Abstract
Endotracheal tube obstruction by a mucus plug causing a ball-valve effect is a rare but significant complication. The inability to pass a suction catheter through the endotracheal tube with high peak and plateau pressure differences are classical features of an endotracheal tube obstruction. A case is described of endotracheal tube obstruction from a mucus plug that compounded severe respiratory acidosis and hypotension in a patient who simultaneously had abdominal compartment syndrome. The mucus plug was not identified until a bronchoscopic assessment of the airway was performed. Due to the absence of classical signs, the delayed identification of the obstructing mucus plug exacerbated diagnostic confusion. It resulted in various treatments being trialed whilst the patient continued to deteriorate from the evasive offending culprit. We suggest that earlier and more routine use of bronchoscopy should be employed in an intensive care unit, especially as a definitive way to rule out endotracheal obstruction.
Highlights
Endotracheal tube obstruction by a mucus plug causing a ball-valve effect is a rare but significant complication
Post-operatively, he was transferred to the surgical intensive care unit (ICU) for ventilatory and haemodynamic support
Difficult ventilation in the patient was due to reduced chest wall compliance, caused by abdominal compartment syndrome secondary to bowel oedema, and poor lung compliance caused by air trapping secondary to the mucus plug
Summary
Endotracheal tube obstruction by a mucus plug causing a ball-valve effect is a rare but significant complication. A 63-year-old male, 170cm tall, weighing 69kg, was admitted to the Singapore General Hospital, Singapore, presenting with epigastric bloating and discomfort He had a history of extensive smoking, hypertension, chronic kidney disease and Child C liver disease complicated by portal hypertension, ascites, oesophageal varies and gastropathy. On post-admission day twenty-eight, post-operative day two, it was noted that the patient had a high intra-abdominal pressure of 26mmHg, complicated by oliguric acute kidney impairment from abdominal compartment syndrome. This was managed medically with paralysis and renal replacement therapy. A duodeno-jejunal anastomotic leak was diagnosed on postadmission day thirty-five, post-operative day nine He underwent a second exploratory laparotomy with tube diversion and primary repair of the wound dehiscence pedicled omentoplasty. At the end of the operation, he was returned to the ICU where a noradrenaline (Labaratoire Aguettant, Lyon, France) infusion of 0.03 mcg/kg/min was continued
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