|LEARNING CASE REPORT
|Year : 2014 | Volume
| Issue : 1 | Page : 32-35
Pneumopericardium - an unusual complication of broken tracheostomy tube presenting as foreign body trachea
Jayita Poduval, F Benazir, Preety Ninan
Department of Ear, Nose and Throat, Pondicherry Institute of Medical Sciences, Kalapet, Puducherry, India
|Date of Web Publication||22-Sep-2014|
D-2-7, Jawaharlal Institute of Postgraduate Medical Education and Research Campus, Dhanvantari Nagar, Puducherry - 605 006
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Foreign bodies in the trachea may be of various kinds and usually present as acute respiratory emergencies, which if not treated expediently, may prove fatal. A broken tracheostomy tube is an unusual foreign body and defeats the purpose for which a tracheostomy is done, namely to facilitate breathing. We present here yet another similar case, but with an impending pneumopericardium, and suggest remedial measures, along with a review of literature.
Keywords: Foreign body, tracheobronchial tree, tracheostomy tube
|How to cite this article:|
Poduval J, Benazir F, Ninan P. Pneumopericardium - an unusual complication of broken tracheostomy tube presenting as foreign body trachea
. J Laryngol Voice 2014;4:32-5
| INTRODUCtION|| |
Tracheostomy is a procedure done for the purpose of facilitating a patent airway. Foreign bodies in the tracheobronchial tree occur due to accidental aspiration during various activities, especially if there is a lesion in the airway or incompetence of the vocal cords. In cases where these foreign bodies are due to a broken part of a tracheostomy tube, the signs and symptoms depend on the size and position of the portion aspirated. A broken tracheostomy tube is an unusual foreign body and defeats the purpose for which a tracheostomy is done, namely to facilitate breathing. Transoral bronchoscopy or tracheoscopy is done for the removal of tracheobronchial foreign bodies including broken tracheostomy tube. We present here a case with a previously unreported complication and suggest remedial measures.
| Case report|| |
A 5-year-old-boy presented to the Accident and Emergency Department of our hospital with sudden cough and difficulty in breathing while playing. He was a known case of bilateral abductor cord paralysis with subglottic stenosis, diagnosed at birth, and tracheostomized at 1 month of age. After the initial tracheostomy, he was discharged with a size 3 Portex uncuffed tube, which was subsequently changed to an age-appropriate double lumen metal tube on two recorded hospital visits, at age 8 months and 2 years, respectively.
The family was extremely poor and visits to the hospital were infrequent, mainly necessitated by an attack of respiratory tract infection. Except for the times that tube changing was carried out, the patient was not seen in the ENT department. Even when the tubes were changed, corrective surgery for the laryngotracheal disorder was not suggested, probably in view of the socio-economic condition of the family and possibly lack of facilities.
At the time of presentation, the child was on a size 16 fenestrated Jackson's tube and only the flange was found attached to the neck with tapes. An anteroposterior chest radiograph revealed the tubular portion of the (outer) tube in the trachea [Figure 1]. The mother admitted to having been using only the outer tube, the inner tube discarded long back! Attempts by the casualty medical officer at suctioning the broken portion out through the stoma only caused more agitation to the child, pushing the tube further down into the trachea, aggravating the respiratory distress. An emergency rigid bronchoscopy with a size 4 ventilating bronchoscope was carried out to remove the broken tube, after widening the stoma slightly, as attempts to remove it through the existing stoma with a smaller bronchoscope proved unsuccessful. Furthermore, due to the unavailability of a similar sized tracheostomy tube at that time, the patient was temporarily intubated with a size 4 uncuffed endotracheal tube which was anchored to the neck with a single stitch with the remaining length of thread tied around the neck.
