Failure of a Tracoetwist™ tracheostomy tube

Abstract

The Tracoetwist™ tracheostomy tube (Tracoe Medical GmbH, distributors Kapitex Healthcare Limited, Wetherby, West Yorkshire, UK) consists of outer and inner tubes. Unlike many other tracheostomy tubes, the inner tube locks into the outer and has the 15-mm connector for the ventilator tubing attached directly to it. Consequently, the ventilator can not be directly attached to the outer tracheostomy tube. The inner tube design is such that the locking mechanism and 15-mm connector are formed from one piece of polyurethane and are linked to the inner tube by a locking flange (Fig. 3). We report an incident of separation of the two components of the inner tube with potentially life-threatening consequences. The inner tube design. A young female with cystic fibrosis, with a previously successful bilateral lung transplant, re-presented to our Critical Care with bilateral pneumonia and respiratory distress requiring intubation and ventilation. After a protracted period of ventilation, percutaneous tracheostomy was performed to facilitate weaning. This was uneventful and a size 8.0 Tracoetwist™ was inserted. Two weeks after tracheostomy insertion, the anaesthetist was called urgently. During routine nursing care, the 15-mm connector with the ventilator tubing and the locking mechanism had become separated from the inner tube which had remained within the outer tube. The senior sister present had maintained some ventilation by holding the two pieces of the inner tube together, but a significant leak and loss of Positive End Expiratory Pressure had occurred. The inspired oxygen concentration was increased to 100% and, with tight approximation of the two pieces, the expired tidal volume remained at approximately 350 ml (similar to previous volumes). No other 8.0 Tracheotwist™ inner tubes were kept by the bed-side. The decision was made to attempt to change the tracheostomy as the stoma was established and the patient’s saturations stable. A bougie was inserted down the outer tube of the original tracheostomy into the trachea, the outer tube was removed, and a 7.0 Portex™ (Portex Limited, Hythe, Kent, UK) tracheostomy tube inserted and attached to the ventilator. Provision had been made for oral intubation had the insertion of the tracheostomy proved difficult. At no time did the patient’s oxygen saturations drop below 100% and the post-procedure arterial blood gas was acceptable. On closer examination the locking flange had failed allowing the inner tube components to separate (Fig. 4). Fortunately, in this case, rapid intervention by nursing and medical staff prevented serious harm. Our Trust transiently withdrew the use of Tracoetwist™ tracheostomies from the critical care areas and made Kapitex Healthcare Ltd. aware. We now require that all patients with a Tracheotwist™ tracheostomy have a spare inner tube by the bed side. It has been noted since however, that spontaneous unlocking of the inner tube from the outer tube has lead to several cases of inadvertent disconnection from the ventilator (with no harm to patients involved) and subsequently, our use of Tracheotwist™ tubes has creased. Failure of locking flange allowing the inner tube components to separate.