Misdirected minitracheostomy tube repositioned using broncho
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Minitracheostomy tube is commonly used for the removal of secretions in patients with excessive pulmonary secretions and poor cough efforts. It can also be used for high-frequency jet ventilation in patients with acute airway obstruction or poor respiratory efforts.

Published in the journal Annals of Cardiac Anaesthesia, the authors describe an obese, male patient (body weight 86 kg, body mass index 33.5 kg/m 2 ) who after an uneventful triple-vessel coronary artery bypass graft surgery and left ventricular aneurysmorrhaphy developed intracerebral hemorrhage and subsequently required minitracheostomy due to obtunded consciousness level, poor cough efforts, and retained tracheobronchial secretions.

A percutaneous, flanged, reclosable 4 mm internal diameter tube was inserted smoothly through the cricothyroid membrane, using Seldinger technique after aspiration of air from the trachea by an experienced operator.

Immediate chest X-ray revealed misdirected tube, facing upward toward the laryngeal opening. The tube was repositioned using bronchoscope and no further untoward event happened.

Learning Points:-

• The case described underlines the importance of the fact that classical method of railroading a minitracheostomy tube over guidewire and introducer may sometimes result in misdirection.

• It may be advisable to perform direct laryngoscopy or bronchoscopy to ensure that retrograde passage of guidewire, introducer, and hence minitracheostomy tube has not occurred.

• Aspiration of air may not necessarily indicate correct placement of the minitracheostomy tube.

• In addition, direction of puncture needle may change during the procedure, resulting in malposition/misdirection of the guidewire.

• In patients with difficult anatomy (short, thick neck, tissue swelling, goiter, previous neck surgery), assistance of an ENT surgeon or a formal tracheostomy may be required.

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