Introduction
The word tracheotomy derives from two Ancient Greek words: the word trachea (Greek tracheiaogy) and the word stoma (Greek stoma) meaning ‘‘mouth,’’ and refers to the making of a semi-permanent or permanent opening and placing a tracheostomy tube to provide appropriate ventilation for patient.1 It is a common airway procedure for life support.
Although the procedure is safe with a mortality rate of less than 5%,2 morbid complications which may occur are categorized into early and late. Early complications are hemorrhage, pneumothorax, tracheostomy tube obstruction, and infection at the stoma site. While the stomal granulations, stenosis, innominate vessel damage, and tracheoesophageal fistula are common late complications.3 The complication with the lower airway foreign body may result from a fracture of the tube. Metallic tracheostomy tubes were often used in patients in the past. The tubes were known to undergo corrosion, fracture, and dislodgement of distal segments in the lower airway. Few case reports highlight this drawback of prolonged usage of metallic tubes, but PVC tubes are less prone to fracture.
Here, we report an unusual case of a 45-year-old male with a broken large piece of PVC tracheostomy tube as a foreign body in the trachea & right main bronchus. This case highlights that even PVC tubes may undergo wear and tear with prolonged usage, which makes them brittle.
Case Summary
A 45-year male came to our hospital emergency with complaints of breathlessness for 7 hours following aspiration of fractured PVC tracheostomy tube after a fall in the field. The patient was tracheotomized 27 years back with a history of laryngeal edema following inhalation of toxic gas while cleaning a well. The patient failed to follow up with an ENT specialist for a long time and used to clean the tube by himself with no supervision of the health care worker. A few years back due to financial problems, the patient refabricated and stitched the flanges of his tracheostomy tube and was continuously using the same tube for the last 6 years.
The patient presented to emergency with mild productive cough with no respiratory distress/stridor. On examination, the patient was having tachypnea and maintaining saturation of 94% on room air & his other hemodynamic parameters were stable. B/L Chest was clear on auscultation.
Postoperatively, the patient was hemodynamically stable. The evaluation of the upper airway tract was normal with no signs of residual disease/edema or any other pathology obstructing the upper airway, thus we planned for decannulation and surgical closure was done after 2 days.
Discussion
There have been a variety of foreign bodies, being reported in the tracheobronchial tree. A fractured tracheostomy tube is rare, further that too of PVC is even rarer. A tracheostomy tube broken and migrated in the distal airway can be a life-threatening emergency requiring precise and prompt management.
The first case published in the medical literature of a fractured tracheostomy tube was in 1960.1 Gupta in 1987 reported a series of fractured tracheostomy tubes, distally migrated in 9 cases.3 The most common reported fracture site, in a metallic tube, is at the junction between the tube and the neck plate.4 The most common etiology was the corrosion with saliva, over prolonged usage. The commonest site of displaced tube lodgement was the trachea and the right main bronchus.5
Figure 1
Chest X-ray PA view showing broken tracheostomy tube in the right main bronchus and distal trachea.
Figure 2
The endoscopic view of broken and distally migrated PVC tracheostomy tube- note the ragged margin.
Figure 3
A: & B: The picture showing both the distal and proximal fragment of the broken PVC tube- note the color change, ragged margin at the breakpoint, and the repaired flanges.
Chest X-ray PA view clinches the diagnosis in most cases, with such a large foreign body.6 In doubtful cases, computed tomography with virtual bronchoscopy is helpful. 6, 7
A foreign body in an airway is an emergency, requiring prompt action. In our case, since the distally migrated PVC tube was hollow, the patient had no respiratory distress or lung field changes. The small foreign body may be retrieved with the small jaw forceps of the fiberoptic bronchoscope, but the large tube, as in our case required rigid bronchoscopy and stout forceps to grasp and pull the same out. Also in our case, the presence of tracheostome, allowed bronchoscope to be introduced from it, making the task more direct and easier.
Conclusion
Patients with tracheostomy tubes should be educated about this potential complication. The tubes should be periodically checked and old worn out replaced, at the earliest. Bronchoscopy via tracheostome is easy, quick, and carries fewer complications.
Declaration
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Data Availability Statement
Previously reported [case reports, case series, and review articles as mentioned in references] data were used to support this study and are available at [DOI]. These prior studies (and datasets) are cited at relevant places within the text as references (#-#)