Over the next few hours, the child developed subcutaneous emphysema of the neck, face and chest wall, which quickly progressed to pneumopericardium, leading to heightened distress, sweating, and visible pallor [Figure 2]. The pulse rate was slightly increased at this point. The thread around the neck, although loosely tied, was cut immediately and a head-low position was given along with supplemental oxygen at 2 litres per minute, the mother constantly reassuring and trying to pacify the child. Slowly but surely, the emphysema settled down without occurrence of further complications.
Next day, a size 18 Fuller's tube was inserted into the stoma after removing the endotracheal tube [Figure 3]. With a short course of antibiotics and mucolytics the child rapidly recovered and was discharged 2-3 days later. Advice for timely review was again neglected, except for a visit after roughly a month for a new attack of respiratory tract infection. Suggestions for corrective surgery have also not been taken seriously and the patient as of now is lost to follow-up.
|Figure 3: X-ray day 2 showing resolution of pneumopericardium and new tracheostomy tube in situ|
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| Discussion|| |
Tracheostomy is a simple life-saving procedure done for the purpose of relieving obstruction, in respiratory insufficiency, for tracheobronchial toilet and for prevention of aspiration. It may be done as a temporary measure in any of these indications, or may be a permanent procedure if the primary lesion is not amenable to medical or surgical correction. In the majority of cases, corrective treatment is possible, but in many cases, multiple surgeries may be required, and the patient may be non-affording or non-compliant, or both. In these cases, a tracheostomy tube is worn by the patient at all times, and home care is explained to the patient and the family.
The tubes recommended for domiciliary care are metal tubes like Jackson's or Fuller's, or in recent times, the uncuffed Shiley tubes. Periodic review is always advised. 
Chronic disease, poor literacy and educational levels and adverse socio-economic conditions are responsible for patients neglecting the advice of caregivers and not using the tube properly, as in removing the inner tube and discarding it after some time, thus wearing only the outer tube. This would eventually lead to weakening and fracture of the outer tube due to loss of support and muscular movements of the neck.  This fact also accounts for such accidents occurring more commonly in males.  Also, patients may be mistakenly diagnosed with a chronic respiratory ailment before the actual culprit is found.
The earliest generation of metal tubes were made of pure silver, which after the first reported incidence of tube fracture from Norway, were found to have manufacturing defects in the form of microcrystalline cracks; they were therefore discontinued, apart from being rather expensive. A fractured metal tracheostomy tube was first reported in 1960 by Bassoe and Boe,  and similar cases have been published from time to time. Gupta reported the largest series of fractured tracheostomy tubes in 1987,  of nine cases over a period of 8 years.
Later modifications using alloys of copper, zinc and silver also proved to be susceptible to the corroding effects of respiratory mucus, and breaches were common at the junction of the flange or neck and the tubular endotracheal segment. , The use of polyvinyl chloride (PVC) for manufacturing tubes was also not viable owing to the release of toxic substances and tube disintegration on boiling or sterilization with hot water or chemicals. ,
Stainless steel is preferentially used in metal tracheostomy tubes made nowadays, and even though these are supposed to be less corrosive and less likely to fracture, most cases of fractured tracheostomy tubes reported in literature have been metallic. 
The most common reported fracture site is at the junction between the tube and the neck plate, and the most common sites for dislodgement reported are the trachea and the right main bronchus. 
Silicone tubes for home care, such as Shiley tubes, are expensive and beyond the reach of many patients, especially in developing countries. Metal tubes are much cheaper and affordable for most patients, even if frequent changing is carried out. As the child grows, th e tube becomes relatively smaller for the child's needs, and must be changed accordingly. Continued use of the same tube in a growing child increases wear and tear of the tube.
Foreign bodies in the tracheobronchial tree occur due to accidental aspiration during eating, drinking, laughing and playing, especially if there is a concomitant lesion in the larynx or trachea or incompetence of the vocal cords. Foreign bodies range from organic material like seeds and nuts to inanimate objects like pins and screws or parts of toys and other objects. In general, organic foreign bodies, apart from causing obstructive symptoms, also incite an intense mucosal inflammatory reaction, making the obstruction worse and interfering with lung function.
