Evidence to Support Nursing Practices
Feature
52 CriticalCareNurse Vol 43, No. 3, JUNE 2023 www.ccnonline.org
Nursing Care of Patient With Tracheostomy Tube Cuff Rupture Caused by Tracheal Polyp: A Case Report Ye Feifei, BSN
Zhen Junhai, MD
Guan Xiaoxiao, BSN
Introduction Tracheostomy is common in patients with critical illness. Mechanical ventilation requires the airway to be closed by an inflated tracheostomy tube cuff. Tracheostomy tube cuff rupture is a serious complication of airway management. This case study summarizes the nursing care of a patient who received prolonged mechanical ventilation and had recurrent tracheostomy tube cuff ruptures caused by a tracheal polyp. Clinical Findings and Diagnosis An 81-year-old woman was admitted because of acute exacerbation of chronic obstructive pulmonary disease. The patient had undergone percutaneous tracheostomy 3 years earlier because of difficulty in weaning from the ventilator and had recurrent lung infections that led to respiratory failure. A tracheal polyp was identified as the cause of multiple tracheostomy tube cuff ruptures. Outcomes After the tracheal polyp was removed with bronchofiberscope guidance, the patient remained hospitalized because of difficulty in ventilator weaning but had no further tracheostomy tube cuff ruptures. Conclusion Tracheal polyps that cause tracheostomy tube cuff ruptures are rare, but nurses should be alert to their occurrence. If a tube cuff ruptures in a patient receiving long-term mechanical ventilation, bronchoscopy should be performed as soon as possible to allow for early identification of the cause and ensure patient safety. (Critical Care Nurse. 2023;43[3]:52-58)
Tracheostomy is a common treatment in critically ill patients, mainly in those with airway problems who require long-term mechanical ventilation because of respiratory failure.1 Mechanical ventilation requires the tracheostomy tube cuff to be inflated to close the airway
and prevent pulmonary infections due to reflux of upper respiratory tract secretions or aspiration of gastric contents into the lower respiratory tract.2 Airway management for patients with a tracheostomy is of great significance. Tracheostomy tube cuff rupture is a serious complication of airway management that leads to poor positive pressure ventilation and is even life-threatening. Therefore, it is crucial to stan- dardize airway management procedures and to accurately and rapidly recognize tube cuff rupture.3
©2023 American Association of Critical-Care Nurses doi:https://doi.org/10.4037/ccn2023649
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Authors
Ye Feifei is a nurse, Department of Critical Care Medicine, Zhejiang Hospital, Hangzhou, Zhejiang, China.
Zhen Junhai is a physician, Department of Critical Care Medicine, Zhejiang Hospital.
Guan Xiaoxiao is a nurse, Department of Critical Care Medicine, Zhejiang Hospital.
Corresponding author: Guan Xiaoxiao, BSN, Department of Critical Care Medi- cine, Zhejiang Hospital, Lingyin Road No.12, Hangzhou, Zhejiang 310013, China (email: 185383392@qq.com).
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A tracheal polyp is a benign tumor of the airway originating from the surface of bronchial mucosa. The cause is undetermined, but tracheal polyps might be asso- ciated with chronic inflammation or mechanical stimula- tion.4 The pathological manifestation of an inflammatory intratracheal polyp is granuloma with infiltration of B lym- phocytes and T lymphocytes in response to chronic air- way infection, inflammatory response of systemic disease, or inhalation injury. After tracheostomy and mechanical ventilation for more than 1 month, inflammatory polyps may result from multiple factors such as airflow impact, airway trauma, patient cough, turning of the patient, long-term repeated suctioning of sputum, regular cannula replacement, and other factors that repeatedly stimulate the lower airway and damage the tracheal wall.5
In clinical practice, multiple causes of tracheostomy tube cuff rupture have been identified, including exces- sive inflation of the tube cuff, improper tube placement, problems with the age or material of the tube, and con- current conditions like mucosal hyperplasia of the upper respiratory tract, bronchial achondroplasia, and cricoid cartilage fracture in patients involved in car accidents.6,7 Only a few cases of repeated tracheostomy tube cuff rupture caused by tracheal polyps have been reported. In this article we report a patient with acute exacerba- tion of chronic obstructive pulmonary disease and mul- tiple tracheostomy cuff ruptures due to a tracheal polyp.
