Broken tracheostomy tube: A fractured mandate

Abstract

Tracheostomy is a common airway procedure for life support. This procedure is safe, although occasional early and late complications are known to occur. Fracture and hence aspiration of a tracheostomy tube in the tracheobronchial tree is a rare late complication, which can be potentially life threatening. Published reports of a fractured tracheostomy tube presenting as a foreign body in the tracheobronchial tree are few. The most common dislodged sites reported were the trachea and the right main bronchus, the inner flange in our patient was lodged in the trachea and the left main bronchus. Foreign-body aspiration is a serious medical emergency demanding timely recognition and prompt action as was successfully done in our patient. Therapeutic rigid bronchoscopic removal is the mainstay of treatment. A periodic review of the techniques of tracheostomy care including timely check-ups for signs of wear and tear can possibly eliminate such avoidable late complications.

INTRODUCTION

Tracheostomy is a common airway procedure for life support. This procedure is safe, although occasional early and late complications are known to occur. The troublesome late complications include tracheostomal stenosis, erosion of the innominate artery, and tracheoesophageal fistula. Fracture and hence aspiration of a tracheostomy tube in the tracheobronchial tree is a rare late complication, which can be potentially life threatening. Published reports of a fractured tracheostomy tube presenting as a foreign body in the tracheobronchial tree are few.[1–4] We promptly diagnosed and successfully managed a similar case in an elderly laryngectomized patient and share our experience.

CASE REPORT

A 60-year-old male patient presented to our outpatient, a day after noting the missing inner flange of his metallic tracheostomy tube following a violent bout of cough. Six years prior, he had undergone a total laryngectomy with adjuvant radiotherapy for carcinoma larynx. (Stage pT4aN0M0) He was on regular follow-up for the initial four years and was being conservatively managed for a concentric stenosis, which developed following a tracheostomal granuloma. He was intermittently using a metallic (stainless steel) tracheotomy tube through his permanent tracheostomy stoma.

On arrival, the patient had occasional cough with labored breathing, his vital signs were normal. Auscultation of the chest revealed decreased breath sounds on the left side. A subsequent X-ray of the chest clearly outlined the metallic density of the inner tube, lodged partly in the trachea and partly along the left main bronchus [Figure 1]. He was immediately shifted to the operating room for a rigid bronchoscopic removal under general anesthesia. The inner flange of the tracheostomy tube was retrieved from the left main bronchus and removed through the tracheostomy stoma with the aid of a long foreign body forceps [Figure 1]. A fracture at the junction between the inner tube and neck plate was found. [Figures 2 and 3]. He was discharged the following day following a complete recovery.

Figure 1.

Chest X-ray clearly outlined the metallic density of the inner flange, lodged partly in the trachea and partly along the left main bronchus

Figure 2.

Bronchoscopy demonstrating the fractured inner flange of the metallic tracheostomy tube

Figure 3.

The fractured inner flange of the metallic tracheostomy tube following rigid bronchoscopic removal

DISCUSSION

Various objects have been reported as overlooked foreign bodies in the tracheobronchial tree. The first case report of a fractured metallic tracheostomy tube was in 1960 by Bassoe and Boe,[1] since then, this complication has been published in medical literature periodically. The largest series of fractured tracheostomy tubes reported to date by Gupta in 1987[2] was of nine cases reported over a period of about 8 years. Patients are usually misdiagnosed as having chronic respiratory ailments before the definite diagnosis is made.

The composition of tracheostomy tubes range from metal, poly vinyl chloride to silicone. The metallic tubes can be washed and boiled and are hence more suitable for prolonged use. Traditionally, metallic tracheostomy tubes were made from silver, copper or zinc, all of which were prone to corrosion by the alkaline tracheal secretions; modern metallic tracheostomy tubes are made from stainless steel, which are supposed to be less corrosive and less likely to fracture. Despite this a majority of the cases of fractured tracheostomy tubes reported in literature have been metallic.[5]

A number of factors predispose to fracture of one of the flanges of the trachesotomy tube. The so-called weak points of the tracheostomy tube are the junctions between the tube and the neck plate, the distal end of the tube and the fenestration site.[4–6] The most common reported fracture site is at the junction between the tube and the neck plate. Prolonged usage leading to the wear and tear of the tubes have been proposed as the major risk factor for tracheostomy tube fracture.[3–6] Manufacturing defects, continued high internal stresses on the tube surface and alkaline tracheobronchial secretions have also reported as causes of this complication.[2–6] The fracture of the tracheostomy tube in our patient was most likely due to prolonged wear and tear as evidenced by the corrosion of the surface of the tube. The most common dislodged sites reported were the trachea and the right main bronchus,[5] the inner flange in our patient was lodged in the trachea and the left main bronchus.

The fractured tracheostomy tubes dislodged into the tracheobronchial tree may produce acute or chronic respiratory symptoms . Air hunger and dyspnoea are the common presenting symptoms in the acute phase. In cases where in the diagnosis is overlooked and the tube remains quiescent, the presenting symptoms are milder, such as occasional coughing and wheezing leading to patients being erroneously treated for common respiratory ailments like asthma, pneumonia, or chronic bronchitis.[2–7] The prolonged stay of a foreign body in the bronchial tree can lead to irreversible pulmonary changes[8] due to mechanical pressure effects, chemical reactions and at times can lead to even malignant transformation.

In most cases, the diagnosis is obvious in a chest radiograph.[2] Computed tomography of the chest with virtual bronchoscopy is helpful in ascertaining the exact position of the fractured fragment in relation to the tracheobronchial tree in long standing cases especially when associated chest disease is suspected.

Foreign-body aspiration is a serious medical emergency demanding timely recognition and prompt action. Therapeutic rigid bronchoscopic removal is the mainstay of treatment[6] since a larger foreign body such as a metallic tracheostomy tube may not be retrievable with a flexible bronchoscope. In cases where in the fractured fragment is lying just below the tracheostomy stoma, removal under direct vision is possible. Bronchoscopic removal of large aspirated objects in general is an arduous task because most conventional instruments are unable to gain a firm and wide grasp of solid objects and the attempts may at times be more locally traumatic than therapeutic. A relieving incision at the site of a narrow tracheotomy opening may be required in some instances; this was however not required in our patient. Lung parenchyma sparing surgery involving tracheobronchotomies constitutes a final, definitive option for retrieval of the offending tracheotomy tube in instances following failed bronchoscopic attempts.[2]

A periodic review of the techniques of tracheostomy care[9] including timely check-ups for signs of wear and tear can possibly eliminate such avoidable late complications.