Fracture and migration of a metallic tracheostomy tube: anesthetic considerations and case review

Fracture and migration of a metallic tracheostomy tube: anesthetic considerations and case review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Fracture and migration of a metallic tracheostomy tube: anesthetic considerations and case review Yashoda Khadka, MD, Raman Goit, MD, Prakash Gupta, MD, Rahul Sharma, MBBS, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8034289/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background 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 are 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. Case Presentation We report a 27-year-old male with a tracheostomy placed 18 years ago for prolonged ventilation after a road accident. He had used the same metallic tube without replacement or follow-up. Presenting 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 inner tube through the tracheostomy stoma. Recovery was uneventful. Literature review identified 16 similar case reports of fractured tracheostomy tubes. Both spontaneous and controlled ventilation techniques were used in these cases, emphasizing that anesthetic management should be individualized based on patient stability, airway conditions, and procedural requirements. Conclusions 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. Anesthesiology & Pain Medicine tracheostomy airway management foreign body anesthesia bronchoscopy tracheostomy tube fracture Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Background Tracheostomy is a commonly performed procedure in both emergency and elective settings to secure the airway or provide prolonged ventilatory support. Its main indications include upper airway obstruction or respiratory failure 1 . In recent years, tracheostomy rates in the pediatric population have increased due to advancements made 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 in 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 retrieving a dislodged fragment can be challenging. The mode of ventilation proposed 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 67 . 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. Case Presentation A 27-year-old male with a history of 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, and continued using the same pediatric metallic tracheostomy tube, which he cared for independently. One day before the presentation, he noticed that the inner 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 were: pulse rate 88/min, SpO₂ 93% on room air, and blood pressure within normal limits. Airway examination revealed a mature tracheostomy stoma with the outer metallic tracheostomy tube in situ, secured with elastic strap, but the inner 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). Preoperative investigations included comprehensive metabolic profile which were within normal reference range. Chest X-ray revealed a foreign body in the right main bronchus (Fig. 2 ). Patient was immediately shifted to the operating room for emergency rigid bronchoscopy and foreign body removal under general anesthesia. Patient was premedicated with intravenous glycopyrrolate 0.2 mg, 100mg of hydrocortisone, and nebulization with 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. Anesthesia was planned under general anesthesia with preservation of spontaneous ventilation to preserve the airway. Then, 2ml of 2% lignocaine was injected locally at the stoma site, and 3ml of 2% lignocaine with adrenaline was given via the transtracheal route to anesthetize the airway and prevent coughing and tendency to breath-hold when using the volatile agent. Induction was achieved with sevoflurane (6%) followed by bolus intravenous fentanyl 100 µg, propofol 50 mg (repeated once). Sedation was maintained with a propofol infusion at 25mg/kg/min, titrated as required. The metallic tracheostomy outer 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 was attempted via the tracheostomy stoma; however, the cough reflex persisted during the first attempt. To deepen anesthesia, an additional 50 mg of propofol and 20 mg of ketamine were administered. Then for muscle relaxation became necessary, 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 ). Subsequently, flexible bronchoscopy was