Tracheal ring fracture and pseudomembrane formation after percutaneous dilatational tracheostomy.

To the Editor: Various complications from percutaneous dilatational tracheostomy (PDT) have been reported in the literature. Tracheal ring fracture can take place while either using single or sequential dilators during the procedure.1 Fibrinous tracheal pseudomembranes can also appear in previously intubated patient.2 Recently, we encountered a case in which both tracheal ring fracture and pseudomembrane developed as a consequence of PDT. A 36-year-old woman with a history of diabetes mellitus and postpartum dilated cardiomyopathy was admitted to intensive care unit (ICU) with decompensated cardiac failure. She required intubation because of acute pulmonary edema. On day 6, she developed ventilatorassociated pneumonia and on the 11th day, she underwent bronchoscopy-guided PDT. The procedure was performed by a thoracic surgeon using a single dilator technique (Blue Rhino; Cook Critical Care Inc.). There were no immediate complications. Moreover, there were no unusual findings during the insertion of the dilator and the tracheostomy cannula as evidenced endoscopically. The patient was disconnected from mechanical ventilation and discharged from the ICU 4 days later. To safely remove the tracheostomy cannula, a flexible bronchoscopy was performed on day 18. A fibrinous tracheal pseudomembrane was found above the tracheal stoma (Fig. 1A). It was removed using argon plasma coagulation through the flexible bronchoscope. Concomitantly, a segment of tracheal cartilage protruding into the tracheal lumen was evidenced (Figs. 1B, C). The cartilage was removed with the help of Kelly’s forceps introduced through the tracheal stoma (Fig. 1D). The tracheostomy cannula was successfully removed and she remained asymptomatic at 15-day, 1month, and 6-month follow-up. PDT is a common and relatively safe procedure.2 Prolonged intubation remains the most common indication. Complications from PDT could be encountered perioperatively or during the early or late postoperative period. Tracheal ring fracture is a perioperative complication that could occur while using single or sequential dilators. It could be un-noticed, despite bronchoscopic guidance during tracheostomy. Its incidence range from 5% to 36%1 and its long-term significance remains poorly defined.3 Tracheal pseudomembranes may appear in previously intubated patients shortly after the extubation and is considered a potentially fatal complication from sudden airway obstruction if undetected and not managed in a timely manner.4 It is usually located at the site where the tracheal tube cuff comes in contact with the tracheal mucosa. It is composed mainly of fibrin and desquamated necrotic epithelium. It could be permanently removed with a rigid bronchoscope or by means of flexible bronchoscopy techniques.4–6 In the presented case, both pseudomembrane and tracheal ring fracture were evidenced during bronchoscopic inspection performed before the removal of the tracheostomy cannula. In the beginning, extraction of the pseudomembrane with forceps through the flexible bronchoscope was not feasible because of its firm adherence to the tracheal wall, and the argon plasma use of coagulation was required. Removal of the piece of cartilage was possible with the use of Kelly’s forceps introduced through the tracheal stoma. In conclusion, tracheal ring fracture and postintubation tracheal pseudomembranes are not infrequent complications of the PDT, the latter being potentially fatal if not detected and treated in timely fashion. Bronchoscopic examination should be performed before decannulation for early detection and prompt management of PDT complications.