Iatrogenic Pneumomediastinum With Hemomediastinum Induced by Tracheostomy Tube Malposition

Abstract

INTRODUCTION: Tracheostomy tube provides airway access for mechanical ventilation. The tube can be changed safely at bedside, which simple procedure sometimes results in serious complications unless adequate attention is given. CASE PRESENTATION: A 55 year old paraplegic man was transferred from a nursing home for possible obstruction of his tracheostomy tube that was placed 5 months ago when he developed acute respiratory failure after motor vehicle accident. Patient had been receiving antibiotics due to fever for unknown duration and the staff at a nursing home failed to introduce suction catheter aimed to clear secretions vi a tracheostomy tube, which prompted transfer. When seen in our facility, patient was breathing spontaneously and speaking in full sentences without any distress. He reported subjective fever and chill, otherwise the rest of review of system was negative. On physical examinations, vital signs were BP 112/68 Pulse 135 RR 24 Oxygen saturation 100% in ambient air and temperature 101degreeF. Tracheostomy tube was in place with collar. Suction catheter did not pass through the tracheostomy tube with and without inner cannula in place, suctioning only a small amount of brownish secretions. Inner cannula was inspected to be clean and non-obstructed. Chest exam revealed bilateral mild rhonchi. Laboratory work ups were remarkable for leukocytosis with left shift. Portable X ray of the chest showed tracheostomy tube located outside next to trachea, which finding raised suspicion of tracheostomy malposition. Chest CT scan was performed for further evaluation and demonstrated tracheostomy tube with tip within the superior mediastinal soft tissues, not entering the trachea (Panel A). Extensive pneumomediastinum and high density air fluid level in the superior mediastinum suggestive of a mediastinal hematoma were also noted (Panel B). There was no evidence of tracheal rupture. Tracheostomy tube was removed and 5cc of viscous bloody fluid was obtained with CT guided drainage. Patient maintained oxygen saturation after decannulation and clinically improved with broad spectrum antibiotics for possible mediastinitis. DISCUSSION: Universally accepted indications for tracheostomy tube change do not exist. It is routinely changed periodically at bedside(1). This case alarms physicians that serious malposition of the tracheostomy tube could happen during the change even when the tracheostomy tract is fully formed and encourages extra attention should be paid. CONCLUSIONS: Careful management of tracheostomy tube during the change procedure can not be overemphasized.