Acute life-threatening airway obstruction with pseudomembrane formation after percutaneous dilational tracheostomy

摘要

A 67-year-old woman underwent transoral resection of squamous cell carcinoma on the base of the tongue. Before surgery, a preventive percutaneous dilational tracheostomy (PDT) (Ciaglia Blue Rhino Percutaneous Tracheostomy Introducer Set + Tracoe~R Twist Tracheotomy Tube; William Cook Europe, Bajaeverskov, Denmark) was performed with bronchoscopy, which was repeated at the end of surgery to ensure airway patency. Four days later, she was admitted to the intensive care unit with signs of acute airway obstruction. Arterial oxygen saturation measured by pulse oximetry was 55%. The patient had ventricular tachycardia runs due to uncorrected hypoxaemia and acidosis, with a heart rate of 190 beats/minute. Oxygen and antiarrhythmic therapy were started. Chest X-ray showed the tracheostomy tube in the midline, but not inserted far enough to be secure (Figure 1). A suction catheter was unable to be passed through the tracheostomy tube; we then successfully rotated the tube to bring the distal tip safely away from the tracheal wall. Distal obstruction of the tracheostomy tube was seen with bronchoscopy (Figure 1). After removal of the tube, bronchoscopy showed the presence of a grey membrane which completely obstructed the airway (Figure 1). It was removed with forceps and this resulted in a sudden improvement of the patient's symptoms. The tracheostomy tube was changed for a longer silicon-armoured tube with an adjustable flange. Bronchoscopy and X-ray examination showed the correct positioning of the silicon-armoured tube.