Inadvertent rupture of a suction catheter with migration of pieces in the respiratory tract is a dramatic event that has not been described yet.
The authors present a case of rupture of a closed-tube endotracheal suction catheter, probably due to inadvertent truncation. The occurence was responsible for major complications and its prompt recognition reversed the clinical situation.
Endotracheal suctioning is an essential and frequently performed procedure for patients requiring mechanical ventilation. Endotracheal suctioning should guarantee optimal oxygenation and avoidance of accumulation of secretions, leading to tube occlusion, increased work of breathing, atelectasis and pulmonary infections. Yet endotracheal suctioning may also have adverse effects, such as mucosal traumatic lesions, disturbances in cardiac rhythm, microbial contamination of the airway and the environment and hypoxaemia due to interruption of mechanical ventilation. The frequency with which endotracheal suctioning is performed differs with each patient, with reported mean values varying from eight to 17 times per day. Nowadays, two systems are available to perform endotracheal suctioning: the single-use, open suction system (OSS) and the multiple-use, closed suction system (CSS). OSS requires disconnection from the ventilator during endotracheal suctioning, which is not necessary when using CSS. The CSS catheter can remain connected to the patient continuously according to the manufacturer, and thus can be used for multiple endotracheal suctioning procedures, reducing the incidence of airway/environmental microbial contamination and hypoxaemia due to interruption of positive pressure ventilation [1–4], which can determine, in several clinical conditions, rapid lung de-recruitment (0.6 – 4 s) .
The patient was a 60-year-old white woman, referred to our intensive care unit for respiratory failure due to community-acquired pneumonia. Comorbid states were chronic obstructive pulmonary disease, diabetes, and cor pulmonale. The patient was intubated and received mechanical ventilation. A DEAS S.r.l. closed suctioning system catheter was used. This is a silicone 18-Ch (6 mm) diameter catheter enclosed in a plastic sheath, which is connected to a specially designed double swivel catheter mount to the airway. On day 10, worsening of clinical respiratory conditions was observed. Anteroposterior chest radiograph showed bilateral pneumonia with signs of obstructive emphysema and atelectasis in each hemithorax. In the following hours, thorax computed tomography (CT) scan, besides confirming bilateral pneumonia, revealed a tubular structure lying on the carina and downwards in the left and right main bronchi. Tracheobronchial fibroscopy was immediately performed and revealed the presence of two pieces of the suctioning catheter of 12 and 1 cm, respectively (Fig. 1, top); the 12 cm fragment was lying on the carina and projecting into the right and left main bronchi (Fig. 1, bottom), whereas the smaller fragment was found in the right lower lobar broncus. The fragments were promptly removed under fibreoptic guidance. No sequelae occurred. The patient was safely discharged from the ICU on day 35.
There is evidence that CSS catheters can cause a bronchial perforation and create a bronchopleural fistula especially in a paediatric population. Inadvertent rupture of a suction catheter with migration of pieces in the respiratory tract is a dramatic event that has not been described yet. Two possible explanations were considered: a defect in the catheter and the suction catheter not being completely withdrawn after suctioning and inadvertently truncated by the closing lever of the suctioning system. We verified several times in vitro the procedure: if the DEAS S.r.l. 18-Ch catheter is not completely extracted from the double swivel mount and the system is closed, this can cause a double section of the catheter without the application of excessive strength to produce two fragments. In our patient, worsening of clinical symptoms of respiratory failure led us to perform a CT scan which was fundamental for the diagnosis. The partial obstruction of the left and right bronchi due to the fragments of the CSS catheter was responsible for the worsening of respiratory conditions. Prompt recognition was fundamental and permitted us to remove even the smaller fragment and allowed clinical resolution of the pneumonia. The closed suction catheter system is an effective device, but it must be completely extracted after suctioning. Adequate training of medical and paramedical staff should be stressed even for minor procedures such as tracheal suctioning. A misuse of the suctioning system, not ensuring the complete extraction of the catheter, can cause sectioning of the latter, leading to major consequences with aspecific clinical and radiological signs that could have been interpreted as a worsening of pulmonary infection despite appropriate antimicrobial therapy.
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