In Anesthesiology june 2012 there is a case report describing a rare complication after tracheostomy. It describes the creation of an obstructing mucosal flap as sequele after a percutaneous dilatational tracheostomy. As long as the patient was cannulated the flap was splinted to the side of the trachea and the airway remained unobstructed. Problems arose at decannulation.

The case report
Rocco Trisolini & co describe how the flap created a one way valve that obstructed  the airway during expiration. The patient became stridorous and had to be recannulated. Eventually the flap had to be coagulated and surgically removed.

The screenshot to your right is taken out of the case report. The trachea is open during inspiration but is clearly obstructed during expiration.

Our own experience
Not too long ago we had a nearly identical case. Our first attempt at decannulation almost went to hell, as we lost the airway after removing the cannula, before successfully recannulating.

Later we obtained some fiberscopic footage of the floating tracheal flap moving in synchrony with respirations. During expiration the patients’ airway was significantly obstructed.

Take-home message
As far as I know this is a rare complication in percutaneous tracheostomies. Still it reminds us how decannulating tracheostomies is a serious event that demands preparation and attention, just like any extubation. Nothing is safe.

Trisolini R, Giovannitti A, Patelli M.Tracheal
Flap after Percutaneous Dilatational Tracheotomy.
Anesthesiology. 2012 Feb 3. [Epub ahead of print] No abstract available.

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