Lower airway obstruction due to a massive clot resulting from late bleeding following mini-tracheostomy tube insertion and subsequent clot removal and re-intubation

Abstract

BackgroundEasier to perform than the conventional procedure, mini-tracheostomy (MT) is widely used in the operating room or intensive care unit to remove sputum or other obstructions of the upper airway. This option, however, does carry the risk of various complications, including malposition, disposition, bleeding, and subcutaneous emphysema. Here, we report a case of endotracheal tube obstruction due to a massive clot resulting from late bleeding around the insertion site of an MT tube. This necessitated removal of the endotracheal tube together with the clot followed tube re-introduction.Case presentationThe patient was an 85-year-old man in whom an MT tube had been inserted 6 days earlier following aortic replacement surgery. On re-admittance to our intensive care unit, large amounts of hemosputum and clotting were observed around the insertion site of the tube. The MT tube was subsequently removed and tracheal intubation performed. Ventilation via the endotracheal tube proved impossible, however, and cardiac arrest ensued. Fiberoptic bronchoscopy revealed that the endotracheal tube was completely obstructed by a massive clot. Therefore, we immediately pushed the clot toward the right main bronchus to secure ventilation via the left lung. After many attempts to remove the massive clot, including suction and grasping with basket forceps, it was successfully dislodged by replacing the endotracheal tube with a new one while maintaining oxygenation by one-lung ventilation. Any small fragments of the clot that still remained were then removed by suction under fiberoptic bronchoscopy.ConclusionsHere, we report a case of endotracheal tube obstruction due to a clot derived from very late (6 days) bleeding after insertion of an MT tube. The patient was successfully rescued by replacing the clot-bearing endotracheal tube with a new one. This experience suggests that the intensive care physician should be aware of the potential risk of clot retention in endotracheal tubes after the elapse of several days.

Fatal airway obstruction due to a ball-valve clot with identical signs of tension pneumothorax

“…Inoue et al [ 2 ] reported a similar case of endotracheal tube obstruction due to a massive clot resulting from late bleeding with a mini-tracheostomy tube. The patient had received anticoagulants, and the massive blood clot may have formed over several days.…”

“…In clinical settings, tracheal intubation is considered the most reliable airway securing technique for ventilation [1]. Obstruction of the endotracheal tube due to a ball-valve clot is a recognized but very rare complication [2][3][4][5][6][7][8]. A ball-valve obstruction in the airway could function as a check valve for the lung and thorax, resulting in tension pneumothorax-like respiratory and circulatory abnormalities.…”

Retrieval of a tracheobronchial blood clot with a Yankauer suction catheter in complete airway obstruction

“…The obstructing clot may act in a ball-valve mechanism to cause selective expiratory obstruction, which may precipitate as tension pneumothorax or may lead to complete airway obstruction with subsequent hemodynamic collapse and even mortality [1]. The alternative options include tracheal suction, cryoprobe, forceps, fibrinolytic agents, or embolectomy catheter [1][2][3][4]. In this patient, such a sequence precipitated as a life-threatening situation.…”