Aspiration of a fractured tracheostomy tube, a rare complication of tracheotomy: the factors involved in this incident and literature review

INTRODUCTION

Tracheostomy is executed routinely for several indications. It is a safe and life-saving procedure.

Because of the primary disease, in some cases decannulation cannot be performed and the tracheostomy tube has to be maintained for a long duration.

In case of it maintained for an extended period of time, it requires a regular follow-up to prevent late complications

We report a rare case of aspiration of a fractured tracheostomy tube, which can be potentially life threatening. And in the light of the literature of the last decade, we will analyze the demographic data related to the patients, types of tracheostomy cannulas and the different modalities of care which require a personalized approach.

CASE REPORT

A 5-year-old boy, presenting to the emergency department for aspiration of a fractured outer cuff of the metal tracheostomy tube accidentally during a cleaning process by his mother. The patient tracheostomized four and a half years ago following subglottic stenosis, developed secondary to prolonged intubation for his Guillain barrere disease. He was advised regular follow-up. But the patient failed to follow-up for the last 2 years and was self-cleaning the tube by his mother as instructed by the ENT physician.

On clinical examination, the patient was slightly symptomatic; tachypneic, a little restless with a mild productive cough. A flexible bronchoscopy was made which objectified the presence of the cannula in the trachea, an additional antero-posterior (AP) chest X-ray was taken, which revealed the aspirated tracheostomy tube in the trachea and right main bronchus (Figure 1).

The extraction procedure was as follows- (a) under general anesthesia, the patient was laid supine with the placement of a block under his shoulders and a sterile field was created around the tracheal stoma; (b) the tracheal lumen was accessed through the stoma; (c) introduction of a rigid bronchoscope through his tracheostoma allowed visualization of the foreign body (Figure 2); (d) halstead mosquito curved was introduced into the tracheal lumen to sound for the distal end of the fractured tube; and (e) the halstead was then moved in a cephalad direction.

The postoperative course of the patient remain uneventful.

DISCUSSION

Demographics data

The displacement of tracheostomy tube is considered to be rare, with an incidence of <1/1000 tracheostomy tube, the first case was reported in 1960 by Bassoe et al then the majority of the cases are reported occasionally.^1,2

The analysis of the last cases reported in the literature during this last decade. Table 1 shows: a sex ratio of males to females: 1:7 and ages commonly affected: pediatric population 53.57%. The common underlying pathology: neurological and laryngeal pathology with the same frequency 35.71%.

The clinical presentation

Aspiration of a fractured tracheostomy tube can be potentially life threatening. The classical triad of foreign body aspiration (coughing/choking, wheezing and reduced breath sounds) was present in 75% patients.¹⁹

The analysis of these last reviews of the literature objective the presentation of 75% of cases in a state of respiratory distress hence the interest in preventing this potentially fatal accident.^{3,5,8-11,13-15,17,20,21}

However, the discovery may sometimes be fortuitous, or the patient is almost asymptomatic after inhalation for the other remaining cases.⁶ Standard radiology retains all its indications, given the importance of differential diagnoses of dyspnea and atypical presentation especially in the elderly, this additional examination remains accessible in emergency with a major diagnostic value.

The location of the tracheotomy tube has no elective seat (right main bronchus in half of the cases), linked apparently to the curved shape of the foreign body.

Duration of tracheostomy

The average duration of wearing the tracheostomy tube is 67 months "Five years and half". These explain that prolonged wearing of the tracheostomy tube is the major cause of poor compliance and loss of sight of patients.

Nature of tracheostomy tube and fractured zone

Stagnation of alkaline bronchial secretion, defective manufacturer, recurrence of the process of withdrawal, boiling of the tube, and cleaning can cause mechanical stress and degradation of the passive film of the tubes. Educating the patient about maintenance and regular checking can possibly prevent this complication.²³

Currently, there is a common use of metallic tracheostomy tubes for extended tracheostomy, and these relate to ease of use and cleaning, they are formed by the following different metallic products: silver, zinc, nickel, copper, and, stainless steel.^24,25 It is recommended to place only pure silver tubes in patients requiring a long-term tracheotomy, because the silver tracheostomy tube appeared free of corrosion on electron microscopic examination Nevertheless the literature suggests that on prolonged use, silver tubes might fracture in comparison to those made by stainless steel.^{17,19,23,25,26} The analysis of the literature in the Table 1 found that 34.48% of patients were carriers of a plastic tracheostomy tube (Romson polyvinyl chloride) and the rest of 65.52% were carriers of a metallic tube. The common fractured zone was the junction between the neck plate and the tube, in more than 86% of patients. And this fractured zone, has no relationship to the nature of the tracheostomy tube.

The management

Rigid bronchoscopy is the preferred procedure for removal of large foreign bodies in approximately 75%.^{3,5,6,9-11,13-15,17,19,20,22} A rigid bronchoscope tube has a large bore which provides adequate ventilation and allows insertion of various types of instruments for operating.

Rigid bronchoscopy was used for removal of fractured metallic tracheostomy tube in most previously reported cases. Insertion through the tracheostomy stoma is the preferred route in order to prevent mechanical injury by the fractured tube to the vocal cords and oral cavity during removal.

In general, rigid grasping forceps is used for removal; however, in our case the proximal end of the tube was severely corroded, and might be broken during grasping.

Thoracotomy or bronchotomy was not required.

CONCLUSION

In conclusion, we reported a rare complication of a metallic TT. Bronchoscopic removal of the fractured tube is feasible and causes less injury to the airway wall. Appropriate cleaning, routine careful examination, and scheduled replacement of the tracheostomy tube may help prevent this complication.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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