Introduction: Modern low-pressure, high-volume
cuffed tracheotomy tubes have been shown to decrease tracheal injury.
However, injury still occurs in patients requiring prolonged mechanical
ventilation and prevents weaning, delays decannulation, prolongs
hospitalization, and may totally obstruct the airway. We describe 37
patients, including the first reported case of failure to wean due to
Methods: Over a 3-year
period, from September 1994 to August 1997, the hospital records of 37
patients requiring prolonged mechanical ventilation (> 4 weeks) and
found to have tracheal obstruction were reviewed retrospectively. They
were a subgroup of 756 patients admitted to hospitals during the same
period. The average endotracheal/tracheostomy cannulation time was 3
weeks/12 weeks (range 2 to 4 weeks/8 to 14 weeks). Average age was 76
years (range, 34 to 81). Underlying diseases included COPD,
postcoronary artery bypass graft surgery, postpneumonectomy, severe
pneumonia, acute lung injury, and ischemic heart disease.
Results: All 37 patients who initially failed to wean had
difficulty in breathing and developed intermittent high peak airway
pressures either early or during the weaning process or just on being
ventilated. The insertion of a longer tracheal tube bypassed the
obstruction, reestablished the airway, decreased peak airway pressures,
and allowed the patient to breathe more easily. The obstruction was
confirmed on bronchoscopy. Treatment consisted of either placement of a
longer tracheal tube (34 of 37 patients) or placement of a tracheal
stent. All but two of the patients (5.4%) were able to be weaned
within a week. The two patients who still failed to be weaned were
subsequently diagnosed as having amyotrophic lateral sclerosis.
Conclusion: Tracheal obstruction in patients requiring
prolonged mechanical ventilation prevented weaning. Reestablishment of
the airway with a longer tracheal tube or tracheal stent allowed most
of the patients to be weaned.