B80-1-05 Silent Pressure: Circumferential Tracheal Necrosis as Complication of Endotracheal Tube Cuff Overinflation

Circumferential tracheal necrosis is an extremely rare complication that has only been described in a handful of isolated case reports or small series in medical literature. A common cause is cuff overinflation where cuff pressure exceeds mean capillary pressure of 20 cm H2O in tracheal mucosa. Despite understanding the pathophysiologic mechanism, few clinical tools exist to assist clinicians in preventing this potentially devastating complication. A 35-year-old male with hypertension, hyperlipidemia, uncontrolled type 2 diabetes mellitus, and tobacco misuse disorder presented via lateral intensive care unit transfer for tracheostomy and gastrotomy tube in the setting of tracheal stenosis. Two months prior, the patient suffered a hemorrhagic left pontine stroke secondary to hypertensive crisis and hospital course was complicated by failed extubation, ventilator-associated tracheobronchitis, and tracheal stenosis confirmed by tracheal inflammation on bronchoscopy. Upon arrival, CT soft tissue of neck showed markedly dilated endotracheal balloon at the level of the thyroid gland and extending from mid C6 to mid T1 level measuring approximately 5 cm in diameter (Figure 1). Patient was found to have 4 cm circumferential tracheal wall necrosis at the site of the inflated endotracheal tube at the level of the cricoid intraoperatively. When the cuff was deflated and drawn back, two 3 cm tracheoesophageal fistulas (TEFs) were found. TEF closure with pharyngoesophagoplasty, tracheostoma inferior to absent trachea with maturation to inferior skin edge, and laryngotracheal separation were subsequently performed. Postprocedural complications included fungal infection and small posterior and superior wall stomal dehiscence. It is important to closely monitor cuff pressures during hospitalization to mitigate risk from its insidious increase under different ventilator settings. Hypotensive, obese, and immunocompromised patients have been indicated to show higher risk for laryngotracheal injury. Although current mechanical ventilator liberation guidelines exist, there is a need for more reports on tracheal necroses and/or stenoses to help develop better risk stratification tools for early detection as well as a more standardized approach to manage this preventable complication. This abstract is funded by: None