Fracture and migration of a metallic tracheostomy tube: anesthetic considerations and case review

doi:10.21203/rs.3.rs-8034289/v1

Background
Tracheostomy is commonly performed to maintain airway patency or to provide prolonged ventilatory support in elective and emergency settings. Although it offers substantial benefits, tracheostomy may be associated with early and late complications. Fracture and migration of a tracheostomy tube are exceptionally rare, with an incidence of less than 1 in 1000 cases. Such events can lead to life-threatening airway obstruction and present significant anesthetic and airway management challenges during retrieval.

Case Presentation

We report a 27-year-old male with a tracheostomy placed 18 years ago for prolonged ventilation after a road accident. He had used the same metallic tube without replacement or follow-up. Presenting with mild cough, blood-tinged sputum, and chest tightness, imaging revealed a metallic foreign body in the right main bronchus. Emergency rigid bronchoscopy under general anesthesia allowed successful retrieval of the fractured inner tube through the tracheostomy stoma. Recovery was uneventful.

Literature review identified 16 similar case reports of fractured tracheostomy tubes. Both spontaneous and controlled ventilation techniques were used in these cases, emphasizing that anesthetic management should be individualized based on patient stability, airway conditions, and procedural requirements.

Conclusions

Fracture and migration of metallic tracheostomy tubes are rare but potentially life-threatening. Regular follow-up and timely tube replacement are vital for prevention. Effective management requires coordinated teamwork, careful anesthetic planning, and flexibility in ventilation strategies to ensure safety and good outcomes.

Anesthesiology & Pain Medicine

tracheostomy

airway management

foreign body

anesthesia

bronchoscopy

tracheostomy tube fracture

Tracheostomy is a commonly performed procedure in both emergency and elective settings to secure the airway or provide prolonged ventilatory support. Its main indications include upper airway obstruction or respiratory failure¹. In recent years, tracheostomy rates in the pediatric population have increased due to advancements made in neonatal and emergency medicine, which have significantly improved survival rates in children with complex conditions such as congenital anomalies, severe respiratory distress, traumatic brain injuries, and birth asphyxia². Furthermore, the development of consensus guidelines has established a more standardized approach to tracheostomy care for both acute management and long-term follow-up in children and adults³.

Although tracheostomy offers clear benefits in airway management, it is not without risk. Complications are broadly categorized as early and late. Early complications, typically occurring within the first week, include bleeding, infection, subcutaneous emphysema, tube obstruction, and accidental dislodgement. Late complications, may involve the suprastomal, stomal, or infrastomal areas and include tracheal stenosis, tracheomalacia, granulation tissue, tracheoesophageal fistula, tracheoinnominate artery fistula, and tracheocutaneous fistula. Some complications are minor and self-limiting, while others may be life-threatening, requiring prompt recognition and intervention⁴.

Incidence of fractured tracheostomy tube is low with an incidence rate of < 1/1000 ⁵. Management of a fractured tracheostomy tube and retrieving a dislodged fragment can be challenging. The mode of ventilation proposed includes either controlled or spontaneous ventilation. Studies suggest that the choice of anesthetic technique is often individualized based on the patient’s airway condition and surgical requirements, and may be modified as needed during the procedure⁶⁷. We report the case of a 27-year-old male who underwent elective tracheostomy at age 9 for prolonged mechanical ventilation and presented 18 years later with tube fracture and migration. This case highlights the importance of individualized anesthetic strategy, long-term follow-up, and awareness of delayed tracheostomy-related complications.

A 27-year-old male with a history of road traffic accident had undergone prolonged mechanical ventilation in the past and subsequently underwent elective tracheostomy to bypass subglottic stenosis. He had been using a metallic tracheostomy tube for the past 18 years and was noncompliant with regular follow-up visits for decannulation assessment, and continued using the same pediatric metallic tracheostomy tube, which he cared for independently.

One day before the presentation, he noticed that the inner tube of his tracheostomy tube was missing. He reported a productive, non-purulent, intermittent cough with blood-tinged sputum and chest discomfort described as tightness and pain on movement. There was no fever, stridor, or respiratory distress.

On pre-anesthetic evaluation, the patient was alert and cooperative. His vital signs were: pulse rate 88/min, SpO₂ 93% on room air, and blood pressure within normal limits. Airway examination revealed a mature tracheostomy stoma with the outer metallic tracheostomy tube in situ, secured with elastic strap, but the inner tube was missing (Fig. 1). Respiratory examination demonstrated bilateral air entry with mild wheeze and conducted sound on the Right middle lung zone; cardiovascular and neurological examinations were unremarkable. He was classified as ASA II (E).

