Authors: Yashoda Khadka, Raman Goit, Prakash Gupta, Rahul Sharma, Suyog Ojha, Linh Nguyen
Categories: Case Report, Tracheostomy, Airway management, Foreign body, Anesthesia, Bronchoscopy, Tracheostomy tube fracture
Source: BMC Anesthesiology
Authors: Yashoda Khadka, Raman Goit, Prakash Gupta, Rahul Sharma, Suyog Ojha, Linh Nguyen
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 is 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.
We report a 27-year-old male (weight 50 kg, height 172 cm, BMI 16.9 kg/m^2^) who had tracheostomy tube placed 18 years ago for prolonged ventilation after a road traffic accident. He had used the same metallic tube without replacement or follow-up. He presented 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 outer tube through the tracheostomy stoma. Recovery was uneventful.
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.
Tracheostomy is a commonly performed procedure in both emergency and elective settings to secure the airway or provide prolonged ventilatory support. Main indications include upper airway obstruction or respiratory failure [1]. In recent years, tracheostomy rates in the pediatric population have increased due to advancements 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 asphyxia [2]. 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 adults [3].
Although tracheostomy offers clear benefits for 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 intervention [4].
Incidence of fractured tracheostomy tube is low with an incidence rate of < 1/1000 [5]. Management of a fractured tracheostomy tube and retrieval of a dislodged fragment can be challenging. The mode of ventilation recommended 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 procedure [6]^,^ [7]. 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 man (weight 50 kg, height 172 cm, BMI 16.9 kg/m^2^) with a history of a 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.
One day before his presentation to the hospital, he noticed that the outer 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 pulse rate 88/min, SpO₂ 93% on room air, and blood pressure within normal limits. Airway examination revealed a mature tracheostomy stoma with the inner metallic tracheostomy tube in situ, secured with an elastic strap, but the outer 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).
Fig. 1Clinical image showing mature tracheostomy stoma with inner metallic tube secured by neck strap
Preoperative investigations included a comprehensive metabolic profile, which was within normal reference range. Chest X-ray (PA view) revealed a foreign body in the right main bronchus (Fig. 2). The patient was immediately transferred to the operating room for emergency rigid bronchoscopy and foreign body removal under general anesthesia. Due to the emergency presentation and financial constraints, a CT scan could not be performed. After a multidisciplinary discussion between the ENT and anesthesia teams, the decision was made to proceed with intervention based on chest radiograph findings alone. Flexible bronchoscopy was not performed, and rigid bronchoscopy was planned as both a diagnostic and therapeutic modality, offering better airway control and safer retrieval of the metallic foreign body.
Fig. 2Chest X-ray showing fractured metallic tracheostomy tube lodged in right main bronchus
The patient was premedicated with intravenous glycopyrrolate (0.2 mg), hydrocortisone (100 mg), and nebulization with 3 ml of 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. General anesthesia was planned with preservation of spontaneous ventilation to maintain airway patency during the initial airway management. Subsequently, 2 ml of 2% lignocaine was injected locally at the stoma site, and 3 ml of 2% lignocaine with adrenaline was given via the transtracheal route to further anesthetize the airway and prevent coughing and tendency to breath-hold when using the volatile agent. The backup strategy (Plan B) involved mechanical ventilation with muscle relaxation, using rocuronium with sugammadex readily available for rapid reversal if indicated, and the Cardiothoracic surgery team was informed regarding the possible need for Extra corporeal membrane oxygenation (ECMO).
Induction was achieved with inhalation of sevoflurane (6%) followed by bolus intravenous fentanyl 100 µg and propofol 50 mg (repeated once). Inhalational induction provides a gradual, controlled, and reversible transition to general anesthesia, allowing for early detection of ventilation difficulties and improving patient safety in this high-risk airway scenario. Therefore, inhalation induction was chosen in our case.
The tracheostomy tube was first checked for patency by suctioning and confirming easy passage of a suction catheter. Under local anesthesia, the remaining metallic tracheostomy tube was removed, and a size 6.0 mm ID Portex (PVC) tracheostomy tube was inserted through the stoma. The anesthesia circuit was primed with sevoflurane in oxygen. The patient was allowed to breathe spontaneously through the tracheostomy tube, using a tight-fitting tracheostomy adapter. Ventilation was continuously monitored using capnography and chest movement.
