Unexpected tracheal compression detected after immediate extubation failure.

EDITOR: Extubation failure is defined as the need for reinstitution of ventilatory support within 24–72 h of planned endotracheal tube removal. It occurs in 2–25% of extubated patients. Many causes, such as an imbalance between respiratory muscle capacity and work of breathing, upper airway obstruction, excess respiratory secretions, inadequate cough, encephalopathy and cardiac dysfunction, have been stated in the literature [1]. In patients on mechanical ventilation for exacerbations of chronic obstructive pulmonary disease (COPD), no exact extubation failure rates are known; however, occurrence rates will probably not be very low. Furthermore, the institution of noninvasive pressure ventilation for extubation failure has not been proven to be safe [2]. In COPD, the decision for reintubation is difficult and will be weighed against the chances of successful treatment of underlying causes. In case the respiratory reserve is marginal, reintubation sometimes will be foregone. We present a case of a 71-yr-old female with COPD and non-small cell lung cancer in which advanced COPD was suspected to be the major reason for extubation failure, but careful examination led to an unexpected and treatable underlying disorder. A 71-yr-old female was encountered at home by paramedics in respiratory distress with reduced levels of consciousness. She was transported to the emergency room of our hospital. Her Glasgow Coma score was 4 and she was gasping. Her medical history revealed a T2N2 non-small cell bronchus carcinoma, treated with curative radiotherapy, and moderate COPD, dyspnoea with moderate exercise and FEV1 ,80% (COPD Gold class II). Physical findings were pulse 96 min, blood pressure 180/ 100 mmHg and temperature 37.68C. A large goitre was palpated in the neck with a deviation of the trachea to the right. She was tachypnoeic, and rhonchi were heard over all lung fields. Arterial blood gas analysis showed pH 7.04, PCO2 16.5 kPa, PO2 26.1 kPa, HCO3 2 32.2 mmol L, base excess 22.7 mmol L and SaO2 100% (with oxygen mask). Leucocytes 12.23 10 g L and C-reactive protein 156 mg L were indicative for infection. The patient was immediately intubated and admitted to the intensive care unit (ICU). Insertion of the central venous line was very difficult because of the abnormal anatomy due to the large goitre. A chest X-ray showed infiltrations at the right middle lobe. Treatment was commenced with antibiotics for pneumonia and corticosteroids for exacerbation of COPD. Haemophilus influenzae was cultured from the sputum. Within 5 days infection parameters and chest X-ray were normalized. Extubation was immediately followed by progressive hypercapnia and severe respiratory failure. No inspiratory or expiratory stridor were noted. Immediate reintubation was performed. Because of the rapid extubation failure without clear cause, an upper airway obstruction was suspected. A chest computed tomography (CT) scan was ordered to find anatomic lesions responsible for airway obstruction. A large retrosternal mediastinal multinodular goitre was found. By endoscopy compression of the trachea was detected at the level of the mediastinal goitre. Thyroid hormones (T3 and FT4) and thyroidstimulating hormone (TSH) were within normal ranges. A diagnosis was made of a non-toxic goitre causing upper airway obstruction and recurrent hypercapnic respiratory failure. A left-sided hemithyroidectomy was performed without complications. Pathological examination showed a multinodular goitre of 185 g. There were no signs of malignancy. On the first postoperative day, the patient was successfully extubated. The patient was discharged from the ICU after 2 days and from the hospital a week later. After treatment for H. influenzae pneumonia and exacerbation of COPD, rapid extubation failure was encountered. Initially, progressive COPD and deteriorating pulmonary reserve was suspected. The discrepancy with the known pulmonary status forced us to consider other options. After diagnostic workup, an intrathoracic goitre was found that deviated and compressed the trachea causing upper airway obstruction. Hemithyroidectomy was performed and the patient could be extubated the next day. Non-toxic goitre is a diffuse or nodular enlargement of the thyroid gland that does not result Correspondence to: Arthur R. H. van Zanten, Department of Intensive Care, Gelderse Vallei Hospital, POB 9025, 6716 RP Ede, The Netherlands. E-mail: [email protected]; Tel: 131 318 434115; Fax: 131 318 434116