Case Presentation An 81-year-old woman experienced recurrent cough
and expectoration with shortness of breath more than 10 years ago. She received a diagnosis of chronic obstruc- tive pulmonary disease. Three years ago, due to aggrava- tion of expectoration, the patient’s oxygen saturation as
measured by pulse oximetry dropped to less than 90%. She was hospitalized and underwent emergency endotra- cheal intubation. After being hospitalized, she under- went percutaneous tracheostomy due to difficulty in weaning from the ventilator. After intermittent weaning, her need for mechanical ventilation gradually increased, leading to long-term hospitalization. One month before she was admitted to our intensive care unit (ICU), the patient’s oxygen saturation decreased and then increased after repeated sputum suctioning. Results of laboratory tests (such as C-reactive protein level) showed an increased inflam- matory index, so she was admitted to our ICU with a diagnosis of acute exacerbation of chronic obstruc- tive pulmonary disease. The patient’s medical history included cerebral infarction in the left frontal lobe, sei- zure, hypoalbuminemia, osteoporosis, surgical repair of thoracic vertebral fracture, colonization with nontu- berculous mycobacteria, urinary tract infection, type 2 diabetes mellitus, and subclinical hypothyroidism.
Upon admission to our ICU, the patient was conscious and in poor spirits, with tracheostomy, ventilator-assisted breathing, exudative edema of airway mucosa, and mod- erate edema of limbs. Her inflammatory index was high at admission (Table 1). Computed tomography of the lungs showed partial bronchodilation with infection, multiple areas of inflammation, regional consolidation, and evi- dence of intubation after tracheostomy. Sputum culture revealed Pseudomonas aeruginosa infection. The patient received oral linezolid and intravenous ceftazidime to treat infection and injectable ambroxol and doxofylline to resolve phlegm and asthma. The patient had a history of epilepsy and was given sodium valproate oral liquid to control epilepsy. The patient’s limbs had mild edema. She was given intravenous torsemide and oral spirono- lactone tablets for diuresis. Because the patient had a tracheostomy and could not eat on her own, we pro- vided enteral nutritional support.
When the patient was admitted to the ICU, she received ventilator-assisted breathing because of difficulty in ven- tilator weaning. The condition of the ventilator was good and the tracheostomy tube cuff had no air leakage. Three
After tracheostomy and mechanical ven-
tilation for more than 1 month, inflamma-
tory polyps may result from factors such
as airflow impact, airway trauma, patient
cough, and turning of the patient.
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days after admission, air leakage was found around the tracheostomy tube, the pressure of the tracheostomy tube cuff was low, and the air leakage reoccurred after the tracheostomy tube cuff was infl ated. The monitoring tube cuff pressure was low. The tube cuff was found to be ruptured, and the tube was replaced immediately. Because the tube had been inserted for only 21 days, the material of the cuff was considered the cause of the rupture. Ten days after admission, the patient’s tracheos- tomy tube cuff ruptured again and the tube was imme- diately replaced. The respiratory therapists performed bronchoscopy and found no evidence of abnormality. Sixteen days after admission, the tube cuff ruptured again and the tube was immediately replaced as before. The respiratory therapists and physicians of our ICU
discussed further options. Bronchofi berscopy was per- formed and a white granular polyp in the tracheal wall next to the tube cuff was identified (Figure 1). The polyp had a rough texture and was considered calcifi - cation. The polyp was confi rmed to be the cause of the repeated tube cuff ruptures.
An extended-length tracheostomy tube is an option for patients with a tracheal polyp. Because our patient was of advanced age and had a small volume of sub- glottic drainage in her previous care, we inserted an extended-length tracheostomy tube under bronchofi - berscopy guidance and kept the head of the tube away from the polyp during insertion. The scale markings on the tube were closely monitored during nursing care because of the patient’s history of seizures. However, the tube cuff ruptured again 5 days after placement. Because of the polyp site and difficulty managing the extended-length tube, after consulting respiratory therapists and communicating with the patient’s family we removed the polyp with a bron- chofi berscope and replaced the extended-length tube with a plastic tracheostomy tube that allowed for suc- tioning of subglottic secretions.
It took 20 days from the fi rst incidence of tracheos- tomy tube cuff rupture to identify and then remove the cause. During this time, the patient’s blood gas analysis results were within reference ranges (Table 1), the patient’s ventilation status was good, and no ventilator alarms occurred. The patient remained hospitalized because of diffi culty weaning from the ventilator, her condition was stable, her airway was unobstructed, and no tracheostomy tube cuff rupture occurred (Table 2).