Sedation was maintained with a propofol infusion at 125 µg/kg/min, titrated up to 150 µg/kg/min to maintain the depth of anesthesia. The metallic tracheostomy inner 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 (Karl Storz rigid bronchoscope size 3.7, of ID 5.7, OD 6.4, length 26 cm) was attempted via the tracheostomy stoma; however, the cough reflex was present during the first attempt. To deepen anesthesia, an additional bolus of 50 mg of propofol and 20 mg of ketamine was administered. Then, for muscle relaxation, 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).
Fig. 3Intraoperative view during rigid bronchoscopy
Fig. 4A Retrieved fractured metallic outer tracheostomy tube; B internal intact and broken external pieces
Subsequently, rigid bronchoscopy was performed to inspect the airway, confirming no mucosal injury or retained fragments. No tracheal stenosis or granulation tissue was observed; the tracheal lumen appeared normal for an adult, and there were no features suggestive of chronic narrowing despite the prolonged presence of a pediatric-sized tube.
Throughout the procedure, vital signs remained stable. After securing the non-metallic tracheostomy tube of 6.0 mm 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.
Fig. 5Newly placed non-metallic tracheostomy tube securely positioned in a mature tracheostomy stoma
The patient was transferred to the high-dependency unit (HDU) for observation. His postoperative course over 24 h 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.
The literature review was conducted in accordance with a structured narrative approach, focusing on anesthetic management and retrieval techniques. We searched 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 43 were case reports. After excluding non-English articles, those articles with no 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 (Fig. 6).
Table 1Summary of reported cases of fractured tracheostomy tubes with dislodgement, anesthetic management, and outcomesNo.Author (Year)Age/SexTube Type / Fracture SiteDislodged Location / Presenting SignsAnesthetic Technique / ManagementOutcome1.Afiadigwe EE, et al. (2024)[8]56/MMetallic, shaft–flange junctionTrachea at carina;Presented with cough, choking, dyspnea, fever, SpO₂ 90%General anesthesia with controlled ventilation.Uneventful recovery; discharged stable2.So-Ngern A, et al. (2016)[9]65/MMetallic, outer tubeLeft main bronchus;Presented with fever, purulent cough, and tachypneaGeneral anesthesia with controlled ventilationUneventful recovery; discharged stable3.Vakili Ojarood M, et al. (2023)[10]11/FMetallic, neck plateRight main bronchus;Presented with respiratory distressSedation with spontaneous ventilationUneventful recovery; discharged stable4.Loh TL, et al. (2013)[11]70/FPVC, mid-shaftRight main bronchus;Presented with right-sided pneumoniaSedation with intermittent assisted ventilationRecovered from pneumonia; stable follow-up5.Bo LJ, et al. (2018)[12]77/MMetallic, junctionLeft main bronchus; Presented with cough and bleeding at the stoma siteGeneral anesthesia with preserved spontaneous ventilationUneventful recovery; discharged stable6.Fityani M, et al. (2025)[13]43/MStainless steel, distal endLeft main bronchus; asymptomaticGeneral anesthesia with controlled ventilationUneventful recovery; discharged stable7.Otto RA, et al. (1985)[14]3/MMetallic, junctionRight main bronchus;Presented with respiratory distressGeneral anesthesia with controlled ventilationUneventful recovery; discharged stable8.Hajipour A, Khan ZH (2007)[15]30/MMetallic (zinc–copper alloy), shield–tube junctionRight main bronchus; Presented with respiratory distressGeneral anesthesia with controlled ventilationUneventful recovery; discharged stable9.Gupta SC (1996)[16]10/MFuller’s biflanged metallic tube; flanges fracturedRight main bronchus and left lung; asymptomaticGeneral anesthesia with controlled ventilationAsymptomatic on follow-up; stable10.Jensen OV (1988)[17]14 mo/MPVC, junctionTrachea;Presented with mild respiratory distressGeneral anesthesia with controlled ventilationSuccessful removal; stable recovery11.Bhargava SK (1993)[18]55/MMetallic, introducerRight main bronchus; Presented with dyspneaLocal anesthesia with spontaneous ventilationUneventful recovery12.Piromchai P (2010)[19]14/MMetallic, inner tube & connectorRight main bronchus; Presented with coughGeneral anesthesia with controlled ventilationPneumonia treated; full recovery at 1-month follow-up13.Williams MA (1987)[20]2.5/F, 