Preoperative investigations included comprehensive metabolic profile which were within normal reference range. Chest X-ray revealed a foreign body in the right main bronchus (Fig. 2). Patient was immediately shifted to the operating room for emergency rigid bronchoscopy and foreign body removal under general anesthesia.

Patient was premedicated with intravenous glycopyrrolate 0.2 mg, 100mg of hydrocortisone, and nebulization with 2% lignocaine with adrenaline via the stoma of the tracheostomy tube. Supplemental oxygen was administered via nasal cannula at a flow rate of 4 L/min and was maintained throughout the duration of the procedure. Anesthesia was planned under general anesthesia with preservation of spontaneous ventilation to preserve the airway. Then, 2ml of 2% lignocaine was injected locally at the stoma site, and 3ml of 2% lignocaine with adrenaline was given via the transtracheal route to anesthetize the airway and prevent coughing and tendency to breath-hold when using the volatile agent.

Induction was achieved with sevoflurane (6%) followed by bolus intravenous fentanyl 100 µg, propofol 50 mg (repeated once). Sedation was maintained with a propofol infusion at 25mg/kg/min, titrated as required. The metallic tracheostomy outer tube was removed and replaced with a non-metallic tube. The ventilation check was done, and it was successful. After removing the non-metallic tube, rigid bronchoscopy was attempted via the tracheostomy stoma; however, the cough reflex persisted during the first attempt. To deepen anesthesia, an additional 50 mg of propofol and 20 mg of ketamine were administered. Then for muscle relaxation became necessary, succinylcholine 100 mg was given, and with the addition of ketamine 20 mg intraoperatively, rigid bronchoscopy was reattempted (Fig. 3). On the third attempt, the foreign body was successfully retrieved (Fig. 4).

Subsequently, flexible bronchoscopy was performed to inspect the airway, confirming no mucosal injury or retained fragments. Throughout the procedure, vital signs remained stable. After securing the non-metallic tracheostomy tube of 6.0mm ID (Fig. 5), adequate ventilation was confirmed, thorough suctioning of the tracheostomy tube was done, and the patient was awakened at the end of surgery.

The patient was transferred to the high-dependency unit (HDU) for observation. His postoperative course over 24 hours was uneventful, with stable hemodynamics and adequate ventilation. He was shifted to the ward the following day and discharged thereafter. At follow-up, he remained asymptomatic with no respiratory distress or cough.

To place this uncommon complication in context, the present case integrates our experience with existing literature on anesthetic and airway management during tracheostomy tube fractures. By examining both our approach and previously reported strategies, we highlight the anesthetic challenges, clinical decision-making, and individualized management necessary to ensure patient safety and successful retrieval of the fractured segment.

We conducted a literature search in MEDLINE without time restrictions using the terms (“tracheostomy”[MeSH Terms] OR “tracheostomy tube”[All Fields]) AND (fracture OR breakage OR migration OR complication) AND (metallic OR metal). The search identified 73 articles, of which 41 were case reports. After excluding non-English articles, those without available full text, and those irrelevant to our topic, 10 case reports were selected for detailed review. Additionally, 6 case reports were identified from reference lists and independent searches on Google Scholar. In total, 16 cases [Table 1] were found to be directly relevant and were included in the discussion [Figure 5].

In this case, we report a fracture and migration of a metallic tracheostomy tube inner cannula into the right main bronchus after 18 years of continuous use in a 27-year-old male who had undergone elective tracheostomy for prolonged ventilation. Fracture of a metallic tracheostomy tube is a rare but potentially serious complication, with reported cases ranging from a few days to over 20 years after insertion (²⁴,²⁵). A retrospective study of four patients with metallic tracheostomy tubes showed that fractured fragments most commonly lodged in the right main bronchus, and patients presented with sudden dyspnea, cough, or even cardiac arrest. Removal required rigid or flexible bronchoscopy under either local or general anesthesia ²⁶.

In our patient, the fracture occurred after an exceptionally long duration of use, and the fragment lodged in the right main bronchus, consistent with reports that the right bronchus is a more common site due to its anatomy. We found 14 cases of metallic tube fracture, where seven cases had localization of fractured metallic tube in right main bronchus Table 1. Presenting symptoms of tracheostomy tube fracture may include cough, hemoptysis, wheezing, recurrent pneumonia, and respiratory distress, with the duration of symptoms before diagnosis ranging from 1 day to 132 months ²⁷. In our case, symptoms were present for only one day and were relatively mild, limited to intermittent cough and chest discomfort, highlighting that even subtle changes in patients with long-standing tracheostomies may indicate potentially life-threatening complications.