Abbreviations: CRP, C-reactive protein; ICU, intensive care unit. a SI conversion factors: To convert CRP to mg/L, multiply by 10; to convert lactate to mmol/L, multiply by 0.111.
ICU day
1
3
10
16
20
24
Lactic acid, mg/dL (3.60-19.82)
14.41
9.01
13.51
14.41
9.91
16.22
PaO 2 ,
mm Hg (80-100)
103
127
109
107
105
108
PaCO 2 ,
mm Hg (35-45)
49
51
54
43
46
43
pH (7.35-7.45)
7.42
7.37
7.54
7.48
7.43
7.44
CRP, mg/dL (0-0.6)
5.74
3.24
4.53
6.23
3.49
2.73
Table 1 Laboratory test results (reference ranges in parentheses)a
Figure 1 Image of tracheal polyp on bronchofi berscopy.
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Nursing Care Recognition of Tracheostomy Tube Cuff Rupture
Continuous real-time tracheostomy tube cuff pres- sure monitoring can allow for timely air leak detection. Mu et al8 reported that continuous tube cuff pressure monitoring improved therapeutic outcomes in patients receiving mechanical ventilation in the ICU. Our patient initially had obvious air leaks and a persistent low- pressure ventilator alarm that continued even when the tube cuff was infl ated to the target pressure via a gauge. However, the tube cuff pressure continued to fall after infl ation. Routine tube cuff pressure monitor- ing every 4 hours can help clinicians rapidly and accu- rately recognize ruptures. The cause of our patient’s tube cuff rupture was unclear. After replacing the tube, we performed continuous close monitoring of the tube cuff pressure with a pressure gauge and recorded tube cuff pressures hourly. The machine delivers an alert if the tracheostomy tube cuff pres- sure is abnormal. Events such as sputum suctioning, patient turning, oral care, and swallowing can place temporary pressure on the tube cuff9 and should be avoided when recording pressures and identifying alarms. Using continuous pressure monitoring and excluding irrelevant events facilitate the immediate recognition of tube cuff rupture, helping clini- cians make timely management decisions, per- form a rescue, and ensure patient safety.
Emergency Management of Tracheostomy
Tube Cuff Rupture
A tracheostomy tube should be replaced immediately upon defi nite identifi cation of a tube cuff rupture. All
nurses, respiratory therapists, and physicians in our ICU are trained with regularly scheduled emergency simula- tions to perform standard tracheostomy tube replacements. The surgical supplies required for tube replacement are prepared in our ICU and are replaced regularly every month.
The patient reported here had a percutaneous tra- cheostomy with a formed tracheocutaneous fistula 3 years before admission to our ICU. One physician, 2 nurses, and 1 respiratory therapist participated in the tracheostomy tube replacement procedure. The proce- dure had 3 steps: preparation, replacement, and moni- toring (Figure 2).
Preparation. All team members washed their hands using a 7-step handwashing method before tube replacement. One nurse (nurse 1) terminated enteral nutrition and monitored vital signs once the tracheostomy tube cuff rupture was identified. The other nurse (nurse 2) prepared supplies according to a list; these supplies included a tracheostomy tube, paraffin cotton ball, povidone-iodine swab, two 10-mL syringes, gauze, fix- ing band, pressure gauge, ster- ile gloves, stetho- scope, and dilating forceps. Nurse 2 also made sure that the bedside sputum suction apparatus and resuscitation bag were in good condition for the tube replacement. The physician obtained written informed consent from
ICU day
1
3
10
16
20
24
Event
The infl ammatory index increased and anti-infective treatment was begun. The ventilator worked well.
Air leak around the tracheostomy tube was identifi ed and found to result from tracheostomy tube cuff rupture. The tracheostomy tube was then immediately changed.
Tracheostomy tube cuff rupture occurred again and the tracheostomy tube was instantly replaced again.
Tracheostomy tube cuff rupture occurred again, bronchofi berscopy was performed, and a white granular polyp was identifi ed in the tracheal wall next to the tracheostomy tube cuff. An extended-length tracheostomy tube was placed.
Tracheostomy tube cuff rupture occurred again, and the polyp was removed using a bronchofi berscope.
No rupture of tracheostomy tube cuff occurred. The patient’s condition was stable, but weaning from the ventilator was diffi cult.
Table 2 Timeline of patient events
Abbreviation: ICU, intensive care unit.
Using continuous pressure monitoring and
excluding irrelevant events facilitate the
immediate recognition of tube cuff rupture,
helping clinicians make timely management
decisions and ensure patient safety.