3/MPVC, junction / footplateNone /Presented with respiratory distress and cyanosisSedation with spontaneous ventilationUneventful postoperative course14.Kantar B et al. (Year not specified)[21]9/MTracheostomy cannula; inner tube–connector junctionLeft main bronchus; Presented with acute respiratory distressGeneral anesthesia with controlled ventilationUneventful recovery15.Kadasah SK et al. (2025)[22]10/FMetallic; fracture site not specifiedRight main bronchus; Presented with respiratory distress, chest tightnessInitially, spontaneous ventilation, subsequently converted to controlled ventilationUneventful recovery; stable16.Kashoob M et al. (2020) [23]20/MMetallic double-lumen, shaft–flange junctionRight main bronchus; Presented with fever, respiratory distress, and altered consciousnessGeneral anesthesia with controlled ventilationICU stay for pneumonia; stable recoveryAbbreviations: GA General anesthesia, PVC Polyvinyl chloride, ET Endotracheal tube, SpO₂ Peripheral oxygen saturation, RR Respiratory rate
Fig. 6Flowchart illustrating the literature search and selection process for tracheostomy fracture cases, including metallic and non-metallic tubes
In this case, we report a fracture and migration of a metallic tracheostomy tube outer 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. This case report describes the first documented case of long-term tolerance of pediatric sized metallic tracheostomy tube into adulthood, highlighting the possibility of physiological adaptation without significant anatomical modification, as supported by the normal bronchoscopic findings. The patient reported adequate and frequent self-tracheostomy care, including periodic removal, cleaning, and reinsertion of the metallic tube, which may have reduced secretion buildup and local complications. The patient’s low physical activity level, absence of significant underlying lung disease, and relatively low metabolic and oxygen demand may have further contributed to this adaptation. Although prolonged tracheostomy is commonly associated with granulation tissue and tracheal stenosis, a retrospective study of 128 bronchoscopy cases have demonstrated that a subset of patients can maintain normal airway anatomy despite long-term cannula, with normal bronchoscopic findings reported in up to 30% of patients with long-term tracheostomy and percutaneous tracheostomy survivors [24]. Nevertheless, this case emphasizes the risk of delayed material fatigue and fracture associated with prolonged metallic tube use, stressing the importance of regular surveillance and timely tube replacement.
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 ( [9]). 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. Although both flexible and rigid bronchoscopy can be used for foreign body retrieval under local or general anesthesia [25], rigid bronchoscopy is the preferred modality for removal of metallic foreign bodies, such as a fractured metallic tracheostomy tube, due to better airway control and retrieval capability.
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, and seven cases had localization of the fractured metallic tube in the 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 [26]. 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 [27], as well as patient noncompliance with regular tube changes. Mechanical stress from repeated removal and reinsertion can lead to early erosion [18], while repeated sterilization may cause corrosion due to exposure to oxygen, moisture, and temperature, creating internal stresses that promote alkali-mediated corrosion [28]^,^ [29]. Design defects of the tubes have also been reported as a contributing factor [27, 28, 30]. 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 the 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 procedure [7].
This case highlights a previously unreported phenomenon of prolonged tolerance of a pediatric-sized metallic tracheostomy tube into adulthood with preserved airway anatomy. While selected patients may physiologically adapt to long-term tracheostomy, long-term use of metallic tracheostomy tubes may predispose them to fracture and migration. Regular tube replacement and follow-up are essential to prevent such late complications. Metallic foreign bodies pose unique anesthetic challenges, particularly with respect to airway management during general anesthesia. Therefore, meticulous multidisciplinary planning between anesthesia and the surgical team is vital for safe management of these rare events.