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CASE REPORT
Year : 2014  |  Volume : 4  |  Issue : 1  |  Page : 50-52  

Foreign body blocking closed circuit suction catheter: An unusual cause of retained tracheal secretions in a mechanically ventilated patient


1 Department of Anaesthesia, SGRD Institute of Medical Science and Research, Amritsar, Punjab, India
2 Department of Anaesthesia, Hargun Hospital, Amritsar, Punjab, India

Date of Web Publication22-Jan-2014

Correspondence Address:
Shubhdeep Kaur
House No. 126, B-Block, Ranjit Avenue, Amritsar - 143 001, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-516X.125696

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   Abstract 

Closed circuit suction system (CCSS) has become a standard of care for the tracheal suctioning of mechanically ventilated patients. The advantages of CCSS over the open suction system include decreased environmental, personnel and patient contamination, preservation of lung volumes and oxygenation especially in the severely hypoxemic patients. On the other hand, CCSS has lower efficacy in removal of secretions and it may have certain other disadvantages due to the invisibility of its tip. We report an unusual case of an airway foreign body causing blockage of the CCSS leading to retained secretions and deterioration of patient. Timely changing over to open suction system helped in its detection and improvement of patient.

Keywords: Catheter, closed circuit suction system, foreign body, suction


How to cite this article:
Kaur S, Singh S, Gupta R, Bindra T. Foreign body blocking closed circuit suction catheter: An unusual cause of retained tracheal secretions in a mechanically ventilated patient. Int J App Basic Med Res 2014;4:50-2

How to cite this URL:
Kaur S, Singh S, Gupta R, Bindra T. Foreign body blocking closed circuit suction catheter: An unusual cause of retained tracheal secretions in a mechanically ventilated patient. Int J App Basic Med Res [serial online] 2014 [cited 2020 Mar 30];4:50-2. Available from: http://www.ijabmr.org/text.asp?2014/4/1/50/125696


   Introduction Top


Removal of tracheobronchial secretions to maintain airway patency is a standard of care in mechanically ventilated patients. Since the endotracheal tube (ETT) cuff abruptly stops the mucociliary escalator, endotracheal suctioning is essential to physically remove the secretions. [1] This can be achieved by the conventional open system or closed circuit suction system (CCSS). The advantages of CCSS include limiting environmental, personnel and patient contamination and preventing the loss of lung volume as well as the alveolar de-recruitment associated with standard suctioning in the severely hypoxemic patients. [2],[3],[4],[5],[6]

We report an unusual case of an airway foreign body blocking the CCSS, the like of which has never been reported before.


   Case Report Top


A 57-year-old farmer presented with a history of fall from a tractor while working in the fields. He sustained head injury, multiple rib fractures on the right side and fracture of the right leg. At the time of presentation he was agitated and tachypnoeic. Computed tomography (CT) head showed small right sided subdural hematoma. Contrast enhanced CT chest showed multiple rib fractures, hemo-pneumothorax, basal consolidative changes and surgical emphysema on the right side. Right sided intercostal drain tube was inserted. The patient's clinical condition remained stable for 3 days while he was treated with analgesics, antibiotics and 5 L/min oxygen (O 2 ) inhalation by face mask. Glasgow coma score remained 15, arterial blood gas (ABG) and chest X-rays showed no deterioration. On the 4 th day he became drowsy and tachypnoeic. His heart rate (HR) increased from 76 to 104 bpm, blood pressure (BP) increased from 130/80 to 150/100 mmHg, respiratory rate (RR) increased from 18 to 35/min and SpO 2 dropped to 89% despite increasing inspired O 2 concentration. ABG analysis showed hypoxemia with respiratory and metabolic acidosis. He was intubated and put on ventilator on bi-level mode, following which his condition stabilized within 5 min. HR settled to 88 bpm, RR to 20/min, BP 140/84 mmHg and SpO 2 97%. As a protocol, CCSS (14 French) was attached and suctioning done every 2 h and as and when required. 6 h after putting on ventilator, he again developed tachypnoea (RR increased from 20/min to 45/min), tachycardia (110 bpm), hypertension (150/110 mm Hg), and de-saturation (SpO 2 dropped from 97% to 90%). Anticipating secretions CCSS catheter was passed through the ETT but nothing could be sucked out. Auscultatory findings (conducted sounds all over the chest) and spirometry findings (decreased inspiratory and expiratory peak flows, low tidal volume) suggested retained secretions. The CCSS was disconnected and on close inspection a tiny stone blocking its tip could be seen [[Figure 1]: Blocked tip of CCSS]; [[Figure 2]: On close observation tiny stone foreign body blocking the tip of catheter] which the patient probably inhaled/aspirated at the time of accident. Later a large volume of secretions was sucked out using a different suction catheter; following that the patient's condition stabilized. A bronchoscopy was performed immediately to rule out the presence of any other foreign body. It showed mucosal inflammation and purulent secretions. No other foreign body was found. The patient was managed on the ventilator and tracheostomy done on the 5 th day of intubation. Antibiotics were modified according to culture-sensitivity of the tracheal secretions. He was weaned off the ventilator on the 11 th day, operated upon for fracture tibia on the 16 th day and discharged on the 23 rd day following admission in satisfactory condition.
Figure 1: Aspirated foreign body blocking suction cather tip

