2020 FSA Posters

P026: SIMPLE TRACHEOSTOMY TUBE EXCHANGE? THINK AGAIN...
Brian Cheung, MD¹; Sharlene Lobo, MD¹; Kalina Nedeff, MD¹; Jessica Reyes, MD¹; Javier Kaplan, MD²; Nicholas Nedeff, MD¹; ¹Kendall Regional Medical Center - Department of Anesthesiology; ²Aventura Hospital and Medical Center - Department of Anesthesiology

A 62-year-old female with a history of muscular dystrophy, chronic respiratory failure, tracheostomy-dependent, presented for a routine tracheostomy tube exchange. She was seen by her ENT physician prior to the procedure, for accurate tracheostomy tube sizing recommendations. She was sedated for the procedure. The general surgeon exchanged the tube and she was connected to the ventilator after inflation of the cuff. Shortly after, there was a period of high inspiratory pressures accompanied with rapid O2 desaturations. Manual mode was initiated and she was bagged back up to 100% SpO2. The ventilator was turned back on and she seemed to be ventilating well until the problem recurred minutes later. We quickly worked through our differentials. A CXR was ordered and the pulmonology/critical care team was consulted to perform an intraoperative bronchoscopy. Studies revealed that the tracheostomy tube was becoming intermittently lodged into the right mainstem bronchus, as well as, severe tracheomalacia. A smaller and shorter tracheostomy tube was placed without any further issues. The patient made an uneventful recovery.