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Journal of Pediatric Surgery (2013) 48, 456–458

Pneumomediastinum, pneumoperitoneum andpneumothorax following iatrogenic perforation ofbronchus: Successful conservative management of apotentially serious complicationArindam Dastidar⁎

Department of Paediatric Surgery, Christian Medical College Hospital, Vellore-632004, Tamil Nadu, India

Received 7 July 2012; revised 25 November 2012; accepted 27 November 2012

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Key words:Rigid bronchoscopy;Complications

Abstract Rigid bronchoscopy is a standard technique of removing a foreign body from paediatricairway. An iatrogenic airway injury during a bronchoscopy can worsen the existing respiratory distress.This article describes a potentially serious complication which was managed successfully in aconservative manner.© 2013 Elsevier Inc. All rights reserved.

Foreign body aspiration in a toddler is a commonemergency.With advancements in bronchoscopes and optics,removal of airway foreign body has become a safe procedure.Occasionally, due to poor visibility, lack of experience andfaulty techniques, there arises risk of complications [1].

We report here a rare complication during a rigidbronchoscopy which was managed non-operatively.

1. Case summary

A 14 month old child presented with a history of chokingwhile eating peanuts 5 days previously. Subsequently, hedeveloped cough and fever. At the paediatric emergency

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ward, he was found to be irritable and tachypnoeic. Oxygensaturation on room air was between 85% and 90%. Clinicalexamination of the chest revealed decreased air entry andcrepitations bilaterally. Portable chest radiograph showedprominent bronchial markings on the right side.

It was arranged for the child to undergo an emergencyrigid bronchoscopy using the direct visualization technique.Bronchoscopy was being performed by a trainee paediatricsurgeon under the supervision of a consultant. At bronchos-copy, there was copious secretion at the carina. Followingsuctioning, a foreign body was seen partially occluding theright main stem bronchus. This was removed in a singleattempt using a grasping forceps for soft foreign body.

The child was re-intubated with the bronchoscope to lookfor any residual foreign body and for tracheobronchialsuctioning. Going by the protocol in our hospital, at the end ofthe procedure the supervising consultant did the final checkbronchoscopy. While doing this, a full thickness lacerationwas detected on the posterior wall of the left main stem

Fig. 1 Pneumomediastinum, pneumoperitoneum, tracking of airalong the great vessels and a small right apical pneumothorax withcollapse of right upper lobe of lung.

457Conservative management of a complication of bronchoscopy

bronchus just distal to the carina. On clinical examination, thechild had a distended abdomen with obliteration of the liverdullness but no subcutaneous emphysema. The air entry wasnormal on the left side of the chest.

An on-table portable radiograph was taken, which showeda pneumomediastinum, pneumoperitoneum, tracking of airsuperiorly along the great vessels and a small right apicalpneumothorax with collapse of the right upper lobe (Fig. 1).

Initially, we attempted to selectively intubate the rightmain stem bronchus and perform one lung ventilation toallow the tear to seal. But this was not tolerated due to thediseased state of the right lung, which was the consequenceof the foreign body occluding its bronchus.

Continued intubation of the trachea and artificialventilation, we believed, would not have allowed the tearto seal. Hence, the child was given a trial of extubation to seeif he could maintain acceptable oxygen saturation. This wasaccomplished and after confirmation of good air entry in thechest the child was shifted to the paediatric intensive careunit for further management. Frequent monitoring was doneto detect any subcutaneous emphysema or pneumothorax.Chest radiography repeated after 6 hours revealed resolutionof the air leak (mediastinum, peritoneal and pleural cavity)and a normal left lung (Fig. 2).

The child was discharged after 24 hours on an oral broadspectrum antibiotic (amoxicillin–clavulanic acid). At follow-up, four weeks following the bronchoscopy the child wasasymptomatic and had bilateral equal breath sounds.

Fig. 2 Resolution of air leak 6 h following the event.

2. Discussion

A foreign body in the paediatric airway is a lifethreatening situation [2]. Removal of the foreign body by asafely performed bronchoscopy gives instant relief fromrespiratory distress. However, tracheobronchial injury as acomplication of bronchoscopy can worsen the pre-existingrespiratory distress.

Common complications during bronchoscopy are oxygendesaturation, subglottic or laryngeal edema and bleedingfrom the bronchial wall at the site of foreign body impaction.These complications are self limiting and can be managedwith simple maneuvers [2,3].

Serious complications such as perforation of bronchus,mediastinal and subcutaneous emphysema, pneumothoraxand cardiac arrest are relatively rare [2].

An air leak during a bronchoscopy can occur from aperipheral or a central location. Vigorous ventilation orentrapment of air distal to the foreign body can lead torupture of an alveolus and a peripheral air leak. This presentsas a pneumothorax.

Central air leak due to tracheobronchial injury is a seriouscomplication. Faulty technique, poor visibility and a sharpforeign body are the important causes of such injuries.Symptoms of central air leak are, loss of tidal volume

(inability to ventilate), soft tissue or mediastinal emphysemaand pneumothorax. Furthermore, air in the mediastinum cantrack superiorly along the great vessels. It can also trackinferiorly into the peritoneal cavity through the esophagealhiatus in the diaphragm leading to a pneumoperitoneum.

A tension pneumothorax or a tension pneumoperitoneumcan rapidly progress to cardiovascular collapse.

In this child, continued positive pressure ventilationwould have prevented the laceration from sealing spon-taneously. Hence, management of these injuries is best

458 A. Dastidar

determined by assessment of ventilation and the local extentof the injury [4]. Nonoperative management of iatrogenictracheobronchial injuries may be a safe option in patientswith uncompromised ventilation (i.e. no loss of tidalvolume), superficial or sufficiently covered tears andnonprogressive emphysema. Immediate surgical repair re-mains warranted for those patients in whom ventilationcannot be delivered across the laceration [4].

3. Conclusion

Extravasation of air following an iatrogenic tracheobron-chial injury is an alarming, though fortunately a raresituation. Not all such injuries require operative intervention.Ineffective ventilation and findings suggesting worseningemphysema, pneumothorax or pneumoperitoneum should bethe guide to management rather than the radiographic image.

Acknowledgment

I am grateful to Dr Supriya for critically reviewingthe manuscript.

References

[1] Zhijun C, Fugao ZG, Niankai ZK, et al. Therapeutic experience from1428 patients with pediatric tracheobronchial foreign body. J PediatrSurg 2008;43:718-21.

[2] Skoulakis CE, Doxas PG, Papadakis CE, et al. Bronchoscopy forforeign body removal in children. A review and analysis of 210 cases.Int J Pediatr Otorhinolaryngol 2000;53:143-8.

[3] Zerella JT, Dimler M, McGill LC, et al. Foreign body aspiration inchildren: value of radiography and complications of bronchoscopy. JPediatr Surg 1998;33:1651-4.

[4] Schneider T, Storz K, Dienemann H, et al. Management of iatrogenictracheobronchial injuries: a retrospective analysis of 29 cases. AnnThorac Surg 2007;83:1960-4.