Misdirected minitracheostomy tube.

We report a patient who after an uneventful coronary artery bypass graft surgery and left ventricular aneurysmorrhaphy developed intracerebral hemorrhage and subsequently required minitracheostomy. Chest X-ray showed misdirected minitracheostomy tube facing upward toward the laryngeal opening which was repositioned using bronchoscope.

Introduction

Tracheostomy is one of the most frequently performed surgical procedures on critically ill patients requiring prolonged mechanical ventilation in the intensive care unit. In the majority of cases, tracheostomy is performed as a temporary measure for patients requiring prolonged respiratory support and/or bronchial toilette. Tracheostomy tube placement can be performed via either a traditional open procedure or more commonly now by the percutaneous technique.

Case Report

Minitracheostomy tube is commonly used for the removal of secretions in patients with excessive pulmonary secretions and poor cough efforts.[1] It can also be used for high-frequency jet ventilation in patients with acute airway obstruction or poor respiratory efforts. We describe an obese, male patient (body weight 86 kg, body mass index 33.5 kg/m2) who after an uneventful triple-vessel coronary artery bypass graft surgery and left ventricular aneurysmorrhaphy developed intracerebral hemorrhage and subsequently required minitracheostomy due to obtunded consciousness level, poor cough efforts, and retained tracheobronchial secretions. A percutaneous, flanged, reclosable 4 mm internal diameter tube [Mini-Trach II, Portex, Smiths Medical International Ltd., Hythe, Kent, UK, [Figure 1] was inserted smoothly through the cricothyroid membrane, using Seldinger technique after aspiration of air from the trachea by an experienced operator. Immediate chest X-ray revealed misdirected tube, facing upward toward the laryngeal opening [Figure 2a]. The tube was repositioned using bronchoscope [Figure 2b] and no further untoward event happened.

Figure 1

Portex Mini-Trach II Seldinger Kit

Figure 2

Chest X-ray showing misdirected minitracheostomy tube facing upward (arrows) (a), and normal position (arrows) of the minitracheostomy tube (b)

Discussion

Misplacement of minitracheostomy tube has been described in pleura, paratracheal space, subcutaneous tissues, oropharynx, esophagus, mediastinum, or blood vessels resulting in pneumothorax, subcutaneous emphysema, vocal cord injury, esophageal/mediastinal perforation, or bleeding complications.[23] The case described underlines the importance of the fact that classical method of railroading a minitracheostomy tube over guidewire and introducer may sometimes result in misdirection. It may be advisable to perform direct laryngoscopy or bronchoscopy to ensure that retrograde passage of guidewire, introducer, and hence minitracheostomy tube has not occurred. Aspiration of air may not necessarily indicate correct placement of the minitracheostomy tube. In addition, direction of puncture needle may change during the procedure, resulting in malposition/misdirection of the guidewire. In patients with difficult anatomy (short, thick neck, tissue swelling, goiter, previous neck surgery), assistance of an ENT surgeon or a formal tracheostomy may be required.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.