performed to inspect the airway, confirming no mucosal injury or retained fragments. Throughout the procedure, vital signs remained stable. After securing the non-metallic tracheostomy tube of 6.0mm 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. The patient was transferred to the high-dependency unit (HDU) for observation. His postoperative course over 24 hours 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. Methods We conducted a literature search in 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 41 were case reports. After excluding non-English articles, those without 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 [Figure 5]. Discussion In this case, we report a fracture and migration of a metallic tracheostomy tube inner 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. 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 ( 24 , 25 ). 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. Removal required rigid or flexible bronchoscopy under either local or general anesthesia 26 . 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, where seven cases had localization of fractured metallic tube in 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 27 . 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 28 , as well as patient noncompliance with regular tube changes. Mechanical stress from repeated removal and reinsertion can lead to early erosion 29 , while repeated sterilization may cause corrosion due to exposure to oxygen, moisture, and temperature, creating internal stresses that promote alkali-mediated corrosion [ 30 , 28,29,31 ]. Design defects of the tubes have also been reported as a contributing factor [ 3028,29,31,32 ]. 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 a 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 . Conclusion Long-term use of metallic tracheostomy tubes may predispose to fracture and migration. Regular tube replacement and follow-up are essential to prevent such late complications. Individualized and flexible anesthetic planning ensures safe management when such rare events occur. Declarations Authors’ contributions: Y.K., R.G., and P.G. contributed equally to the conception, data collection, and drafting of the manuscript. R.G. and P.G. also performed data analysis and literature review. R.S. and S.O. assisted in manuscript editing and formatting. L.N. contributed to figure preparation and critical revision of the manuscript. All authors reviewed and approved the final version of the manuscript. Acknowledgements: Not applicable Funding: Not applicable. Data availability: The data sets are available from the corresponding author on request. Ethics approval and consent to participate: This case report was approved by institution ethics committee of Institute of Medicine, Tribhuwan University Teaching Hospital. The patient has signed the informed consent for the surgical and anesthetic management. Consent for publication: Written consent was obtained from the patient for publication and any accompanying images. Competing interests: The authors declare that they have no competing interests. References Wilkinson KA, Freeth H, Martin IC. Are we “on the right trach?” The National Confidential Enquiry into Patient Outcome and Death examines tracheostomy care. J Laryngol Otol. 2015 Mar;129(3):212–6. Komori M. Update on pediatric tracheostomy. Auris Nasus Larynx. 2024 Jun;51(3):429–32. Mitchell RB, Hussey HM, Setzen G, Jacobs IN, Nussenbaum B, Dawson C, et al. Clinical consensus statement: tracheostomy care. Otolaryngol Head Neck Surg. 2013 Jan;148(1):6–20. Fernandez-Bussy S, Mahajan B, Folch E, Caviedes I, Guerrero J, Majid A. Tracheostomy Tube Placement: Early and Late Complications. J Bronchology Interv Pulmonol. 2015 Oct;22(4):357–64. Hosur B, Ahuja CK, Virk RS, Singh P. Unusually dislodged tracheostomy tube with intact airway. BMJ Case Rep. 2020 Jul 16;13(7). Liu Y, Chen L, Li S. Controlled ventilation or spontaneous respiration in anesthesia for tracheobronchial foreign body removal: a meta-analysis. Paediatr Anaesth. 2014 Oct;24(10):1023–30. Farrell PT. Rigid bronchoscopy for foreign body removal: anaesthesia and ventilation. Paediatr Anaesth. 2004 Jan;14(1):84–9. Afiadigwe EE, Umeh US, Obasikene G, Chukwuanukwu TO, Ezeanolue BC. Fractured Metallic Tracheostomy Tube: A Rare Presentation of Bronchial Foreign Body. Niger J Clin Pract. 