Acute Crit Care.  2020 Nov;35(4):298-301. 10.4266/acc.2019.00570.

Fatal airway obstruction due to a ball-valve clot with identical signs of tension pneumothorax

• Munakata H
• Higashi M
• Tamura T
• Adachi YU

• KMID: 2510550
• DOI: http://doi.org/10.4266/acc.2019.00570

Abstract

Endo-tracheal tube obstruction due to an extensive blood clot is a recognized but very rare complication. A ball-valve obstruction in the airway could function as a check valve for the lung and thorax, resulting in tension pneumothorax-like abnormalities. A 47-year-old female patient had undergone implantation of a left ventricular assist device 3 weeks prior. On post-operative day 17, planned thoracentesis was performed for drainage of a pleural effusion. Despite the drainage, the patient’s oxygenation did not improve, and emergency tracheal intubation was conducted. Subsequent computed tomography revealed bilateral pneumothorax. Two days later, the patient’s trachea was extubated without complication, and a mini-tracheostomy tube was placed. Three hours later, reintubation was conducted due to progressive tachypnea. Although successful intubation was confirmed, ventilation became increasingly difficult and finally impossible. Marked increase in pulmonary artery and central venous pressures suggested progression of the previous tension pneumothorax. After emergency extracorporeal membrane oxygenation was initiated, fiberoptic bronchoscopy revealed the presence of a massive clot and ball-valve obstruction of the endotracheal tube. Two weeks later, the patient died due to severe hypoxic brain damage. Diagnosis of ball valve clot is not simple, but intensivists should consider this rare complication.

Keyword

ball valve obstruction; mini-tracheostomy; tension pneumothorax

Figure

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  Figure 1. Computed tomogram immediately after the first intubation revealed right pneumothorax and left hemothorax.

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  Figure 2. The clot removed after the first ventilation failure. The clot was aspired by a large-bore suction catheter.

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  Figure 3. The fatal, obstructing, ball-valve clot that was removed after the second failed ventilation. The clot was approximately 1 cm in diameter and 4 cm in length.

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  Figure 4. Computed tomogram immediately after the second intubation with extracorporeal membrane oxygenation showed pneumothorax and subcutaneous emphysema.

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