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

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.