateral positioning. The tracheal cuff was inflated using the manual soft-feel technique without objective pressure measurement, and no intermittent cuff pressure adjustment or deflation was performed. The operation was initiated using a three-port VATS approach but was converted to an anterolateral mini-thoracotomy because of persistent diffuse oozing. Left upper lobectomy with systematic lymph node dissection (stations 6, 7, 8, 9, 11, and 12) was completed, and a 28-Fr chest tube was inserted. The patient was extubated uneventfully. Ten hours postoperatively, chest tube drainage abruptly increased to 460 mL/h with acute anuria, necessitating emergent reoperation for suspected intrathoracic bleeding. A large intrathoracic hematoma was evacuated. The hemoglobin concentration had decreased to 7.7 g/dL, and two units of packed red blood cells were transfused. No sustained hypotension was documented before reoperation; however, blood pressure transiently decreased to 78/54 mmHg after induction and promptly responded to vasopressor treatment. For the reoperation, the patient was reintubated with a 37-Fr DLT, with fiberoptic bronchoscopic confirmation of tube position. No failed or repeated intubation attempts or other airway complications were documented, and cuff pressure was not objectively measured. The bleeding source was diffuse oozing from the pleural surface and previous staple lines, and hemostasis was achieved with wedge resection and electrocautery. The patient was again extubated uneventfully.

On postoperative day (POD) 1, chest radiography demonstrated left lung atelectasis with a persistent air leak through the chest drainage system (Figure 1). By POD3, the air leak persisted, and progressive subcutaneous emphysema developed in the neck and anterior chest wall. As these findings did not improve despite continuous chest tube drainage, flexible bronchoscopy was performed on POD6 and demonstrated a tracheal wall defect estimated to be at least 1–1.5 cm in size at the posterolateral membranous–cartilaginous junction, approximately at the 7–8 o’clock position (Figure 2). Exact measurement was limited by oxygen desaturation during the examination. Chest computed tomography performed on POD7 demonstrated left hydropneumothorax, passive atelectasis of the left lung, and extensive chest-wall subcutaneous emphysema, although the tracheal defect itself was not clearly identified on CT. Repeat bronchoscopy on POD12 localized the defect approximately 5 cm above the carina and showed no appreciable interval change. The precise depth and full extent of tracheal wall involvement could not be determined from the available bronchoscopic and operative records.

Figure 1.

Chest radiograph obtained on postoperative day 1 showing left lung atelectasis (arrow).

Figure 2.

Bronchoscopic image obtained on postoperative day 6 showing a posterolateral tracheal wall defect at the membranous–cartilaginous junction, approximately at the 7–8 o’clock position (arrow). The defect was estimated to measure at least 1–1.5 cm; exact measurement was limited by oxygen desaturation during bronchoscopy.

Bronchopleural fistula and esophageal injury were considered as differential diagnoses. However, bronchoscopy showed no evidence of bronchial stump dehiscence, and chest CT showed no evidence of esophageal perforation or mediastinal contamination. Based on these findings, a diagnosis of a tracheal wall defect at the DLT cuff level was established.

Following diagnosis of the tracheal defect, conservative management with continued chest drainage, supplemental oxygen therapy, and close clinical observation was initially undertaken. Ciprofloxacin, which had been administered from POD0, was continued, and piperacillin/tazobactam was added on POD7. Despite these measures, persistent air leakage and failure of left lung re-expansion continued. Repeat bronchoscopy on POD12 demonstrated no appreciable interval improvement in the tracheal defect. Given the persistent defect and ongoing air leakage, definitive surgical repair was performed through a left thoracotomy on POD13. A 37-Fr left-sided DLT was positioned under bronchoscopic guidance for one-lung ventilation. The tracheal defect was primarily closed using 4–0 Prolene sutures. Air-leak testing was performed twice after closure, and intraoperative bronchoscopy confirmed closure of the defect without residual air leakage. Postoperatively, the patient was admitted to the intensive care unit and managed with mechanical ventilation. The left chest tube showed no evidence of an air leak, and serial chest radiographs demonstrated improvement in the left lung atelectasis and subcutaneous emphysema. On POD17, bedside bronchoscopy was performed twice during airway management; however, no specific findings regarding the repaired tracheal defect were documented. An initial extubation attempt was followed by respiratory instability and oxygen desaturation requiring reintubation. The patient was successfully extubated on POD18 and subsequently maintained adequate oxygenation with supplemental oxygen or high-flow nasal cannula support. No follow-up chest CT was performed after tracheal repair. During the later hospital course, right-lung consolidation developed. Aspirin 100 mg daily was resumed on POD23 and continued through POD35. On POD35–36, anemia with gastrointestinal bleeding, thrombocytopenia, and progressive respiratory and hemodynamic deterioration developed. The patient died on POD37 despite supportive treatment. Because no post-repair bronchoscopy documenting the repaired tracheal defect or CT surveillance was available, late airway complications such as tracheal stenosis could not be assessed.