2024 May 1;27(5):678–81. So-Ngern A, Boonsarngsuk V. Fractured metallic tracheostomy tube: A rare complication of tracheostomy. Respir Med Case Rep. 2016;19:46–8. Vakili Ojarood M, Samady Khanghah A. Successful removal of an aspirated broken metal tracheostomy tube from the right main bronchus: a case report. Ann Med Surg (Lond). 2023 Sep;85(9):4547–52. Loh TL, Chin R, Flynn P, Jayachandra S. Fracture and aspiration of a tracheostomy tube. BMJ Case Rep. 2014 Feb 19;2014. Bo LJ, Yu PX, Qi X, Kang RT. Anesthetic management of a patient with an unusual broken tracheostomy tube: a case report. J Int Med Res. 2019 Feb;47(2):718–21. Fityani M, Juma Y, Omari M, Tayyem I, Sweity R, Deeb M, et al. Fractured Metallic Tracheostomy Tube as an Unusual Foreign Body in The Left Main Bronchus: A Case Report. Clin Med Insights Case Rep. 2025;18:11795476251346992. Otto RA, Davis W. Tracheostomy tube fracture: an unusual etiology of upper respiratory airway obstruction. Laryngoscope. 1985 Aug;95(8):980–1. Hajipour A, Khan ZH. Fracture and aspiration of metallic tracheostomy tube. Saudi Med J. 2007 Mar;28(3):468. Gupta SC, Ahluwalia H. Fractured tracheostomy tube: an overlooked foreign body. J Laryngol Otol. 1996 Nov;110(11):1069–71. Jensen O V, Pedersen U. Fractures in polyvinyl chloride tracheostomy tubes. J Laryngol Otol. 1988 Apr;102(4):380–1. Bhargava SK, Bhat N, Bhargava KB. Broken tracheostomy introducer--an unusual tracheobronchial foreign body. J Laryngol Otol. 1993 May;107(5):463–4. Piromchai P, Lertchanaruengrit P, Vatanasapt P, Ratanaanekchai T, Thanaviratananich S. Fractured metallic tracheostomy tube in a child: a case report and review of the literature. J Med Case Rep. 2010 Aug 2;4:234. Williams MA. Tracheotomy tube failure. Int J Pediatr Otorhinolaryngol. 1987 Jun;13(1):57–60. Kantar B; UF; YAA; NO; ST; KM. Emergency management of aspirated tracheostomy cannula. Vol. 31. 2014. p. 269. Kadasah SK, Alshammari AM, Alharbi NS, Alshehri IS, Alasiri RY, Al Qahtani A, et al. Fractured tracheostomy tube as a foreign body in a pediatric patient: a case report and review of literature. J Surg Case Rep. 2025 Apr;2025(4):rjaf194. Kashoob M, Al Washahi M, Tandon R. Aspiration Pneumonia Due to Migration of Fracture Tracheostomy Tube after 14 Years of Use. Oman Med J. 2020 Mar;35(2):e113. Agarwal N, Agarwal R. Fractured tracheostomy tube migrating into the tracheobronchial tree: a rare complication. Indian J Chest Dis Allied Sci. 2011;53(2):111–2. So-Ngern A, Boonsarngsuk V. Fractured metallic tracheostomy tube: A rare complication of tracheostomy. Respir Med Case Rep. 2016;19:46–8. Mahattanasakul P, Kaewkongka T, Sriprasart T, Kerekhanjanarong V. Fracture Outer Metallic Tracheostomy Tube as an Airway Foreign Body. Indian J Otolaryngol Head Neck Surg. 2022 Oct;74(Suppl 2):1752–6. Karakoc F, Cakir E, Ersu R, Uyan ZS, Colak B, Karadag B, et al. Late diagnosis of foreign body aspiration in children with chronic respiratory symptoms. Int J Pediatr Otorhinolaryngol. 2007 Feb;71(2):241–6. Parida PK, Kalaiarasi R, Gopalakrishnan S, Saxena SK. Fractured and migrated tracheostomy tube in the tracheobronchial tree. Int J Pediatr Otorhinolaryngol. 2014 Sep;78(9):1472–5. Bhargava SK, Bhat N, Bhargava KB. Broken tracheostomy introducer--an unusual tracheobronchial foreign body. J Laryngol Otol. 1993 May;107(5):463–4. BASSOE HH, BOE J. Broken tracheotomy tube as a foreign body. Lancet. 1960 May 7;1(7132):1006–7. Lynrah ZA, Goyal S, Goyal A, Lyngdoh NM, Shunyu NB, Baruah B, et al. Fractured tracheostomy tube as foreign body bronchus: our experience with three cases. Int J Pediatr Otorhinolaryngol. 