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Case Reports
. 2014 Feb 25;4(1):e13152.
doi: 10.5812/aapm.13152. eCollection 2014 Feb.

A case of death caused by tracheal tube aspiration

Alireza Mirkheshti  1 , Morteza Jabbary Moghadam  1 , Mohamad Shahab Kalantar  1 , Dariush Abtahi  1 , Elham Memary  1
Affiliations
Case Reports

A case of death caused by tracheal tube aspiration

Alireza Mirkheshti et al. Anesth Pain Med. .

Abstract

Introduction: Airway management, especially outside the operating room, needs meticulous observation in order to avoid certain risks, such as; endotracheal tube (ETT) disloca-tion, esophageal intubation, and unwanted extubation. ETT or tracheostomy dislocation is responsible for one-half of death or brain damage cases in the ICU. Despite appropri-ate fixation of an ETT, the previously mentioned compli-cations can still occur . A broken ETT and consequent airway obstruction may lead to lethal complications.

Case presentation: We report a case of death caused by tracheal tube aspiration, where it was located distal to the vocal cords, with a part of it entering the right bronchus and the mediastinum, after tearing the right bronchus.

Discussion: The vigilance and experience of medical personnel in the ICU, appropriate IV sedation, and using a bite block are the best ways to prevent mortality caused by aspiration of an ETT in all intubated patients.

Keywords: Airway Management; Endotracheal Intubation Complications; Endotracheal Intubation Mortality.

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Figures

Figure 1.
Figure 1.. Broken Endotracheal Tube Showing the Bite Site
Figure 2.
Figure 2.. Chest X-Ray of Patients After Second Intubation (Postmortem)
See this image and copyright information in PMC

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