Section 4Treatment issues
A recognised risk of intubation The outcome
A 37-year old fit and healthy man was admitted The MDU obtained expert advice from an anaesthetist
for arthroscopy of his hip. The patient had who was of the view that a small degree of damage to
undergone previous anaesthetics with no the tracheal lining probably occurred during insertion of
problems. He was warned of some of the common the endotracheal tube. This damage was exacerbated
complications associated with anaesthesia and the when the patient developed upper airway obstruction
procedure. following removal of the tube.
The anaesthetist administered general anaesthesia and When the patient attempted to breathe in against the
proceeded to intubate the patient. On laryngoscopy obstruction this created negative pressure in the airways,
there was a full view of the larynx and the tube was which is a recognised cause of post-operative pulmonary
inserted between the vocal cords under direct vision. oedema. Attempts to breathe out against the obstruction
The patient was monitored appropriately and his pulse resulted in a rise in pressure within the large airways and
and blood pressure remained stable throughout the this led to tearing of the tracheal lining in an area of
lengthy 3-hour procedure. pre-existing damage. The expert felt that it was unlikely
The patient’s trachea was extubated at the end of the
there was a major tear present during the operation as
procedure, an oropharyngeal airway was put in place
positive pressure ventilation would have forced air out
and high flow oxygen was given via a facemask.
through the tear and into the surrounding tissues
causing surgical emphysema that would have been
However, on arrival in recovery a few minutes later, the evident on chest x-ray.
patient developed difficulty in breathing and the oxygen
saturation reading was low at 70%. There were no
In the expert’s view, superficial damage to the lining of
obvious signs of upper airway obstruction but
the trachea during intubation is a recognised risk and
examination of the chest revealed evidence of
does not indicate substandard care by the anaesthetist.
pulmonary oedema and this was confirmed on chest
The problem in this case occurred because the patient
x-ray. The anaesthetist's working diagnosis was that the
developed upper airway obstruction during the recovery
patient had developed pulmonary oedema, either
period. This too is a recognised risk, which cannot be
because of airway obstruction following extubation or
entirely eliminated, even with good post-operative care.
due to absorption of the irrigation fluid that had been Absorption of a large volume of irrigation fluid was also
used by the surgeon during the procedure. considered as a possible cause of the pulmonary oedema,
The patient was treated with diuretics, bronchodilators
but given the patient’s youth, the expert felt he would
and adrenaline nebulisers, and transferred to the
have been able to cope with any irrigation fluid absorbed
intensive care unit.
from the joint during the procedure. In his opinion,
therefore, negative pressure pulmonary oedema was the
The following morning the patient was examined with a more likely mechanism.
fibre-optic bronchoscope and this revealed a tear at the
back of the trachea, just below the larynx. Further
In the light of the supportive expert opinion, liability was
imaging of the chest showed abnormal shadowing
denied on the part of the anaesthetist which led to the
consistent with pulmonary oedema, but no evidence of
successful rebuttal of the claim by the MDU.
pneumothorax or surgical emphysema.
The patient's condition slowly improved and he was
discharged a few days later. However he complained for
some months of shortness of breath walking up stairs.
The anaesthetist member received a letter from the
patient’s solicitor seeking compensation for his
prolonged stay in hospital and pain and suffering.
“…the patient developed upper
airway obstruction during the
recovery period…”
28
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