In the case of foreign bodies due to a broken part of a tracheostomy tube, the signs and symptoms depend on the size and position of the broken portion. A tubular piece lying in line with the airway would allow the patient to breathe and cause only alarm and anxiety, with a little cough; another which lies horizontally and blocks the lumen of the trachea could be rapidly fatal. 
In neglected or missed cases where a foreign body stays in the bronchial tree for a prolonged period, irreversible pulmonary changes  may occur due to mechanical pressure effects and chemical reactions; this could lead to even malignant transformation.
Plain X-rays of the neck and chest in anteroposterior and lateral views are mandatory not only to confirm the presence of the foreign body but also to assess the status of the lungs.  Computed tomography of the chest with virtual bronchoscopy may help to ascertain the exact position of the fractured fragment in relation to the tracheobronchial tree in long standing cases especially when associated chest disease is suspected. 
Transoral bronchoscopy or tracheoscopy through the stoma, with sedation and local anaesthesia or general anaesthesia with a ventilating bronchoscope, is done for the removal of tracheobronchial foreign bodies, including broken tracheostomy tube. In many cases, the existing stoma needs to be widened because the patient might have already outgrown the tube, as was necessary in this case. Tracheobronchotomy may be needed for retrieval of an offending tracheotomy tube where bronchoscopy has failed. 
It is unfortunate that a straightforward procedure to save life can turn into a complicated problem that imperils life, in some instances. Since, in spite of the best efforts of healthcare workers, non-compliance is common among patients, alternative remedies could be explored. A few suggestions are:
- Stringent quality control of metal tubes-German silver (60% copper, 20% nickel, 20% zinc) or stainless steel, and defining an expiry date
- A modified design where the shaft of the tube fans out into the collar instead of a separate joint being created
- 2 sets of inner tubes so that a new one can be inserted as soon as the one in use is removed for cleaning, or using two separate complete sets at each cleaning session.
A valvular mechanism whereby the outer tube gets blocked as soon as the inner tube is removed, thus necessitating the immediate use of an inner tube, could be explored, though this might require some very innovative engineering!
Along with the above, heightened awareness and education campaigns must be instituted in hospitals where tracheostomy is carried out, and these should be directed to-
- Patients that need to be on life-long tracheostomy-in these cases a permanent stoma can be created which would be wide enough to avoid a tracheostomy tube
- Doctors and healthcare workers in all disciplines so as to provide adequate and correct advice to patients on home care
- Timely referral to specialist ENT surgeons in order to address the primary disorder in the airway, if any.
Increased public funding and public-private partnerships must be encouraged to facilitate complex surgical procedures to correct airway disorders. Specialized laryngology units and infrastructure to recognize and treat difficult laryngotracheal problems could facilitate earlier decanulation or avoid tracheostomy altogether in patients who otherwise end up with a permanent tracheostomy.
| Acknowledgment|| |
Head of Department Dr. Balasundaram D for support and encouragement.
| References|| |
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|4.||Bassoe HH, Boe J. Broken tracheotomy tube as a foreign body. Lancet 1960;1:1006-7. |
|5.||Gupta SC. Fractured tracheostomy tubes in the tracheobronchial tree: A report of nine cases. J Laryngol Otol 1987;101:861-7. |
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|7.||Piromchai P, Lertchanaruengrit P, Vatanasapt P, Ratanaanekchai T, Thanaviratananich S. Fractured metallic tracheostomy tube in a child: A case report and review of the literature. J Med Case Rep 2010;4:234. |
|8.||Hagipour A, Khan ZH. Fracture and aspiration of metallic tracheostomy tube. Saudi Med J 2007;28:468. |
|9.||Krishnamurthy A, Vijayalakshmi R. Broken tracheostomy tube: A fractured mandate. J Emerg Trauma Shock 2012;5:97-9. |
[Figure 1], [Figure 2], [Figure 3]