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the patient’s family, who were fully informed of the patient’s medical condition and the need for tube replacement.
Replacement. Nurse 1 was responsible for all medications and vital sign monitoring. Nurse 2 suctioned oral and tracheal secretions and then placed the patient in the supine position with the tracheostomy site fully exposed. Subsequently, nurse 2 worked with the respira- tory therapist to perform the replacement. The respira- tory therapist fi rst removed the gauze and straps used to secure the tracheostomy tube. The skin surrounding the tracheostomy site was disinfected and the residual gas in the tube cuff was removed with a syringe. During these procedures, nurse 2 fi xed the tube that was no longer secured with neck straps and an infl ated cuff. The respi- ratory therapist then put on a pair of sterile gloves, examined the new tube cuff, and lubricated the tube with a sterile paraffi n cotton ball. Nurse 2 removed the previous tube, and the respiratory therapist rapidly inserted the new tube. The respiratory therapist used a pressure gauge to infl ate the tube cuff to 25 to 30 mm Hg (about 5-8 mL of air) and fi xed the tube around the patient’s neck with cotton tape. The physician immedi- ately connected the tube to the ventilator. The physician led the team, which completed the procedure and took measures in case the tube replacement failed or the patient’s vital signs became abnormal.
Monitoring. Nurse 1 closely monitored the patient’s vital signs, ventilator alarms, and airway sputum. Nurse 2 and the respiratory therapist ensured that the tube was well fi xed and recorded the intubation time and type. Our patient’s tube replacement was successful, and effective ventilation and oxygenation were maintained through- out the procedure.
Care of the Extended-Length Tracheostomy Tube
A common tracheostomy tube is suffi cient for most patients. For patients with thick necks, tracheal mucosal injuries, or tracheal polyps, an extended-length tracheos- tomy tube might be a better alternative because of its fl exibility and soft texture. After the tube is successfully placed with bronchofi berscope guidance, the scale marks on the tube and the cotton tape used to secure the tube (at a 1-finger-width distance to prevent tube slipping) are recorded and checked during nursing shifts. Patients are helped to turn over once every 2 hours. During patient turning maneuvers, a nurse adjusts the tracheotomy tube and ventilator tubing to accommodate the change in the patient’s position and avoid placing additional strain on the tracheostomy site and cuff. After turning, the tube scale marks should be observed to avoid tube displace- ment. Oral and nasal secretions should be suctioned before turning the patient to observe the color and amount of secretions and avoid aspiration.
Figure 2 Flowchart of physicians, nurses, and respiratory therapists’ tasks during emergency replacement of a tracheostomy tube.
All team members wash their hands
Replacement
Monitoring Monitors the patient closely
Administers all medications and
monitors vital signs
Takes respon- sibility for the
procedure and connects trache-
ostomy tube to the ventilator
Makes sure the tube is well fi xed and records the intubation
time and type of tube
Nurse 1 Stops enteral nutrition and monitors vital
signs
Nurse 2 Prepares supplies according to the
list
Physician Obtains written
informed consent from the patient’s
family
Respiratory therapist
Preparation
Removes residual gas in the tube cuff,
disinfects skin around the tracheostomy site, and rapidly inserts the
new tracheostomy tube
Works with the respiratory
therapist to perform
replacement
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The parameters and alarm range of the
ventilator should be set according to the
patient’s medical condition, and indications
for ventilator weaning should be assessed
daily to reduce damage to the tracheal
wall by the airflow.
Preventing Ventilator-Associated Pneumonia
During Tube Cuff Rupture
Ventilator-associated pneumonia is a complication of pneumoperitoneum caused by artificial airway and can lead to prolonged hospital stays and an increased risk of death.10 The patient described here received long- term mechanical ventilation, and 20 days elapsed before the cause of the tracheostomy tube cuff rupture was identified and removed. During this period, preventing ventilator-associated pneumonia was of vital importance. Continuous real-time tube cuff pressure monitoring was conducted with a pressure gauge. Our patient’s body temperature ranged from 36.2 °C to 36.8 °C during repeated tracheostomy tube cuff ruptures, with no evident variation in inflammatory indicators.
