Tracheostomy Pseudotract

Abstract

CASE REPORT A 75-year-old man underwent a redo coronary artery bypass surgery with mitral valve repair. His postoperative course was complicated by respiratory failure requiring reintubation and subsequent tracheostomy 1 month after surgery. He was weaned from ventilatory support within 2 weeks after the latter procedure. Because he was breathing spontaneously, his tracheostomy tube was plugged when he began his rehabilitation. His tracheostomy was changed and downsized on the regular nursing floor. Several hours after the tube change, the patient experienced difficulty in clearing his secretions. Despite multiple attempts, the respiratory therapist was unable to get a good return during suction through the tracheostomy tube. Emergency bronchoscopy through the tracheostomy stoma revealed tissue occluding the lumen. A consult was called to the interventional pulmonology team for possible laser photoresection. Bronchoscopy performed through the nasal route revealed a paralyzed left vocal cord. The cuff of the tracheostomy tube was seen bulging through the tracheostoma, but the tracheostomy tube was not in the lumen of the trachea. The tracheostomy tube was removed revealing a pseudotract created by the reinsertion of the tracheostomy tube. Tracheal lumen was fully patent (Fig. 1). It appeared that at each attempt at suctioning, the catheter entered the false passage. The misplaced tracheostomy tube was subsequently removed, and the false tract and tracheostoma eventually healed. The patient continued to an uneventful recovery.FIGURE 1: Bronchoscopic image of the pseudotract anteriorly (←) with a patent tracheal lumen (TR).DISCUSSION Complications associated with tracheostomy fall into three categories: perioperative, postoperative, and late or postdecannulation. Postoperative complications include bleeding, subcutaneous emphysema, wound infection, tracheoesophageal fistula, vocal cord paralysis, and tube occlusion or displacement.1 Overall risk of complications ranges from 0% to 37%. Late and/or postdecannulation complications include tracheal stenosis, disfiguring scar, or residual stoma with the incidence ranging from 0% to 1.9%. Overall, the acute and long-term complications associated with tracheostomy placement have improved since the days of Chevalier Jackson, who is credited for standardizing the procedure.2 The approach to the tracheostomy care can be divided into that for the early or late periods with the former encompassing the initial first 7 days after the procedure. The late period refers to the time after the formation of a “mature stoma,” which is usually after the first 7 days. Complications in the early and late period can defer significantly. Tracheostomy tube changes in the late period are routinely needed to address tube malfunctions, soiling, or when a new type or size of tube is considered. Although tracheal tube changes are common, it should not be viewed as totally innocuous.3 Potential complications of premature tube change (ie, before tracheostoma maturation) include the possibility of creating a false passage, development of pneumothorax, subcutaneous emphysema, and inability to control the airways and ventilate the patient.4 Obstruction of the tracheostomy tube by its passage into the paratracheal soft tissue plane is a potentially life-threatening situation. Depending on whether the tube is partially or completely obstructed, the patient can present with varying degrees of respiratory distress. The literature describes reinsertion of the tracheostomy tube through an immature tract or during the early period as the main reason for the creation of a false channel in the subcutaneous tissue anterior to the trachea, although this case demonstrates that such a scenario is possible even while dealing with a mature tract.5