Case of the Month

Tracheostomy is a commonly performed procedure indicated for facilitation of prolonged ventilatory support, relief of upper airway obstruction and management of secretions. Postoperative complications may arise and are associated with significant morbidity and mortality₁. It has been shown that health care professionals lack knowledge in the management of displaced tracheostomy tubes.²

A 68-year old male presented to the Emergency Department with a progressively enlarging right neck mass, new dyspnea, dysphagia, and hoarse voice. Imaging showed a 6 x 6 x 9 cm lobulated mass within the right thyroid lobe with leftward laryngeal displacement, substernal extension and tracheal invasion with concern for aggressive thyroid neoplasm causing airway obstruction. He was scheduled for thyroid biopsy and tracheotomy. 

After topical application of the oropharynx with Lidocaine 1%, a fiberoptic intubation was performed with the patient awake to secure the airway. An uncomplicated general anesthetic was administered, and the patient tolerated the procedure well. He was discharged from the hospital on post-operative day (POD) 7 with a Bivona 7 TTS tracheostomy tube.

On POD 12, the patient returned to the emergency department with shortness of breath, increased secretions, cough and inability to suction his tracheostomy tube. Bedside tracheoscopy showed crusting in the tube and copious secretions concerning for obstruction. The patient’s respiratory status began to decline, so BiPAP was initiated and the patient was emergently brought to the operating room.

Under Monitored Anesthesia Care with midazolam and dexmedetomidine, the tracheostomy tube was exchanged for a Bivona Hyperflex. No end-tidal CO₂ was noted on capnometry. Absence of end-tidal CO₂ persisted after the Bivona was replaced with at 6.0 endotracheal tube. Given concern for formation of a false passage and worsening respiratory status, preoxygenation and was performed in anticipation of fiberoptic intubation. Simultaneously, a fiberoptic bronchoscope was inserted into the tracheal stoma and maneuvered until the tracheal lumen was seen. A 6.0 ETT was passed over the scope into the trachea, and end-tidal CO₂ was confirmed on capnometry. A flexible bougie was inserted through the endotracheal tube. The ETT was exchanged for a Bivona Hyperflex, and end-tidal CO₂ was re-confirmed. The tracheostomy tube was visualized in the airway via fiberoptic scope through the oropharynx. The tracheostomy tube was secured, and the patient was returned to the Medical ICU in stable condition. 

DISCUSSION

The reported incidence of tracheostomy tube displacement varies greatly, but typically ranges from 0.35-2.66%.¹  Though rare, inadvertent displacement carries a 25-100% mortality rate.¹ Risk factors for displacement include obesity, poorly secured tubes, excessive coughing, agitation or undersedation, and ill-fitting tracheostomy tubes. Decannulation in the early post-operative period predisposes tissue planes to collapse, and may lead to loss of airway. Therefore, tube exchange should not be attempted until stomal maturation, often cited between 6-10 days post-operatively⁽²⁾ . Displacement may not always be immediately apparent, especially if airway obstruction is incomplete. Patients may present with respiratory distress and inability to pass a suction catheter. When a tracheostomy tube is lost before stomal maturation, no attempts at replacement should occur and the airway should be secured by trans-oral intubation. Should inadvertent dislodgment occur after stomal maturation, one blind attempt may be made to replace the tube. Subsequent attempts have been shown to create and enlarge false passages². Instead, the stoma should be examined to see if the tracheal lumen can be seen and adjunct equipment like tube exchangers, bronchoscopes, or suction catheters may be used as guidewires to facilitate tracheostomy tube insertion. A failed technique should not be repeated. However, if inadequate ventilation or oxygenation persists, the priority becomes securing the airway through oropharyngeal intubation. The tracheostomy tube may be replaced or revised in a more controlled environment such as the operating room.

CONCLUSION

Inadvertent decannulation is a rare but potentially life-threatening complication of tracheostomy. The priority remains reestablishing an airway whether though oropharyngeal intubation or endoscopy-guided tracheostomy tube replacement.

REFERENCES

1. Cipriano A, Mao ML, Hon HH, et al. An overview of complications associated with open and percutaneous tracheostomy procedures. Int J Crit Illn Inj Sci. 2015;5(3):179–188. doi:10.4103/2229-5151.164994
2. Morris L, Afifi S. Tracheostomies: A Complete Guide. Springer Publishing Company, 2010. 
3. Fernandez-Busy S, Mahajan B, Folck E, et al. Tracheostomy Tube Placement Early and Late Complications. Journal of Broncology & Inverventional Pulmonology. 2015;22(4)357-356. doi: 10.1097/LBR.0000000000000177