Obostrani pneumotoraks kao komplikacija perkutane traheotomije: prikaz slučaja

Abstract

Percutaneous dilatational tracheostomy is a common surgical procedure that is becoming the method of choice in critically ill patients whenever prolonged airway secure and/ or ventilation support is needed. Although adverse events are relatively uncommon, serious life threatening complications can arise from this bedside procedure. We report a case of a 70-year-old female who developed extensive subcutaneous emphysema and bilateral pneumothorax immediately after a percutaneous dilatational tracheostomy procedure. Different mechanisms, such as damage to posterior or anterior tracheal wall, false passage or paratracheal placement or dislocation of the cannula are considered to be responsible for the development of pneumothorax and subcutaneous emphysema. Although bronchoscopic control after the tracheostomy procedure did not reveal any tracheal injury, we believe that subcutaneous emphysema and bilateral pneumothorax are most likely caused by procedure induced injuries of the trachea in addition to the applied high airway pressure induced by excessive or inappropriate ventilation. In our case report, we would like to emphasize that continuous bronchoscopic guidance during percutaneous tracheostomy is invaluable in decreasing the incidence of its overall complications, especially during enhancing the team experience.Perkutana dilatacijska traheotomija je učestali kirurški zahvat koji postaje metodom osiguravanja dišnoga puta u kritičnih bolesnika i bolesnika na dugotrajnoj mehaničkoj ventilaciji. Iako su popratni učinci relativno rijetki, metoda je vezana uz mogućnost nastanka za život opasnih komplikacija. Prikazujemo slučaj 70-godišnje žene kod koje je došlo do razvoja opsežnog potkožnog emfizema i obostranog pneumotoraksa neposredno nakon izvođenja perkutane traheotomije. Različiti mehanizmi kao što su oštećenje stražnjeg ili prednjeg zida dušnika, lažni prolaz ili paratrahealno postavljanje ili dislokacija kanile mogu se smatrati odgovornim za nastanak pneumotoraksa i potkožnog emfizema. U našem prikazu slučaja, iako nakon perkutane traheotomije bronhoskopskim pregledom nije nađeno oštećenje dušnika, smatramo da je uzrok nastanka potkožnoga emfizema i obostranog pneumotoraksa najvjerojatnije procedurom nastala ozljeda dušnika i primjena visokog tlaka u dišnim putovima izazvanog prejakom ili neodgovarajućom ventilacijom. Ovim prikazom slučaja željeli bismo naglasiti važnost bronhoskopske vizualizacije tijekom izvođenja perkutane traheotomije u prevenciji nastanka mogućih komplikacija, osobito u razdoblju usvajanja ove kliničke vještine