Bougie-associated bronchial injury complicated by a nephropleural fistula after percutaneous nephrolithotomy: a tale of two complications

Abstract

We present a case of bronchial injury following bougie-assisted endotracheal intubation in a patient with difficult airway scheduled to undergo right percutaneous nephrolithotomy under general anaesthesia. The patient developed pleuritic pain along with right pleural effusion on the third postoperative day which was diagnosed by the anaesthesiologist who was following up the patient for airway trauma-associated complications. However, the patient was diagnosed to have a nephropleural fistula, a rare complication of supracostal access to percutaneous nephrolithotomy, which was managed successfully.

Comparison of the new flexible tip bougie catheter and standard bougie stylet for tracheal intubation by anesthesiologists in different difficult airway scenarios: a randomized crossover trial

“…Anyhow, a reduction of a few seconds in any manner doesn't seem to be clinically relevant. Although not investigated in this study, the endotracheal tube may encounter resistance when railroaded over the bougie, and therefore makes intubation over the bougie more difficult [26,27]. Airway perforation and soft tissue damage are important clinical concerns, although there is limited published evidence to support [28].…”

2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway

“…Observational studies reported intubation success ranging from 87 to 100% of patients (Category B3-B evidence ), 240–242 and case reports observed intubation success with bougies and stylets (Category B4-B evidence ). 243–248…”

“…Observational studies reported intubation success ranging from 87 to 100% of patients (Category B3-B evidence), [240][241][242] and case reports observed intubation success with bougies and stylets (Category B4-B evidence). [243][244][245][246][247][248] Videolaryngoscopes. Meta-analyses of randomized controlled trials comparing video-assisted laryngoscopy with direct laryngoscopy in patients with predicted difficult airways reported improved laryngeal views, a higher frequency of successful intubations, a higher frequency of first attempt intubations, and fewer intubation maneuvers with video-assisted laryngoscopy (Category A1-B evidence); [249][250][251][252][253][254][255][256][257][258][259] findings for time to intubation were equivocal (Category A1-E evidence).…”

Iatrogenic postintubation tracheal perforation in a patient with acute asthma exacerbation complicated with subcutaneous emphysema, pneumomediastinum, pneumopericardium, pneumothorax and pneumoperitoneum

“…Iatrogenic tracheal lacerations, although rare, carry substantial morbidity and mortality, underscoring the imperative of timely diagnosis to prevent clinical deterioration 2. Tracheal introducers, despite aiding in endotracheal intubation, have been reported with potential airway injuries to pharynx, oesophagus, bronchus, trachea and lung 2–5. In our case, inadvertent advancement of the less flexible bougie during difficult endotracheal tube placement likely led to tracheal perforation.…”