Tear of the Windpipe

Tracheal Tear

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Article Written by Dr. Daniel A. Degner, Board-certified Veterinary Surgeon (DACVS)

Key Points

By far the most common cause of a tracheal tear is iatrogenic, meaning that the cuff (balloon) at the end of the tube literally pops the trachea.

Cats more commonly develop tracheal tears.

Most of the tracheal tears that are iatrogenic can be treated conservatively, and will seal on their own with no specific treatment.

Surgery is indicated only if the trachea is not healing and continues to leak large amounts of air under the skin and in the chest or if the patient has severe breathing difficulty.

Anatomy

The windpipe or trachea is a tube that passes air from the back of the throat to the smaller airways in the lungs called bronchi. This tube is composed of multiple cartilage, C-shaped rings. The open part of the C-shaped cartilage is covered with a membrane and thin muscle. It is the incomplete rings and membrane roof of the windpipe that gives the trachea lot of flexibility. The trachea anatomically consists of the cervical part that is in the neck and the thoracic part that is within the chest cavity.

 

What is a tracheal tear?

Most of the tears of the trachea are along the edge of the membrane-cartilage ring junction (along the side of the roof). By far, most of the tracheal tears are due to iatrogenic trauma from an endotracheal tube. This tube is a breathing tube that is passed into the windpipe while the patient is under general anesthesia.

Causes of a tracheal tear from an endotracheal tube include overinflation of the cuff of the endotracheal tube, removing the endotracheal tube from the windpipe before the cuff has been deflated, moving the patient while the endotracheal tube is inflated, and chemical burns of the windpipe from chemical disinfection of the endotracheal tube.

If the endotracheal tube is inflated too much, the blood supply to the windpipe in the area of the cuff is dramatically decreased which could lead to necrosis (tissue death) of the tissue membrane, which could result in a tear. Because these tears are noted frequently just after anesthesia likely the tears are more mechanical in nature.

Excessive ventilation pressure (i.e. the pop-off valve is left closed during anesthesia) could literally pop the windpipe like a balloon popping.

In spite of taking every precaution possible, sadly, tracheal tears are inevitable in some cases.

Noniatrogenic causes of tracheal tears includes foreign bodies, cancer and parasitic granulomas that weaken the tissue of the windpipe.

 

Diagnosis

Most tracheal tears are noted following a dental cleaning The common sign of this is the development of air pockets under the skin. The pet owner may note that the skin "crackles" when they stroke their companion over the back and neck. Additional signs may include coughing, difficulty breathing, shallow rapid breathing, anorexia and lethargy. Signs that a veterinarian may also find include dehydration, rapid heart rate, rapid shallow breathing, gagging, coughing, drooling and fever. The diagnosis of a tracheal tear is often based on the history of having a recent general anesthesia with intubation of the airway and the presence of air under the skin. A definitive diagnosis is made by examining the trachea with an endoscope (camera on a tube) or by surgically exploring the trachea for a tear. Take note that even endoscopy of the trachea can miss a tear.

Radiograph below shows: 1. Air in retroperitoneal space (abdomen); 2. Air under skin of the lower abdomen; 3. Air in heart sac; 4. Air under skin over the shoulders

 

 

 

Treatment

Most tracheal tears can be treated with conservative measures. This includes, confining the patient to a cage, administering pain medication, oxygen support if the patient has difficulty breathing and placement of an active drain system to remove air from beneath the skin. A drain is usually not needed in most cases, as the air will get resorbed with time. If the patient has a tear in the cervical region, a bandage could be applied to the neck; the problem however, is that the location of the tear is generally not known in most cases. If the patient has a tear of the trachea within the chest and air is escaping into the chest cavity, a chest tube may be needed. The indications for surgery include severe breathing difficulty and rapid and progressive accumulation of air under the skin.

 

Prognosis

The prognosis for patients that sustain a tracheal tear is generally excellent. In one study of 20 cats with tracheal tears, 15 were successfully managed with medical treatment alone and 5 needed surgery due to severe breathing difficulty.

 

References

1. Kästner SB, Grundmann S, Bettschart-Wolfensberger R. Unstable endobronchial intubation in a cat undergoing tracheal laceration repair. Vet Anaesth Analg. 2004 Jul;31(3):227-30.

2. Hudson LC: Respiratory system, in Hamilton WP (ed): Atlas of Feline Anatomy for Veterinarians. Philadelphia, WB Saunders, 1993, pp 137-141.

3. Dyce KM, Sack WO, Wensing CJG: The respiratory apparatus, in Textbook of Veterinary Anatomy, ed 2. Philadelphia, WB Saunders, 1996, pp 159-161.