Several factors contribute to tracheostomy tube fracture. These include prolonged wear-and-tear and aging ²⁸, as well as patient noncompliance with regular tube changes. Mechanical stress from repeated removal and reinsertion can lead to early erosion²⁹, while repeated sterilization may cause corrosion due to exposure to oxygen, moisture, and temperature, creating internal stresses that promote alkali-mediated corrosion [³⁰, ^28,29,31]. Design defects of the tubes have also been reported as a contributing factor [^{3028,29,31,32}]. This may have played a role in our case, as the patient had been lost to follow-up and was managing the metallic tracheostomy tube independently.

Anesthetic management was a crucial aspect in the treatment and removal of the tracheostomy tube fragment in this case. We administered General anesthesia while preserving spontaneous ventilation initially, supplementing with local transtracheal lignocaine to minimize coughing and airway irritation during rigid bronchoscopy. During the procedure, the patient developed a persistent cough, which resolved upon increasing the depth of anesthesia and administration of neuromuscular blockade. A review and meta-analysis of fractured tracheostomy tubes and dislodgement into the bronchial tree have described the use of both controlled and spontaneous ventilation during the administration of general anesthesia. It also describes no definitive advantage between the two techniques in the process of retrieving foreign bodies, but found that controlled ventilation was associated with a lower incidence of laryngospasm and shorter operative duration. The findings emphasize that the selection of an anesthetic technique should be individualized according to the patient’s clinical condition and procedural requirements ⁶. In our case, we had to switch from spontaneous ventilation to controlled ventilation during the retrieval of a foreign body.

In a review of 16 published cases, eight procedures were performed under general anesthesia with controlled ventilation, six under general anesthesia with spontaneous respiration, one initially under spontaneous ventilation and later converted to controlled ventilation, and one under local anesthesia, reflecting the variability in anesthetic approaches for such cases. (Table 1). Spontaneous ventilation offers the advantage of reducing the risk of distal displacement of the foreign body and allows continuous assessment of airway patency during removal. However, it requires deep anesthesia, which may depress cardiac output and ventilation, while instrumentation further increases airway resistance, worsening hypoventilation. In contrast, using a muscle-relaxant technique provides a paralyzed airway, improving surgical conditions and facilitating extraction. It also enables balanced anesthesia with better hemodynamic stability, while positive-pressure ventilation enhances oxygenation, reduces atelectasis, and overcomes increased airway resistance caused by telescopes. A review found no significant difference in outcomes between spontaneous and controlled ventilation, although some spontaneous cases required conversion to positive-pressure ventilation during the procedure⁷.

Long-term use of metallic tracheostomy tubes may predispose to fracture and migration. Regular tube replacement and follow-up are essential to prevent such late complications. Individualized and flexible anesthetic planning ensures safe management when such rare events occur.

Authors’ contributions:

Y.K., R.G., and P.G. contributed equally to the conception, data collection, and drafting of the manuscript. R.G. and P.G. also performed data analysis and literature review. R.S. and S.O. assisted in manuscript editing and formatting. L.N. contributed to figure preparation and critical revision of the manuscript. All authors reviewed and approved the final version of the manuscript.

Acknowledgements:

Not applicable

Funding:

Not applicable.

Data availability:

The data sets are available from the corresponding author on request.

Ethics approval and consent to participate:

This case report was approved by institution ethics committee of Institute of Medicine, Tribhuwan University Teaching Hospital. The patient has signed the informed consent for the surgical and anesthetic management.

Consent for publication:

Written consent was obtained from the patient for publication and any accompanying images.

Competing interests:

The authors declare that they have no competing interests.

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Table 1. Summary of reported cases of fractured tracheostomy tubes with dislodgement, anesthetic management, and outcomes.

No.

Author (Year)

Age/Sex

Tube Type / Fracture Site

Dislodged Location / Presenting Signs

Anesthetic Technique / Management

Outcome

1.

Afiadigwe EE, et al (2024)⁸

56/M

Metallic, shaft–flange junction

Trachea at carina; cough, choking, dyspnea (4 h), RR 46, mucus via stoma, fever, SpO₂ 90%

Emergency bronchoscopy under GA via tracheostomy stoma; fragment retrieved with forceps

Uneventful recovery; discharged stable

2.

