A52-09 Troubleshooting the Ventilator: Obstructive Shock Following Tracheostomy Cuff Overinflation

Introduction Tracheostomy cuff overinflation causing obstructive shock is an exceptionally rare, life-threatening event that may mimic other ventilator emergencies. This complication is preventable through cuff pressure monitoring and vigilant stepwise troubleshooting during mechanical ventilation. Case Description A 66-year-old woman with diabetes, hypertension, and morbid obesity presented with altered mental status following heat exposure. On arrival, she was tachycardic, hypotensive (BP 70/40 mmHg), febrile (104.8 °F), and tachypneic, with a Glasgow Coma Scale of 7, necessitating intubation. Bilateral crackles were present; WBC was 25.3 K with left shift. She was treated for septic shock from presumed urinary tract infection and aspiration pneumonia, as well as heat stroke, using fluids, antibiotics, and norepinephrine.After clinical improvement, failed ventilator weaning led to brain MRI revealing a parietal infarct. Following discussion with her family, she underwent percutaneous tracheostomy and PEG tube placement. Immediately post-procedure, the patient developed hypotension requiring escalating norepinephrine and showed fluctuating tidal volumes (0-450 mL). Systematic ventilator troubleshooting was initiated: tracheostomy position was confirmed, suctioning performed, circuit integrity checked, and ventilation mode switched to pressure control, all without improvement.Upon tracheostomy cuff deflation, both hemodynamics and tidal volumes normalized instantly. Vasopressor support was discontinued, and the patient subsequently tolerated PEG placement and was discharged days later. Discussion This case illustrates acute obstructive shock secondary to tracheostomy cuff overinflation, a mechanism rarely described in adults. Excess cuff pressures (>50 cm H2O) can compress the tracheal wall or distort the tube’s alignment, creating near-complete airway obstruction. The resulting rise in intrathoracic pressure reduces venous return, mimicking tension physiology and precipitating obstructive shock. Patients may initially exhibit high peak inspiratory pressures, low compliance, or tidal volume variability before manifesting overt hypoxemia or hypotension.Existing literature describes similar events after endotracheal or tracheostomy cuff hyperinflation, with rapid reversal upon deflation. Manual estimation of cuff tension is unreliable; manometry remains the only accurate method to maintain pressures within 20-30 cm H2O. The DOPES mnemonic (Displacement, Obstruction, Pneumothorax, Equipment, Stacked breaths) guided our approach, underscoring that cuff overinflation should be considered when conventional troubleshooting fails.This report reinforces the importance of standardized cuff pressure monitoring protocols during tracheostomy management. Early recognition of this reversible cause of obstructive shock can prevent progression to cardiopulmonary arrest and highlights a critical, under-recognized pitfall in ventilator troubleshooting.