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Severe airway compromise after percutaneous dilatational tracheostomy

Introduction

Percutaneous dilatational tracheostomy (PDT) is considered a safe alternative to open surgical tracheotomy, with comparable complication rates. Major complications are reported to be <1.5%, with a mortality rate of 0.3% [1].

Methods

A 52-year-old male was admitted to our ICU following craniotomy for an intracranial hemorrhage. Prior history revealed hypertension and morbid obesity (BMI 46).

PDT was performed on the fourth day after intubation, because of persisting low Glasgow Coma Score and failure to clear secretions. PDT was performed with a Seldinger technique. With bronchoscopic guidance, endotracheal placement was confirmed. Initial airway pressure was high, but normalized quickly. Although oxygenation was maintained, saturation was 84% at the end of the procedure.

Results

After 3 days a subcutaneous swelling occurred around the tracheostomy tube (TT), compromising the airway. An abscess was expected but could not be confirmed by stab incision or CAT scan. A rise of airway pressure with loss of tidal volume was seen in the next hours. On oral and transtracheostomy bronchoscopy, a diffusely swollen larynx with narrowing of the proximal trachea was seen. The TT was exchanged for a Bivona TT.

On retrospection, the CAT scan revealed a dislocated cuff visualized as a double bubble. This was caused by tissue swelling, gradually enlarging the distance between skin and trachea. In this morbid obese patient, the standard TT was too short and dislocation could occur. A second CAT scan confirmed an adequate position of the Bivona TT. After 1 week, a TT with increased skin-to-trachea length was inserted and the patient was successfully weaned from ventilation.

Conclusion

Since the complication rate is increased when performing a PDT in the obese [2], we suggest the following. First, PDT should be guided by fiberoptic bronchoscopy. Second, a TT of adequate diameter and length should be used. Inadequate skin-to-trachea length of the TT can result in improper placement with cuff dislocation not necessarily resulting in air leak with ventilation. An experienced team should perform the procedure: one person doing a bronchoscopy, another placing the TT.

References

  1. 1.

    Marx WH, et al.: Chest. 1996, 110: 762-766. 10.1378/chest.110.3.762

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    Byhahn C, et al.: Anaesthesia. 2005, 60: 12-15. 10.1111/j.1365-2044.2004.03707.x

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Bos, A., Cleffken, B. & Breedveld, P. Severe airway compromise after percutaneous dilatational tracheostomy. Crit Care 12, P336 (2008). https://doi.org/10.1186/cc6557

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Keywords

  • Morbid Obesity
  • Glasgow Coma Score
  • Tracheostomy Tube
  • Percutaneous Dilatational Tracheostomy
  • Fiberoptic Bronchoscopy