The key perioperative events are summarized in Table 1.

Table 1.

Timeline of the Major Clinical Events

Day	Event	Key Findings and Management
POD 0	Initial surgery and reoperation	LUL lobectomy; 37-Fr left-sided DLT; emergency reoperation for postoperative bleeding
POD1–3	Postoperative findings	Persistent air leak, left lung atelectasis, and progressive subcutaneous emphysema
POD 6	Bronchoscopy	Posterolateral tracheal defect at 7–8 o’clock, estimated ≥1–1.5 cm
POD 7–12	Conservative management	Chest drainage and antibiotics; no appreciable improvement on POD12 bronchoscopy
POD 13	Surgical repair	Primary closure with 4–0 Prolene; closure confirmed by bronchoscopy and air-leak testing
POD17–18	Postoperative airway management	Unsuccessful extubation on POD17 requiring reintubation; successful extubation on POD18
POD35–37	Late clinical course	Gastrointestinal bleeding, anemia, and progressive respiratory and hemodynamic deterioration; death on POD37

Abbreviations: LUL, left upper lobectomy; LN, lymph node; DLT, double-lumen tube.

Discussion

Tracheobronchial rupture from DLT insertion is rare but potentially fatal.¹ Although historically reported more frequently with red rubber DLTs, airway injury can still occur with modern polyvinyl chloride DLTs despite their improved flexibility and high-volume, low-pressure cuffs.

Clinical presentation is variable. Intraoperative signs include changes in airway pressure, ventilation difficulty, hypoxemia, persistent air leak, or hemodynamic instability.⁶ Diagnosis can be delayed until the postoperative period, when subcutaneous emphysema or pneumomediastinum becomes apparent. Small lacerations, particularly those located near an inflated tracheal cuff, may remain clinically occult.³ In our patient, the defect was located at the tracheal cuff level and was not identified during the initial bronchoscopic assessments. Several factors may have contributed to the delayed recognition. Because the lesion was located at the cuff level, the inflated cuff could have obscured the defect during bronchoscopic assessment, although this mechanism could not be directly confirmed. In addition, routine bronchoscopic confirmation of DLT position primarily focuses on tube placement rather than systematic inspection of the entire tracheal wall, allowing a subtle cuff-level injury to remain undetected. The present case is therefore notable for the cuff-level location of the tracheal defect, its delayed clinical recognition, and its persistence despite initial conservative management.

Tracheal injuries typically involve the membranous portion, which lacks cartilaginous support, and present as linear, longitudinal tears in localized, nondependent regions.⁴ In our patient, the tracheal defect was located approximately 5 cm above the carina at the posterolateral membranous–cartilaginous junction, corresponding approximately to the 7–8 o’clock position. During the emergent reoperation, the bleeding source was identified as diffuse oozing from the pleural surface and previous staple lines, without evidence of airway bleeding. Although no sustained hypotension was documented before reoperation, substantial postoperative blood loss occurred; therefore, a contribution of transient perioperative hypoperfusion to tracheal wall injury cannot be confirmed or excluded. The tracheal injury may have been multifactorial, although the relative contribution of the potential mechanisms cannot be determined. Its location at the tracheal cuff level raises the possibility of cuff-related pressure injury. Surgical manipulation is another recognized mechanism of airway injury during thoracic surgery.² However, no direct tracheal injury was documented during lymph node dissection in this patient. Details regarding bronchial arterial preservation and mediastinal pleural dissection were not sufficiently documented in the operative record to assess their potential contribution. Therefore, the precise contribution of cuff-related pressure, perioperative hypoperfusion, and surgical manipulation remains uncertain.^2,7,8 Several patient- and procedure-related factors have been associated with DLT-related airway rupture, including difficult or repeated intubation, stylet use, inappropriate tube size, and cuff overdistention.^2,7,8 In our case, DLT placement was technically straightforward, whereas cuff inflation was guided by a manual soft-feel technique without objective pressure measurement. Prolonged or excessive cuff pressure may contribute to tracheal mucosal ischemia and tissue injury.⁷ The timing and progression of the tracheal injury in our patient could not be established.