2012 Nov;76(11):1691–5. Al-Momani HM, Alzaben KR, Mismar A. Upper airway obstruction by a fragmented tracheostomy tube: Case report and review of the literature. Int J Surg Case Rep. 2015;17:146–7. Table Table 1. Summary of reported cases of fractured tracheostomy tubes with dislodgement, anesthetic management, and outcomes. No. Author (Year) Age/Sex Tube Type / Fracture Site Dislodged Location / Presenting Signs Anesthetic Technique / Management Outcome 1. Afiadigwe EE, et al (2024) 8 56/M Metallic, shaft–flange junction Trachea at carina; cough, choking, dyspnea (4 h), RR 46, mucus via stoma, fever, SpO₂ 90% Emergency bronchoscopy under GA via tracheostomy stoma; fragment retrieved with forceps Uneventful recovery; discharged stable 2. So-Ngern A, et al (2016) 9 65/M Metallic, outer tube Left main bronchus; fever, purulent cough, tachypnea GA; flexible bronchoscopy with balloon catheter; fragment removed through stoma with rigid bronchoscope Uneventful recovery; discharged stable 3. Vakili Ojarood M, et al (2023) 10 11/F Metallic, neck plate Right main bronchus; respiratory distress Deep sedation; rigid bronchoscopy via tracheostomy; fragment removed Uneventful recovery; discharged stable 4. Loh TL, et al (2013) 11 70/F PVC, mid-shaft Right main bronchus; right-sided pneumonia Sedation with intermittent ventilation; flexible bronchoscopy; new tube inserted Recovered from pneumonia; stable follow-up 5. Bo LJ, et al (2018) 12 77/M Metallic, junction Left main bronchus; cough, bleeding at stoma GA with spontaneous respiration (dexmedetomidine, sufentanil, midazolam, tetracaine, propofol); fragment removed; new tube placed Uneventful recovery; discharged stable 6. Fityani M, et al (2025) 13 43/M Stainless steel, distal end Left main bronchus; asymptomatic; SpO₂ 88% RA → 95% on 2 L NC GA; initial flexible bronchoscopy failed; rigid bronchoscopy with standby ECMO; fragment removed Uneventful recovery; discharged stable 7. Otto RA, et al (1985) 14 3/M Metallic, junction Right main bronchus; respiratory distress Rigid bronchoscopy under GA Uneventful recovery; discharged stable 8. Hajipour A, Khan ZH (2007) 15 30/M Metallic (zinc–copper alloy), shield–tube junction Right main bronchus; aspiration during suctioning GA; IV sufentanil, midazolam, lidocaine; halothane induction; rigid bronchoscopy; plastic tube inserted Uneventful recovery; discharged stable 9. Gupta SC (1996) 16 10/M Fuller's biflanged metallic tube; flanges fractured Right main bronchus and left lung; asymptomatic Bronchoscopy under GA; partial retrieval; thoracotomy deferred Asymptomatic on follow-up; stable 10. Jensen OV (1988) 17 14 mo/M PVC, junction Trachea; mild respiratory distress GA; rigid bronchoscopy via tracheostoma; new tube inserted Successful removal; stable recovery 11. Bhargava SK (1993) 18 55/M Metallic, introducer Right main bronchus; dyspnea Rigid bronchoscopy under local anesthesia; fragment removed Uneventful recovery 12. Piromchai P (2010) 19 14/M Metallic, inner tube & connector Right main bronchus; cough ×2 weeks GA; bronchoscopic removal via tracheostomy stoma Pneumonia treated; full recovery at 1-month follow-up 13. Williams MA (1987) 20 2.5/F, 3/M PVC, junction / footplate None / cyanosis Sedation; spontaneous ventilation; tracheostomy tube exchanged over Frova catheter Uneventful postoperative course 14. Kantar B et al. (Year not specified) 21 9/M Tracheostomy cannula; inner tube–connector junction Left main bronchus; acute respiratory distress, SpO₂ 78% Mask ventilation; propofol + rocuronium; rigid bronchoscopy; new tube inserted Uneventful recovery 15. Kadasah SK et al. (2025) 22 10/F Metallic; fracture site not specified Right main bronchus; desaturation to 65–70%, chest tightness Initially spontaneous; converted to controlled; fragment removed with forceps; new Shiley tube inserted Uneventful recovery; stable 16. Kashoob M et al. (2020) 23 20/M Metallic double-lumen, shaft–flange junction Right main bronchus; fever, respiratory distress, altered consciousness GA; rigid ventilating bronchoscope (8.5 mm); fragment removed; new cuffed tube inserted ICU stay for pneumonia; stable recovery Abbreviations: GA: general anesthesia; PVC: polyvinyl chloride; RA: room air; NC: nasal cannula; ECMO: extracorporeal membrane oxygenation; ET: endotracheal tube; SpO₂: peripheral oxygen saturation; RR: respiratory rate. Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8034289","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":540162795,"identity":"21e599b9-5e2a-4f85-a6b0-d7b65de5dd7c","order_by":0,"name":"Yashoda Khadka, MD","email":"","orcid":"","institution":"Tribhuvan University Teaching Hospital, Nepal, Department of Anesthesia and Critical Care Medicine","correspondingAuthor":false,"prefix":"","firstName":"Yashoda","middleName":"","lastName":"Khadka","suffix":"MD"},{"id":540162796,"identity":"42ebd673-01f9-4319-bae7-345962230020","order_by":1,"name":"Raman Goit, MD","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBElEQVRIiWNgGAWjYFACxgYIzd7Y+PhHBZDBzNxASEsjRAXP4cPGDGdAWmCGELRGIi1NmrEN2V4cQN69uf1xRc02eXOGHAPpwnm10fztQC0/Krbh1GJ45mBj45ljtw13NpwxMJ657XjujMOMDYw9Z27j1jIjsbGxge0244aDPQYJvNuO5TYAtTAzthHS8u+2/YbDPAYHeOccy51PSIu8BFBLY9vtxA3H2BKbeRtqcjcQ0mLAc7BxZmPf7eQNZ5gPM844diB3I1DLQXx+kW9vf/Cx4dtt2w33H7b/+FBTlzvv/OGDD35U4LHlACr/MJg8gKEO2ZYGVH4dPsWjYBSMglEwQgEAAdFpwALP2cUAAAAASUVORK5CYII=","orcid":"","institution":"Kathmandu University, Nepal, Department of Anesthesia and Critical Care Medicine","correspondingAuthor":true,"prefix":"","firstName":"Raman","middleName":"","lastName":"Goit","suffix":"MD"},{"id":540162797,"identity":"964341fc-c8f4-4705-b582-646992653757","order_by":2,"name":"Prakash Gupta, MD","email":"","orcid":"","institution":"Karnali Academy of Health Sciences, Nepal","correspondingAuthor":false,"prefix":"","firstName":"Prakash","middleName":"","lastName":"Gupta","suffix":"MD"},{"id":540162798,"identity":"33e916de-07b9-4a6e-9450-b3d790eede77","order_by":3,"name":"Rahul Sharma, MBBS","email":"","orcid":"","institution":"Kathmandu University, Nepal, Department of Anesthesia and Critical Care Medicine","correspondingAuthor":false,"prefix":"","firstName":"MBBS","middleName":"Rahul","lastName":"Sharma","suffix":""},{"id":540162799,"identity":"12adde1d-9e67-4ce2-abe3-e6b56488bc5b","order_by":4,"name":"Suyog Ojha, MBBS","email":"","orcid":"","institution":"Kathmandu University, Nepal, Department of Anesthesia and Critical Care Medicine","correspondingAuthor":false,"prefix":"","firstName":"MBBS","middleName":"Suyog","lastName":"Ojha","suffix":""},{"id":540162800,"identity":"efba3bca-e61a-4b94-982d-e7b443b6ab89","order_by":5,"name":"Linh Nguyen, MD","email":"","orcid":"","institution":"SJSM, Saint Vincent and Grenadines, Department of Anesthesia and Critical Care Medicine","correspondingAuthor":false,"prefix":"","firstName":"Linh","middleName":"","lastName":"Nguyen","suffix":"MD"}],"badges":[],"createdAt":"2025-11-05 05:11:24","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":true,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-8034289/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8034289/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":95313699,"identity":"d5b9eccb-1d71-4fb8-b74a-a49f3bdfa3d7","added_by":"auto","created_at":"2025-11-06 15:51:52","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":2065951,"visible":true,"origin":"","legend":"","description":"","filename":"Manuscript05.docx","url":"https://assets-eu.researchsquare.com/files/rs-8034289/v1/ba32a3dc38c37b4bfabf7643.docx"},{"id":95267894,"identity":"c7434a14-3362-4f1a-bdb6-bac4e52e33e5","added_by":"auto","created_at":"2025-11-06 06:24:19","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":342,"visible":true,"origin":"","legend":"","description":"","filename":"rs8034289.json","url":"https://assets-eu.researchsquare.com/files/rs-8034289/v1/8b8104d991c7e3db8b19124c.json"},{"id":95313471,"identity":"2b7f7c31-ea7b-4296-85a5-dcb43a033008","added_by":"auto","created_at":"2025-11-06 15:51:29","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":79639,"visible":true,"origin":"","legend":"","description":"","filename":"rs80342890enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-8034289/v1/f5bf91f0f9fe29ef4669ae40.xml"},{"id":95313525,"identity":"0eac88b4-5eaa-4a5e-9c33-cad0d3b8cba0","added_by":"auto","created_at":"2025-11-06 15:51:37","extension":"jpeg","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":279778,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8034289/v1/b7aaa4d2d4aeba53bbf63c73.jpeg"},{"id":95267899,"identity":"5eca5ffc-ea23-498f-8afb-9b766ab130e8","added_by":"auto","created_at":"2025-11-06 06:24:19","extension":"jpeg","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":85831,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8034289/v1/d2a5db023fc9c15d7b30657e.jpeg"},{"id":95267904,"identity":"a5e28477-657b-4503-b389-c22f69ec47a4","added_by":"auto","created_at":"2025-11-06 06:24:19","extension":"jpeg","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":118812,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8034289/v1/4381e9a471902c1a87955b87.jpeg"},{"id":95267909,"identity":"b67b7f1f-dc0d-4d72-88e6-3975788e815d","added_by":"auto","created_at":"2025-11-06 