4. Reiss AJ, McKiernan BC: Laryngeal and tracheal disorders, in Wingfield WE, Raffe MR (eds): The Veterinary ICU Book. Jackson Hole, WY, Teton NewMedia, 2002, pp 606-607.

5. Hardie EM, Spodnick GJ, Gilson SD, et al: Tracheal rupture in cats: 16 cases (1983-1998). JAVMA 214:508-512, 1999.

6. Mitchell SL, McCarthy R, Rudloff E, et al: Tracheal rupture associated with intubation in cats: 20 cases (1996-1998). JAVMA 216:1592-1595, 2000.

7. Ko J: Anesthesia tips 1-2-3. Atl Coast Vet Conf Proc:2005.

8. Ko J: Anesthetic mishaps. Atl Coast Vet Conf Proc:2005.

9. King LG: Ventilator-induced complications: Recognition, prevention, and management. Int Vet Emerg Crit Care Symp Proc:2005.

10. Nelson AW: Lower respiratory system, in Slatter D (ed): Textbook of Small Animal Surgery. Philadelphia, WB Saunders, 1993, pp 780-803.

11. White RN, Burton CA: Surgical management of intrathoracic tracheal avulsion in cats: Long-term results in 9 consecutive cases. Vet Surg 29:430-435, 2000.

12. Krahwinkel DJ: Tracheal trauma. Atl Coast Vet Conf Proc:2004.

13. Macintire DK, Drobatz KR, Haskin SC, Saxon WD: Respiratory emergencies, in Troy DB (ed): Manual of Small Animal Emergency and Critical Care Medicine. Philadelphia, Lippincott Williams & Wilkins, 2005, pp 124-125, 143.

14. Suter PF, Lord P: Trauma to the thorax and airways, in Suter PF (ed): Thoracic Radiography, A Text Atlas of Thoracic Disease in the Dog and Cat. Wettswil, Switzerland, Peter F. Suter, 1984, pp 127-159.

15. Krake AC, Arendt TD, Teachout DJ: Cetacaine-induced methemoglobinemia in domestic cats. JAAHA 21:527-534, 1985.

updated 9/11/11

Frequently Asked Questions After Surgery - General Information

When should my cat have the first bowel movement after surgery?

  • Many cats will not have a bowel movement for the first 4 to 5 days after surgery
  • Reasons that a cat will not have regular bowel movements after surgery include:
    • The cat has been fasted prior to surgery
    • Cats do not eat well during the hospital stay
    • They frequently do not eat well when the go home
    • They are fed highly digestible food that produces little stool
    • Pain medication that contain narcotics (such as fentanyl patches, tramadol, morphine) can be constipating
  • If a pet does not have a bowel movement on the 5th day of being home a stool softener such as metamucil can be fed
    • Dose of metamucil 1/4 tsp per mixed in with each meal (canned cat food)

My cat had surgery and will not eat.  What can be done?

  • Offer smelly foods that contain fish such as tuna or smelly cat foods
  • Try Gerber strained meats for babies such as the chicken, beef, turkey or veal
  • Hand feeding;  place a small amount of food in the mouth so that they get the flavor
  • Warm the food slightly in a microwave as the food will be more aromatic; remember to stir the food before feeding and test the temperature with your finger; it should  be only luke-warm.
  • Some cats will only eat dry food, try kibble if your cat normally has been fed that food
  • Petting and stroking your cat frequently will help to stimulate appetite
  • Remember that most pets will not eat the first day or two after they get home from surgery
  • Appetite stimulants such as cyproheptadine may be helpful
  • If your cat refuses to eat anything for 7 days a stomach tube should be placed to provide nutrition so that a serious liver problem (hepatic lipidosis) does not develop

My cat is vomiting now that he/she is at home.  What can be done?

