INTRODUCTION: We present an uncommon case of acute hypoxemia in the early post-percutaneous tracheostomy placement period
CASE PRESENTATION: This is a 38 year-old male referred to our institution for management of pneumonia with acute respiratory failure. His past medical history is relevant for tobacco use, alcoholism, severe malnourishment, alcoholic hepatitis and congenital esophageal atresia corrected surgically at birth. He was initially admitted to an outside hospital for management of alcohol withdrawal, developed an aspiration pneumonia which resulted in acute respiratory failure requiring mechanical ventilation. After 18 days of mechanical ventilation and a failed extubation, a percutaneous tracheostomy was placed under the guidance of flexible bronchoscopy without any immediate complications. Few hours after placement, the patient developed an episode of acute hypoxemia with inavility to ventilate or pass a suction catheter through the tracheostomy tube; therefore, the tracheostomy tube was removed and oral intubation was performed with complete resolution of the acute event. Post intubation flexible bronchoscopy did not reveal any mucus plug, blood clots, or airway obstruction to explain the acute event. Examination of the removed tracheostomy tube was normal with a patent lumen without any defects. Four days later, a second tracheostomy was placed again under direct flexible bronchoscopy guidance without any immediate complications. Another episode of acute hypoxemia developed within few hours again with inability to ventilate or pass a suction catheter through the trachesotomy tube. The tracheostomy was removed, the patient was re-intubated orally with resolution of the acute event then transported to the operating room for an urgent rigid bronchoscopy. Careful examination of the airway revealed a posterior mid tracheal blind pouch measuring 1 cm in length where the tracheostomy tube was getting trapped leading to the above mentioned events. A hyperflexible adjustable flange long tracheostomy tube (120 mm in length) was placed under direct visualization with the tip secured 1 cm above the carina and the tracheostomy cuff inflated inferior to the tracheal pouch. The patient had no further events and he was successfully extubated few days later.
DISCUSSION: Congenital esophageal atresia and tracheoesophageal fistula are common congenital anomalies affecting 1 in 2,400 to 4,500 life births and are corrected surgically.(1,2) Long term respiratory complications include cough, tracheomalacia, and recurrence of the tracheoesophageal fistula. Little is known about the risk of developing posterior tracheal pouches following traumatic intubations or tracheostomy and its association with the history of esophageal atresia repair.
CONCLUSIONS: In the setting of acute life threatening hypoxemia following a percutaneous tracheostomy, bronchoscopic evaluation is required after the airway is secured to evaluate for underlying causes including possible anatomical airway defects.
Reference #1 Harmon CM,Coran AG(1998) Congenital anomalies of the esophagus.O′Neill JA, Jr Rowe MI, Grosfeld JL, eds.Pediatric surgery,941-967.Mosby.St.Louis,MO
Reference #2 Kovesi T, Rubin S (2004) Long-term complications of congenital esophageal atresia and/or tracheoesophageal fistula. Chest.2004Sep;126(3):915-25
DISCLOSURE: The following authors have nothing to disclose: Antonio DeGorordo Arzamendi, Ali Ashraf, Ryan Chua, Reda Safieddine, Samaan Rafeq
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