Posterior tracheal wall leading to life-threatening obstruction of tracheostomy tube
A 28-year-old male patient with severe traumatic brain injury (diffuse axonal injury with cerebral edema on magnetic resonance imaging) was admitted to the intensive care unit (ICU) in unconscious state Glasgow coma scale = 8: E2 M5 VT, with endotracheal tube in situ. In ICU, he was placed on mechanical ventilation (MV). Because of persistent poor neurological status, on the 5th day, a surgical tracheostomy was carried out with standard portex TT of 8.0 mm internal diameter. He was given daily intermittent spontaneous breathing trial by T-piece. On the 4th day of post-tracheostomy while the patient was on T-piece, he developed sudden tachypnea and tachycardia. With each inspiration and expiration an audible sound like vocalization was heard from inside the TT, which was heard despite fully inflated cuff. He was immediately placed on MV, which showed high peak inspiratory pressures (PIP) >40 cm H2O with every inspiratory effort. Positive pressure ventilation with Bain circuit was also not possible. Suction of the tracheostomy tube was carried out, which could be negotiated up to the carina with no secretions being aspirated. However, the high PIP with spontaneous inspiration did not subside and the audible sound continued. Immediate fiber optic bronchoscopy revealed indrawing of the posterior tracheal wall into the TT with each inspiratory effort causing almost complete closure of TT. This was causing a flap such as mechanism leading to audible sound and the high PIP. Ventilation with Bain was also not possible due to indrawing of the posterior tracheal wall and blockage of the TT during patient's own inspiration. Immediately, TT was removed over a bougie and replaced with 7.5 mm cuffed TT. Post-insertion, fiber optic bronchoscopy revealed patent tracheal lumen, PIP dropped and audible sound vanished. Inspection of TT cuff revealed elliptical deformity of the cuff leading to the lumen of TT facing posterior tracheal wall and deep inspiratory efforts lead to the indrawing of the posterior wall into the lumen causing airway blockade.