Other nursing measures were carried out according to the guidelines of our ICU. The main points of the guidelines are as follows. (1) The patient’s back is clapped during turning maneuvers. To help the patient expel sputum, percussion is applied to the patient’s back twice daily, during which the tube is fixed firmly and the head of the bed is elevated by 30° to 45°. (2) Subglottic secre- tions are suctioned in a timely manner when a patient has a tracheal catheter that allows for subglottic suction; oral and nasal secretions are suctioned before turning a patient with an extended-length tube. After tube cuff rupture, the tracheostomy tube is replaced immediately and oral and nasal secretions are suctioned. (3) The ventilator circuit is replaced weekly or when it becomes contaminated. The condensate collected in the ventila- tor is removed in a timely manner. (4) Oral care is performed every 6 hours and checked by the responsi- ble head nurse. The tracheostomy site is disinfected twice daily at the time of gauze replacement. (5) Aseptic procedures are strictly followed during airway opera- tions. (6) Early rehabilitation training is recommended when the patient’s condition allows.
Prevention and Treatment of Complications
After Polyp Removal
Bleeding. Measures to prevent bleeding included the following: (1) 1 mL epinephrine (diluted 1:1000 with normal saline) injected at the basal part of the surgical site using a bronchofiberscope; (2) 1 mL epinephrine (diluted 1:1000 with normal saline) instilled into the airway at the bedside 3 times daily, 3 days after excision of the tracheal polyp; (3) continuous tube cuff pressure monitoring
during the week after the operation to prevent excessive pressure that would cause bleeding; and (4) placement of a tracheal catheter that allowed for subglottic suction so bleeding could be observed. A pressure of –40 to –60 mm Hg11 was used for continuous subglottic suctioning, and the color and volume of sputum were observed. The patient had a hemoglobin level of 8.1 g/dL (to convert to g/L, multiply by 10) before tracheal polyp removal, and her hemoglobin level ranged from 7.9 g/dL to 8.5 g/dL within 1 week of polyp removal. No postoperative bleed- ing was observed in subglottic or airway secretions.
Tracheal Polyp Recurrence. Tracheal polyps can result from multiple factors, such as improper placement of the tracheostomy tube, frequent translocation, improper sputum suctioning, airway infection, and airflow impact.5 In addition to the mea- sures used to prevent ventilator- associated pneumo- nia, the tube and ventilator circuit should be well fixed during turning maneuvers to avoid traction and translocation, thereby preventing polyp recurrence. Sputum suction- ing should be performed as required in a gentle manner. During sputum suctioning, the frontal part of the tube should be lubricated with sterile paraffin to decrease irritation to the tracheal wall. The parameters and alarm range of the ventilator should be set according to the patient’s medical condition, and indications for ven- tilator weaning should be assessed daily to reduce dam- age to the tracheal wall by the airflow.
Conclusion The patient reported here had a tracheal polyp with
a rough texture that induced repeated tracheostomy tube cuff rupture. Identifying the cause of the rupture took a long time because of the limited clinical experi- ence. However, the tube cuff rupture was managed immediately after it was recognized because of coopera- tion between the physicians and respiratory therapists in our ICU, and there was no evidence of tube cuff rup- ture after successful treatment. With the continuous development of mechanical ventilation technology,
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more and more patients receive long-term mechanical ventilation, and complications related to artificial airway also increase accordingly. Tracheal polyps are a common clinical complication of long-term artificial airway.
The experience with this patient suggests that when caring for patients with long-term intubation or mechani- cal ventilation, nurses should follow standard procedures for sputum suctioning. When a patient has a cough, auscultation reveals a sound consistent with sputum, or oxygen saturation as measured by pulse oximetry decreases, sputum should be suctioned. Regularly sched- uled suctioning is not recommended. The suctioning procedure should be gentle. The ventilator circuit should be properly fixed and the patient should be evaluated for ventilator weaning and extubation. Oxygenation, venti- lator low-pressure alarms, and changes in tube cuff pres- sure should be monitored to identify a tube cuff rupture as soon as possible. After a tube cuff rupture is identified, bronchoscopy should be performed as soon as possible. If tracheal polyps are found, they should be removed as
necessary due to the patient’s condition to ensure the patient’s safety. The case described here provides a refer- ence for the treatment and nursing of patients with sim- ilar medical conditions. CCN
Financial Disclosures None reported.
See alsoSee also To learn more about caring for patients with tracheostomy tubes, read “Speech and Safety in Tracheostomy Patients Receiving Mechanical Ventilation: A Systematic Review” by Pandian et al in the American Journal of Critical Care, 2019;28(6):441-450. https://doi.org/10.4037/ ajcc2019892. Available at www.ajcconline.org.
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