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Figure 2: Magnified view of the stone foreign body

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   Discussion Top


CCSS has become popular in the recent past because of certain advantages over the traditional open system. It prevents problems associated with ventilator disconnection like hypoxemia, hemodynamic instability, alveolar derecruitment, loss of lung volume and ventilator malfunction. [2],[3] It has also been reported to have some role in protecting against ventilator associated pneumonia and in decreasing environmental contamination with patient's secretions. [4],[7],[8] It has been found to be more cost effective in patients requiring prolonged ventilation. [9] Despite all these benefits it has been postulated to have lower efficacy in removing endotracheal secretions. [10] In our case, it got totally blocked by an airway foreign body; leading to its failure to remove secretions. Since there are chances of the catheter tip, which is not visible in the CCSS, getting blocked by inspissated secretions, blood clot or in rare cases like authors' by an aspirated small foreign body, the authors suggest that one should be watchful for other signs of retained secretions; particularly if a closed-suction system is being used. To conclude, closed-suction system has many proven benefits, but the invisibility of its tip can pose serious problems. Hence while using CCSS, it is advisable to be extra cautious about the signs-symptoms of retention of tracheal secretions.

 
   References Top

1.Sackner MA, Hirsch J, Epstein S. Effect of cuffed endotracheal tubes on tracheal mucous velocity. Chest 1975;68:774-7.  Back to cited text no. 1
[PUBMED]    
2.Branson RD. Secretion management in the mechanically ventilated patient. Respir Care 2007;52:1328-42;1342.  Back to cited text no. 2
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3.Maggiore SM, Iacobone E, Zito G, Conti C, Antonelli M, Proietti R. Closed versus open suctioning techniques. Minerva Anestesiol 2002;68:360-4.  Back to cited text no. 3
[PUBMED]    
4.Cobley M, Atkins M, Jones PL. Environmental contamination during tracheal suction. A comparison of disposable conventional catheters with a multiple-use closed system device. Anaesthesia 1991;46:957-61.  Back to cited text no. 4
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5.Cereda M, Villa F, Colombo E, Greco G, Nacoti M, Pesenti A. Closed system endotracheal suctioning maintains lung volume during volume-controlled mechanical ventilation. Intensive Care Med 2001;27:648-54.  Back to cited text no. 5
    
6.Maggiore SM, Lellouche F, Pigeot J, Taille S, Deye N, Durrmeyer X, et al. Prevention of endotracheal suctioning-induced alveolar derecruitment in acute lung injury. Am J Respir Crit Care Med 2003;167:1215-24.  Back to cited text no. 6
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7.Combes P, Fauvage B, Oleyer C. Nosocomial pneumonia in mechanically ventilated patients, a prospective randomised evaluation of the Stericath closed suctioning system. Intensive Care Med 2000;26:878-82.  Back to cited text no. 7
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8.Rabitsch W, Köstler WJ, Fiebiger W, Dielacher C, Losert H, Sherif C, et al. Closed suctioning system reduces cross-contamination between bronchial system and gastric juices. Anesth Analg 2004;99:886-92.  Back to cited text no. 8
    
9.Lorente L, Lecuona M, Martín MM, García C, Mora ML, Sierra A. Ventilator-associated pneumonia using a closed versus an open tracheal suction system. Crit Care Med 2005;33:115-9.  Back to cited text no. 9
    
10.Lasocki S, Lu Q, Sartorius A, Fouillat D, Remerand F, Rouby JJ. Open and closed-circuit endotracheal suctioning in acute lung injury: Efficiency and effects on gas exchange. Anesthesiology 2006;104:39-47.  Back to cited text no. 10
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    Figures

  [Figure 1], [Figure 2]


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