Lung Collapse in Intubated Patient is not Always because of Tube Factor?

Abstract

Case Summary50 year old male, diagnosed case of Chronic Obstructive Pulmonary Disease (COPD) was admitted to ICU as a case of cellulitis of left lower limb with septic shock and multi-organ dysfunction. On admission, he was managed with intravenous fluids, vasopressor (noradrenaline), broad spectrum antibiotics, nebulisation and mechanical ventilation. Gradually, he showed improvement clinically as well as in laboratory parameters. On fourth day, he became haemodynamically stable, maintaining oxygen saturation on minimal ventilatory support (Pressure Support mode) and was planned for extubation on the next day. But, he developed respiratory distress (respiratory rate 35/minute, use of accessory muscle present) while on Pressure Support Ventilation along with hypoxemia. He was immediately placed on control mode of mechanical ventilation with tidal volume of 350 ml (6 mls/kg) which showed high airway pressures (PIP>40 cm H2O) with every inspiratory effort. Suctioning of the endotracheal tube was done with a 12 Fr Gauge suction catheter by open method which could be negotiated up to the carina with minimal secretions being aspirated with poor cough reflex. Chest auscultation revealed diminished air entry on left side. The position of the tube was re-confirmed with direct laryngoscopy. Chest radiograph revealed collapse of left lung with endotracheal tube in situ and at proper position (Figure 1). In view of whole left lung collapse and worsening hypoxemia, immediately fibreoptic bronchoscopy was done which showed thick mucus plug in the left main bronchus which after toileting was removed, following which left lung fully expanded (Figure 2).