Percutaneous dilatational tracheostomy associated with mismatched tracheostomy tubes and introducer sets in a 57-year-old Korean man: a case report
Year: 2026
Type: article
Study design: Case Report
Abstract: Percutaneous dilatational tracheostomy (PDT) is widely used for prolonged ventilation; however, dilatation-related complications may be underrecognized. We report a complication of tracheostomy malposition induced by tissue stretching during PDT, in which an excessively dilated tract fails to recoil adequately around the tube, compromising the cuff seal. A 57-year-old Korean man was admitted for recurrent seizures. PDT was performed under bronchoscopic guidance without immediate complications. Three days after the first PDT, partial tracheostomy tube dislodgment resulted in a 40%–60% ventilator leak. Sedation, tube reinsertion, and cuff reinflation were attempted; however, the leak worsened to 99%, necessitating rapid sequence intubation. Retrospective review of the bronchoscopic images demonstrated tracheal tissue stretching during initial insertion, suggesting excessive traction on the anterior tracheal wall. A size mismatch between the loading dilator and the tracheostomy tube likely created a gap that allowed tracheal tissue to be drawn into the tract and then recoil, contributing to malposition. Clinicians should recognize this potential complication, monitor for high ventilator leak rates, cuff-pressure abnormalities, and radiographic malalignment, and be prepared to perform repeat tracheostomy or endotracheal intubation if necessary.
Source: JOURNAL OF ACUTE CARE SURGERY
Institution: National Health Insurance Service Ilsan Hospital
Language: English
Subfield: Pulmonary and Respiratory Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: diamond
OpenAlex ID: W7140859808