  • The first thing for you to discern is whether your pet is vomiting or regurgitating.  Both will result in fluid or food being brought up.  Vomiting always will have heaving or retching of the abdomen prior to expulsion of the vomitus.  Regurgitation is not associated with heaving and the cat usually just opens the mouth and fluid or food will be expelled.  Usually the regurgitant will be clear or brown colored fluid. 
  • Next is to identify the cause of the vomiting or regurgitation.
  • Causes and treatment of vomiting after surgery
    • When some pets return home after a stay in the hospital they may drink excessive amounts of water at one time and then vomit; if this appears to be happening the water should be limited to frequent smaller amounts.
    • Medications such as antibiotics are a common cause of vomiting after surgery.  In order to see which medication is causing the problem the administration of each drug should be separated 2 hours apart.  Usually the pet will vomit or appear nauseated (drooling and sick look) within 1 hour of administration of the medication that they are sensitive to.  The antibiotic in some cases may be changed to a different one, or may be discontinued. 
    • Stomach upset from anesthesia is a potential cause of vomiting and will pass within a couple of days. 
    • Unusual cause of vomiting after surgery is internal organ failure.  Blood testing will confirm this problem. For this reason vomiting should not be ignored if it persists for more than 24 hours.
    • If your pet had surgery of the bowels or stomach, vomiting is always a concern, as it may indicate that infection of the abdominal cavity, called peritonitis, is present.  Do not ignore this sign.
    • Symptomatic treatment of vomiting involves with holding food for 12 to 24 hours, then introducing small amounts of bland food such as rice and lean cooked hamburger, if your pet does not vomit after that then.  In order to decrease the acidity of the stomach Pepcid AC 0.5 mg/kg given by mouth twice daily for 5 days can sooth an upset stomach.  Metoclopramide is a good anti-vomiting medication for cats.  You should always consult a veterinary healthcare professional before administering medication.
  • Causes and treatment of regurgitation after surgery
    • The most common cause of regurgitation is reflux of acid from the stomach into the esophagus while your pet is under anesthesia.  Acidic fluid from the stomach can cause a chemical burn of the esophagus and result in a bad case of heart burn, which is called esophagitis.  This results in poor motility of the esophagus so water and food will accumulate in this structure.  In most cases esphagitis is self-eliminating and will resolve within two or three days. 
    • Regurgitation also can be caused by a neuromuscular degeneration of the esophagus and this problem will persist.  It is not associated with surgery, rather other underlying diseases.
    • If the esophagitis is severe the esophagus may develop one or more strictures.  A stricture is a narrowing or stenosis of the esophagus, does not allow passage of food down the esophagus, thus the pet has persistent regurgitation.  This problem should be brought to the attention of your doctor within the first two weeks so that it can be treated by ballooning the stricture (minimally invasive procedure as it is done with the aide of an endoscope).  If an esophageal stricture is chronic surgery is needed.
    • Symptomatic treatment of regurgitation caused by esophagitis includes feeding bland food, and administering a coating agent such as sucralfate.  You should consult a veterinary health care professional if the regurgitation continues for more than a couple of days.

How do I know that my cat is in pain following surgery?

  • Pain is more difficult to assess in cats versus dogs as signs can be more subtle and they usually do not vocalize
  • Signs of pain in a cat include the following:
    • biting if you get near the surgical site
    • growling or deep cry
    • not wanting to eat
    • hiding and not wanting to be near owner (remember that this could also be caused by the cat just being upset about leaving home and coming back)

What can be done for pain at home for my cat?

  • Pain medication such as buprenorphine or a Duragesic (fentanyl) patch
  • Tylenol will kill a cat as they lack abundant glutathione enzyme in the liver
  • Anti-inflammatories can be used, but the dose is much less than dogs and they should be given only for a few days

Is it okay for my cat to lick or scratch the incision?

  • If a cat licks the incision it will actually delay the healing process because they usually lick too much and traumatize the area.
  • Cats have a barbed tongue, therefore a lot of damage can be done in a short period of time
  • Licking can remove stitches and cause the incision to open
  • Licking can become a severe habit that is difficult to break
  • Licking can cause infection as the mouth has many bacteria
  • Cats will frequently lick the incision when the owner is not watching such as at night time; if the skin looks red or excoriated the most common cause is from licking.
  • To stop your pet from licking/scrtaching the following can be tried:
    • Elizabethan collar can be placed on the neck; this will not help stop your pet from scratching at the region
    • Cervical collar (bite not collar) is a less awkward device and can be effective at stopping a pet from licking the surgical site
    • If the incision is over the chest an infant tee shirt can be put on your pet and the waist of the shirt fastened in place with an ace bandage or duct tape.
    • If the incision is over the paw or lower limb a bandage or sock could be put on and kept up with tape.
    • Bitter apple can be applied around the incision; many dogs will continue to lick  after application of this topical
    • Bitter Apple and Liquid HeetTM (obtain this from a drugstore...it is used for sore muscles) mixed in a 2:1 ratio can be applied around the skin incision
    • Antipsychotic medication in some cases is needed

Board-certification by the American College of Veterinary Surgeons

What does it mean?

  • Four years of advanced training in surgery beyond the Doctor of Veterinary Medicine Degree

  • Experience in the development of new surgical treatments

  • Rigorous examination by the American College of Veterinary Surgeons to ensure competency in advanced surgical techniques

  • Assurance that a veterinarian is a surgical specialist

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