Sibel ILICA, Ahmet MAHLİ, Lale KARABIYIK, Hande ARPACI, Demet COŞKUN

Cardiac arrest as aresult of one-way valve type obstruction of the endotracheal tube

Mekanik ventile edilen bir hastada ani hiperkarbi gelişmesi durumunda ilk şüphe edilmesi gereken endotrakeal tüpün obstrüksiyonu olmalıdır. Biz burada; tek yönlü valv tipi endotrakeal tüp obstrüksiyonunun, mekanik ventile edilen yoğun bakım ünitesi (YBÜ) hastasında mortalite ve morbiditeye neden olabileceğini vurgulamak istedik. Olgu Sunumu: 74 yaşında özgeçmişinde koroner arter hastalığı, hipertansiyon ve diyabeti olan erkek hasta, koroner bypass operasyonundan sonra pnömoni ve postoperatif ensefalopati gelişmesi üzerine kardiyovasküler cerrahi ünitesinde extübe edilemeyip, postoperatif 35.gün YBÜ'mize devredildi. On iki saat sonra bradikardi ve kardiyak arrest gelişti, yapılan kardiyopulmoner resusütasyona (KPR) 40.dakikada cevap almdı. Bununla birlikte PaCO, ve Pa02 sırasıyla 116 ve 83 mmHg idi. Oskültasyonda bilateral olarak akciğer sesleri duyulmuyordu. Bu bulgularla, KPR sırasında oluşan kot kırıklarının pnömotoraksa yol açtığı düşünülerek, bilateral olarak anterior mid-klavikular yaklaşımla 2. interkostal aralıktan torasentez yapıldı. Hava ile karışık 3 ml hemorajik materyal aspire edildi. Torasentezden 30 dakika sonra, akciğer grafisinde bilateral pnömotoraks gözlendi ve bilateral göğüs tüpü yerleştirildi. Doksanıncı dakikada ventilasyon ne mekanik ventilator ne de ambu ile sağlanamadı ve endotrakeal tüp değiştirildi, büyük bir tıkaç olduğu görüldü. Reentübasyondan sonra vital bulgular ve kari gazı değerleri normal limitlere geri döndü. Sonuç: Bu olguda; aspirasyon sondalarının, tıkacı trakeada ileri ittiğini ve tanıyı güçleştirdiğini düşünüyoruz. Özellikle uzun dönem mekanik olarak ventile edilen hastalarda humidifikasyon sistemleri kullanılmalıdır. Bu olguda olduğu gibi, aniden ventilasyonda güçlük gelişirse, diğer işlemlerden önce endotrakeal tüp değiştirilmelidir.

Endotrakeal tüpün tek yönlü valf tipi obstrüksiyonu sonucu gelişen kardiyak arrest

In cases of sudden hypercapnia developing in a mechanically ventilated patient, obstruction of the endotracheal tube (ETT) should be suspected first at the outset. Herein we aimed to show that one-way valve type ETT obstruction is a major clinical event that can lead to patient morbidity and mortality in mechanically ventilated intensive care unit (ICU) patients. Case Report: A 74-year-old male who had coronary arteiy disease and diabetes mellitus and developed pneumonia after coronary by-pass surgery could not be extubated in the cardiovascular surgery unit and was sent to our ICU on the 35th day of the postoperative period. After 12 hours, the patient had developed bradycardia and cardiac arrest. The patient underwent approximately 40 minutes of cardiopulmonary resuscitation (CPR) prior to recovery. However, PaC02 and Pa02 were 116 and 83 mmHg respectively. Lung sounds were not heard on auscultation bilaterally. With these findings, pneumothorax was suspected due to rib fractures that developed after CPR and anterior midclavicular thoracentesis was performed with 2nd intercostal access bilaterally. Three milliliters of hemorrhagic material containing air was aspirated totally. Thirty minutes after thoracentesis, a chest X-ray showed pneumothorax bilaterally; thus a bilateral chest tube was placed. In the 90"' minute, ventilation could not be achieved either by respirator or bag-valve device and then the ETT was changed and a large plug was detected. After reintubation vital signs and blood gases returned to normal limits. Conclusion: In this case we thought that the, suctioning tubes had pushed the plug into the trachea and caused diagnostic difficulties. For patients who are on long-term ventilatory support, humidification systems must be used. If the patients develop sudden ventilation difficulties, the ETT must be changed before the other procedures.

PDF

___

1. Shah C, Kollef MH. Endotracheal tube intraluminal volume loss among mechanically ventilated patients. Crit Care Med. 2004;32:120-5.
2. Petersen GW, Baier H. Incidence of pulmonary barotrauma in a medical I.C.U. Crit Care Med 1983;11:67-9.
3. Russomanno JH, Brown LK. Pneumothorax due to ball- valve obstruction of an endotracheal tube in a mechanically ventilated patient. Chest 1992;101:1444-5.
4. Hosking MP, Lennon RL, Warner MA. Endotracheal tube obstruction: recognition and management. Milt Med 1989;154:489-91.
5. Munson ES, Stevens DS, Redfern RE. Endotracheal tube obstruction by nitrous oxide. Anesthesiology 1980; 52:275-6.
6. Ripley JF, McAnear JT, Tilson HB. Endotracheal tube obstruction due to impaction of the inferior turbinate. J Oral Maxillofac Surg 1984;42:687-8.
7. Zmyslowski WP, Kam D, Simpson GT. An unusual cause of endotracheal tube obstruction. Anesthesiology 1989;70:833.
8. Harrington JF. An unusual cause of endotracheal tube obstruction. Anesthesiology 1984;61:116-7.
9. Shlamovitz GZ, Halpern P. Delayed obstruction of endotracheal tubes by aspirated foreign bodies: report of two cases. Ann Emerg Med 2004;43:630-3.
10. Kawati R, Vimlati L, Guttmann J, et al. Change in expiratory flow detects partial endotracheal tube obstruction in pressure-controlled ventilation. Anesth Analg 2006;103:650-7.
11. Tung A, Morgan SE. Modeling the effect of progressive endotracheal tube occlusion on tidal volume in pressure- control mode. Anesth Analg 2002;95:192-7.
12. Kawati R, Lattuada M, Sjostrand U, et al. Peak airway pressure increase is a late warning sign of partial endotracheal tube obstruction whereas change in expiratory flow is an early warning sign. Anesth Analg 2005;100:889-93.
13. Boque MC, Gualis B, Sandiumenge A, et al. Endotracheal tube intraluminal diameter narrowing after mechanical ventilation: use of acoustic reflectometry. Intensive Care Med 2004;30:2204-9.
14. Adair CG, Gorman SP, Feron BM, et al. Implications of endotracheal tube biofilm for ventilator-associated pneumonia. Intensive Care Med 1999; 25:1072-6.
15. Feldman C, Kassel M, Cantrell J, et al. The presence and sequence of endotracheal tube colonization in patients undergoing mechanical ventilation. Eur Respir J 1999;13:546-51.
16. Villafane MC, Cinnella G, Lofaso F, et al. Gradual reduction of endotracheal tube diameter during mechanical ventilation via different humidification devices. Anesthesiology 1996;85:1341-9.
17. Schumann S, Lichtwarck-Aschoff M, Haberthur C, et al. Detection of partial endotracheal tube obstruction by forced pressure oscillations. Respir Physiol Neurobiol 2007;155:227-33.
18. Zar HA, Wu WW. The inability to detect expired carbon dioxide after endotracheal intubation as a result of oneway valve obstruction of the endotracheal tube. Anesth Analg 2001;93:971-2.