Endobronchial Obstruction from an Intubation Stylet Sheath

Abstract

Many clinicians intubate newborns using a stylet, but how many always check if the device is intact after use? We describe a case of endobronchial obstruction by a plastic sheath coating the metal stylet, and suggest ways to reduce the incidence of this serious iatrogenic complication.

Extremely Preterm Neonate with a Tracheobronchial Foreign Body: A Case Report

“…Tracheal intubation is a common procedure for neonates in the NICU. In these patients, procedure-related complications are rare but can be severe, often resulting in respiratory compromise as illustrated in this case and other reports [1][2][3][4][5][6][7][8][9]. While it is not clear how the sheath sheared during this patient's intubation procedure, others have reported that repeated bending of the sheath, reuse of a stylet, and excessive grasping of the tube while removing the stylet can result in a sheared fragment of the plastic sheath [1].…”

“…These stylets are often plastic coated to prevent airway injury from the metal end and to facilitate removal after insertion of the ETT. A review of the relevant literature in English yielded nine published reports related to the shearing of the plastic sheath covering intubation stylets in neonates between 1985 and 2016 [1][2][3][4][5][6][7][8][9]. Most cases reported either a partial or complete obstruction of ETT by the sheared portion of plastic coating.…”

“…Stylets are commonly used to facilitate endotracheal intubation of neonates in the delivery room, operating room, and neonatal intensive care unit (NICU). While several types of stylets are available for use, rare complications related to plastic-coated stylets or those covered by a plastic sheath have been reported [1][2][3][4][5][6][7][8][9]. In the majority of the documented cases, the endotracheal tube (ETT) was obstructed by the sheared-off portion of the stylet sheath.…”

A Near Miss: Case Report and Literature Review

“…Case reports are scarce in the literatures but mainly included premature infants intubated with ETT size 2.5 mm, but term infants, ETT size 3 mm, and adult cases have been reported. [1][2][3][4][5][6][7][8][9] We believe the few literature reports may not reflect the true incidence neither the magnitude of the problem. Signs of airway obstruction, persistent respiratory distress, oxygen desaturation, and difficult suctioning of ETT, despite a correct placement of the ETT should alert the physician of possibility of this complication.…”

“…10 Using a forceful withdrawal commonly attributed as a risk factor for the shearing. [1][2][3][4][5][6][7][8][9] The sheared fragment may dislodge or be pushed in further, causing more damage to the airways or pulmonary parenchyma such as pneumothorax. 3 Suctioning of the ETT will be almost impossible in the presence of the obstructing fragment.…”