So-Ngern A, et al (2016)⁹

65/M

Metallic, outer tube

Left main bronchus; fever, purulent cough, tachypnea

GA; flexible bronchoscopy with balloon catheter; fragment removed through stoma with rigid bronchoscope

Uneventful recovery; discharged stable

3.

Vakili Ojarood M, et al (2023)¹⁰

11/F

Metallic, neck plate

Right main bronchus; respiratory distress

Deep sedation; rigid bronchoscopy via tracheostomy; fragment removed

Uneventful recovery; discharged stable

4.

Loh TL, et al (2013)¹¹

70/F

PVC, mid-shaft

Right main bronchus; right-sided pneumonia

Sedation with intermittent ventilation; flexible bronchoscopy; new tube inserted

Recovered from pneumonia; stable follow-up

5.

Bo LJ, et al (2018)¹²

77/M

Metallic, junction

Left main bronchus; cough, bleeding at stoma

GA with spontaneous respiration (dexmedetomidine, sufentanil, midazolam, tetracaine, propofol); fragment removed; new tube placed

Uneventful recovery; discharged stable

6.

Fityani M, et al (2025)¹³

43/M

Stainless steel, distal end

Left main bronchus; asymptomatic; SpO₂ 88% RA → 95% on 2 L NC

GA; initial flexible bronchoscopy failed; rigid bronchoscopy with standby ECMO; fragment removed

Uneventful recovery; discharged stable

7.

Otto RA, et al (1985)¹⁴

3/M

Metallic, junction

Right main bronchus; respiratory distress

Rigid bronchoscopy under GA

Uneventful recovery; discharged stable

8.

Hajipour A, Khan ZH (2007)¹⁵

30/M

Metallic (zinc–copper alloy), shield–tube junction

Right main bronchus; aspiration during suctioning

GA; IV sufentanil, midazolam, lidocaine; halothane induction; rigid bronchoscopy; plastic tube inserted

Uneventful recovery; discharged stable

9.

Gupta SC (1996)¹⁶

10/M

Fuller's biflanged metallic tube; flanges fractured

Right main bronchus and left lung; asymptomatic

Bronchoscopy under GA; partial retrieval; thoracotomy deferred

Asymptomatic on follow-up; stable

10.

Jensen OV (1988)¹⁷

14 mo/M

PVC, junction

Trachea; mild respiratory distress

GA; rigid bronchoscopy via tracheostoma; new tube inserted

Successful removal; stable recovery

11.

Bhargava SK (1993)¹⁸

55/M

Metallic, introducer

Right main bronchus; dyspnea

Rigid bronchoscopy under local anesthesia; fragment removed

Uneventful recovery

12.

Piromchai P (2010)¹⁹

14/M

Metallic, inner tube & connector

Right main bronchus; cough ×2 weeks

GA; bronchoscopic removal via tracheostomy stoma

Pneumonia treated; full recovery at 1-month follow-up

13.

Williams MA (1987)²⁰

2.5/F, 3/M

PVC, junction / footplate

None / cyanosis

Sedation; spontaneous ventilation; tracheostomy tube exchanged over Frova catheter

Uneventful postoperative course

14.

Kantar B et al. (Year not specified)²¹

9/M

Tracheostomy cannula; inner tube–connector junction

Left main bronchus; acute respiratory distress, SpO₂ 78%

Mask ventilation; propofol + rocuronium; rigid bronchoscopy; new tube inserted

Uneventful recovery

15.

Kadasah SK et al. (2025)²²

10/F

Metallic; fracture site not specified

Right main bronchus; desaturation to 65–70%, chest tightness

Initially spontaneous; converted to controlled; fragment removed with forceps; new Shiley tube inserted

Uneventful recovery; stable

16.

Kashoob M et al. (2020) ²³

20/M

Metallic double-lumen, shaft–flange junction

Right main bronchus; fever, respiratory distress, altered consciousness

GA; rigid ventilating bronchoscope (8.5 mm); fragment removed; new cuffed tube inserted

ICU stay for pneumonia; stable recovery

Abbreviations: GA: general anesthesia; PVC: polyvinyl chloride; RA: room air; NC: nasal cannula; ECMO: extracorporeal membrane oxygenation; ET: endotracheal tube; SpO₂: peripheral oxygen saturation; RR: respiratory rate.

The authors declare no competing interests.

Fracture and migration of a metallic tracheostomy tube: anesthetic considerations and case review

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Abstract

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Background

Case Presentation

Methods

Discussion

Conclusion

Declarations

References

Table

Additional Declarations

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