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.
Ventilator-associated pneumonia (VAP) is a common and serious nosocomial infection in mechanically ventilated patients and results in high mortality, prolonged intensive care unit- (ICU) and hospital-length of stay and increased costs. In order to reduce its incidence, it is imperative to better understand the involved mechanisms and to identify the source of infection. The role of the endotracheal tube (ET) in VAP pathogenesis became more prominent over the last decades, along with extensive research dedicated to medical device-related infections and biofilms. ET biofilm formation is an early and constant process in intubated patients. New data regarding its temporal dynamics, composition, germ identification and consequences enhance knowledge about VAP occurrence, microbiology, treatment response and recurrence.
This paper presents a structured analysis of the medical literature to date, in order to outline the role of ET biofilm in VAP pathogenesis and to review recommended methods to identify ET biofilm microorganisms and to prevent or decrease VAP incidence.
Introduction: Tracheal diverticulum has been associated with problems during endotracheal intubation but there are no reports concerning air leakage around an endotracheal tube (ETT).
Case report: The case of an elderly woman under mechanical ventilatory support because an exacerbation of chronic obstructive pulmonary disease (COPD) is reported. She presented with an inexplicably air leak around the endotracheal tube not attributed to structural defects. The intra-cuff pressure value was as high as 30 mmHg to prevent an air leakage. Bronchoscopy revealed a tracheal diverticulum at the site ofthe tube cuff that allowed air leakage around it. The problem was overcome by re-intubating the patient with a larger diameter tube and positioning its distal end above the diverticular opening.
Discussion: Endotracheal tube air leak is a frequently neglected problem. COPD and other inflammatory conditions are associated with changes in the elastic properties of the airways resulting in tracheomegaly or acquired tracheal diverticulum. Both entities have been linked to problems during intubation or ventilation of patients. However tracheal diverticulum has not been described previously as a cause of air leakage.
Conclusion: Acquired tracheal diverticulum should be recognized as a cause of air leakage in the intubated patient, especially if associated with a normal or elevated intracuff pressure.