Bronchoscopy remains the primary diagnostic tool for tracheobronchial injury, enabling assessment of location and extent.⁴ Chest radiography and computed tomography can identify associated complications. Cuff masking may hinder bronchoscopic detection and has been described in previous reports.⁹ In our patient, the cuff-level location raises this possibility, although cuff masking could not be directly confirmed. In such situations, sudden tidal volume reduction or massive air leak should raise suspicion, and alternative bronchoscopic approaches may help identify cuff-level lesions. Therefore, persistent postoperative air leak, progressive subcutaneous emphysema, or unexplained atelectasis despite apparently normal intraoperative bronchoscopy should prompt repeat bronchoscopic evaluation with particular attention to the tracheal cuff level.

Management depends on the patient’s clinical condition, the size and location of the defect, and the presence of associated complications. The Cardillo morphological classification stratifies post-intubation tracheal injuries according to the depth of tracheal wall involvement and the presence of associated esophageal injury or mediastinitis, providing a useful framework for selecting conservative vs surgical management.⁵ Nonoperative management may be considered in carefully selected patients with small, contained injuries who remain clinically stable without respiratory deterioration, mediastinitis, or uncontrolled air leakage. This approach includes lung-protective ventilation, adequate chest drainage, supplemental oxygen, antibiotic therapy when clinically indicated, and close clinical and bronchoscopic follow-up.^4,6,10 Surgical repair is generally recommended when conservative management fails or when patients develop persistent or worsening air leakage, progressive subcutaneous emphysema, failure of lung re-expansion, respiratory compromise, mediastinitis, or large airway defects.^10,11 In the present case, persistent air leakage and failure of lung re-expansion despite conservative management supported the decision to proceed with definitive surgical repair.

Based on the lessons learned from this case, several preventive measures may help reduce the risk of DLT-related tracheal injury and delayed recognition. Routine cuff pressure monitoring with a manometer should be performed to avoid excessive cuff pressure, particularly during prolonged procedures. Fiberoptic bronchoscopy should be routinely performed after DLT placement and after patient repositioning to confirm correct tube position. However, because cuff-level injuries may remain occult despite apparently normal bronchoscopic findings, persistent clinical suspicion should prompt repeat bronchoscopic evaluation with particular attention to the tracheal cuff level.^2,8,9 Finally, persistent postoperative air leakage, progressive subcutaneous emphysema, or unexplained atelectasis should prompt early bronchoscopic evaluation.^3,9

This case has several limitations. The precise timing and mechanism of the tracheal injury could not be established, and objective cuff pressure was not measured during either procedure. In addition, the initial bronchoscopic examinations were performed to confirm DLT positioning rather than to systematically evaluate the entire tracheal wall. Although the Cardillo classification provides a useful framework for post-intubation tracheal injuries, a Cardillo level could not be reliably assigned retrospectively because the precise depth and complete extent of tracheal wall involvement were not documented. The factors underlying the timing of surgical repair could not be fully determined retrospectively. Furthermore, no post-repair bronchoscopic assessment of the repaired defect or CT surveillance was available, precluding evaluation of late airway complications such as tracheal stenosis. Finally, as a single case report, these observations cannot be generalized.

Conclusion

Tracheal cuff-level injuries after DLT intubation may remain unrecognized during routine bronchoscopic confirmation of tube position. Careful bronchoscopic inspection of the tracheal wall at the cuff level during DLT withdrawal after cuff deflation may facilitate early detection. Persistent postoperative air leakage, particularly when accompanied by subcutaneous emphysema or failure of lung re-expansion, should prompt early repeat bronchoscopy.

Funding Statement

The authors received no funding for this work.

Ethics Approval and Consent to Participate

Institutional approval was required for publication of this case report. This retrospective case report was reviewed and approved by the Institutional Review Board of Yeungnam University Medical Center (IRB No. YUMC 2026-01-028).

Consent for Publication

Written informed consent was obtained from the patient for publication of the case details and any accompanying images.

Author Contributions

EKC: Conceptualization, supervision, data curation, investigation, data analysis, and writing – original draft, writing – review and editing. MGK: Data curation, data analysis, and writing – original draft. JHB: Supervision, data curation, data analysis, and writing – original draft, writing – review and editing. All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The author(s) report no conflicts of interest in this work.