To the Editor:—Recently, a 60-yr-old woman presented to our emergency department with the complaint of an inability to insert the inner cannula of a metal tracheostomy apparatus. Her tracheostomy had been placed in 1985 after a cerebral vascular accident. The patient had been managing her own tracheostomy care since the placement of a permanent tracheostomy. On examination, the patient was breathing normally and had no signs of acute respiratory distress. On inspection of the tracheostomy apparatus, it was found that the outer cannula was missing although the retention plate was well secured around the patient's neck. Chest x-ray revealed the outer cannula lodged in the right mainstem bronchus with the distal end 2 cm below the carina (Figure 1). Both lung fields were well aerated with no evidence of atelectasis or pneumothorax. In the operating room after routine anesthesia preparation, the stoma was anesthetized with Cetacaine topical spray, and the cannula was easily removed with a foreign-body forceps. A new #6 tracheostomy tube was inserted after careful inspection of the stoma.
Figure 1. Chest x-ray showing outer cannula of tracheostomy apparatus lodged in right main stem bronchus.
Figure 1. Chest x-ray showing outer cannula of tracheostomy apparatus lodged in right main stem bronchus.
A metal tracheostomy apparatus often is incompatible with anesthesia circuit connectors, requiring anesthesiologists to substitute disposable plastic cuffed endotracheal tracheostomy tubes to allow positive pressure ventilation. At this point, our specialty can have some impact in reducing potentially fatal complications of the tracheostomy apparatus, such as that described above. After removal from the patient, every metal tracheostomy apparatus should be inspected for signs of wear, corrosion, and hairline fracture, especially at the junction of retention plate and tubular components. If a metal tracheostomy tube has been in use for many years, it may be prudent to replace it, thereby circumventing the possibility of fracture. It seems plausible to prevent this complication with regular inspection and replacement of the metal tracheostomy apparatus.
Claude Brunson, M.D., Mahesh Mehta, M.D., Department of Anesthesiology, University of Mississippi Medical Center, Jackson, Mississippi 39216.
(Accepted for publication October 6, 1994.)
