Occlusive Tight Strapping for Tracheostomy Decannulation; Is it Safe?

Abstract

Decannulation following tracheostomy is an important transition. Subcutaneous emphysema (SE) following decannulation has been rarely reported. We, herein, report a case of massive subcutaneous emphysema following decannulation of a short-term tracheostomy, discuss the various decannulation methods and causes of SE. We report and hypothesize the tight occlusive dressing method for tracheostomy decannulation to be the possible cause of SE in the present case.

Introduction

Subcutaneous emphysema, pneumomediastinum or/and pneumothorax following tracheostomy is a known entity; however very little reports exist regarding its occurrence during decannulation. We, herein, report a case of massive subcutaneous emphysema following decannulation of a short-term tracheostomy following difficult airway management.

Case Report

A fifty-four-year old female weighing 98 kg was scheduled for laparoscopic-assisted vaginal hysterectomy under general anaesthesia (GA). Patient was morbidly obese (BMI 34) with anticipated difficult airway. Patient was accepted for surgery under ASA physical status I. Following routine induction of anaesthesia, on laryngoscopy Cormack-Lehane grade was III (i.e. only epiglottis visible) and two intubation attempts by a senior anaesthesiologist failed. Thereafter, ventilation got difficult and oxygen saturation dropped to 78%. Emergency tracheostomy was done. Following resumption of spontaneous respiration, patient developed ventricular premature contractions and surgery was abandoned. Patient shifted to ICU. For the first two days in ICU, the patient intermittently required oxygen via a tracheostomy mask following which maintained on room air. On day 6, endoscopy revealed normal vocal cord mobility following which tracheostomy tube (TT) was downsized to 6.5 mm with corking. The patient did not tolerate and cork was removed. Another trial with corking next day i.e. on day 9 provided better response and TT was removed. Strapping with a tight occlusive dressing was done over the tracheostomy site as an institutional protocol. Within four hours, subcutaneous emphysema (SE) was noted around the tracheostomy site, neck region, peri-orbital region, upper chest with crepitus on palpation (Fig. 1). Soon, patient complained breathlessness and the occlusive strapping was removed and 6.5 size TT was inserted. Chest and neck X-ray were suggestive of SE (Fig. 2). Her emphysema slowly resolved after 4 days and was shifted to ward. In ward following abrupt decannulation this time, patient discharged on day 8.

Fig. 1.

Subcutaneous emphysema on the face, neck and chest (Note: Occlusive dressing)

Fig. 2.

Chest X ray PA view, neck AP view and lateral view

Discussion

Massive SE after removal of a tracheostomy tube with closure by secondary intention is a rare complication. In the present case report the TT site was tightly strapped as a part of decannulation. We attribute two reasons for SE. Firstly, the tracheal injury at the time of tracheostomy or while downsizing of TT on day 6 of ICU. Secondly, air leak between the subcutaneous planes of neck tissues during forced inhalation or coughing resulting in SE extending to upper chest and neck (Fig. 3). Unlike the present case, the susceptibility for SE is more common after prolonged tracheostomy (approx.12 months) due to the formation of trachea-cutaneous fistula (TCF) [1], or during the surgical closure of a TCF [2] or routine surgical closure of tracheostomy [3]. Hence the evidence is more favorable for the second reason.

Fig. 3.

Hypothetical or potential air tracks leading to subcutaneous emphysema following forced inhalation or coughing through occlusive dressing over tracheostomy site

The various indications for tracheostomy include acute respiratory failure requiring prolonged mechanical ventilation, failure to wean from mechanical ventilation, copious secretion, upper airway obstruction, and difficult airway. Out of all aforementioned indications, in tracheostomy for difficult airway, the decannulation is expected after a short period.

There has been no universal decannulation protocol especially after short-term tracheostomy. The prerequisite for successful decannulation include intact sensorium, coordinated swallowing and protective coughing. These are usually not a concern while dealing with the decannulation of patients on short-term tracheostomy like in the present case. The adopted method of decannulation is variable. Various decannulation methods are TT occlusion after downsizing to fenestrated or non-fenestrated tube, capping of the TT without downsizing and abrupt remove of the TT (3). Corking trial is often used as a decannulation technique with short term tracheostomy; whereas, downsizing and blocking is recommended method with long term ventilation [4]. The choice of method also depends upon the physician’s experience and patient’s tolerability.

Posterior tracheal wall laceration/TCF is a common mechanism for SE, pneumomediastinum and pneumothorax following tracheostomy [4]. However, on literature search, only two case reports have reported SE/pneumomediastinum following decannulation and both were following surgical decannulation [3, 5]. Lazzarrato et al. have reported SE and pneumomediastinum following the tight surgical closure [3] and the other paediaric case has reported it following surgical tracheostomy closure [5]. On the contrary, in this case, the possibility of tracheal injury is meagre, and we attribute the forced inhalation or coughing through the tight occlusive strapping to be the potential cause of SE.

Conclusion

We hypothesize the tight occlusive dressing method for tracheostomy decannulation to be the cause of SE and emphasize upon its cautious use. There is a growing need to formulate specific decannulation protocol for short term tracheostomy and an increasing need to understand the various practices of tracheostomy decannulation in ICU by the intensivists also.

Authors Contributions

Conception and Drafting of manuscript.

Funding

No funding has been taken from any source.

Declarations

Ethical Approval

Not applicable.

Informed Consent

Informed consent was taken from the patient.

Conflict of Interest

Not applicable.