06:24:19","extension":"png","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":1247764,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-8034289/v1/8ded536969daf507d756d4a3.png"},{"id":95267907,"identity":"f8d4c5a9-72ce-4d17-8e8f-89a513795bf3","added_by":"auto","created_at":"2025-11-06 06:24:19","extension":"jpeg","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":111180,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8034289/v1/3f3948e0bab8b03c166e05c4.jpeg"},{"id":95267910,"identity":"74491e5e-6269-4c8c-80fa-874f868b2460","added_by":"auto","created_at":"2025-11-06 06:24:19","extension":"png","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":135444,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage6.png","url":"https://assets-eu.researchsquare.com/files/rs-8034289/v1/eae6d0b9a42247f3c976c85c.png"},{"id":95267911,"identity":"f8f3c1ec-0f79-4fc4-a876-3ec62f201adb","added_by":"auto","created_at":"2025-11-06 06:24:19","extension":"png","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":375684,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8034289/v1/3be3178af0a7e7b60b3e8c9e.png"},{"id":95313468,"identity":"94ce67bf-cfbb-4b43-9bdf-b8857dd3e723","added_by":"auto","created_at":"2025-11-06 15:51:28","extension":"png","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":198246,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8034289/v1/3d53b38306c349639bd0226c.png"},{"id":95313551,"identity":"52eff9c3-7cff-4321-9bec-b703cde35142","added_by":"auto","created_at":"2025-11-06 15:51:41","extension":"png","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":200055,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8034289/v1/e3235e4998e476c7ff30de58.png"},{"id":95313631,"identity":"9a85ed27-23bf-4143-9737-00c1deb52065","added_by":"auto","created_at":"2025-11-06 15:51:47","extension":"png","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":211681,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-8034289/v1/6017dcd164de249c524fe718.png"},{"id":95267914,"identity":"49adf56b-63ed-40fc-b904-6d80245a1b07","added_by":"auto","created_at":"2025-11-06 06:24:19","extension":"png","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":188130,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-8034289/v1/cec3319ba9192b087db34ef5.png"},{"id":95313249,"identity":"3235ed44-5fae-49d4-8d30-a7d8c42ad32f","added_by":"auto","created_at":"2025-11-06 15:51:10","extension":"png","order_by":14,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":42403,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage6.png","url":"https://assets-eu.researchsquare.com/files/rs-8034289/v1/962f856b74791cd16501aa98.png"},{"id":95313103,"identity":"a92a6262-271f-46a9-826e-5262e4c89279","added_by":"auto","created_at":"2025-11-06 15:50:53","extension":"xml","order_by":15,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":74446,"visible":true,"origin":"","legend":"","description":"","filename":"rs80342890structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8034289/v1/0488bedfe7b01b46db47990a.xml"},{"id":95267916,"identity":"b658622b-c9f0-415e-9b2f-2ced0586685a","added_by":"auto","created_at":"2025-11-06 06:24:19","extension":"html","order_by":16,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":85020,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8034289/v1/8ce51d4a87d5404a2672b4a6.html"},{"id":95313225,"identity":"66b0e127-3c66-498d-b991-111b51f865cc","added_by":"auto","created_at":"2025-11-06 15:51:08","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":401793,"visible":true,"origin":"","legend":"\u003cp\u003eClinical image showing mature tracheostomy stoma with outer metallic tube secured by neck strap.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8034289/v1/9c9ddb0623a1c3385b8a1570.png"},{"id":95267897,"identity":"9d1c84a2-8108-4239-9a97-9d4816b76d01","added_by":"auto","created_at":"2025-11-06 06:24:19","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":264149,"visible":true,"origin":"","legend":"\u003cp\u003eChest X-ray showing fractured metallic tracheostomy tube lodged in right main bronchus.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8034289/v1/c16b1ccd9045c9eea6457dc5.png"},{"id":95313772,"identity":"70747784-652a-4a9b-b2c6-0c2024e3ff60","added_by":"auto","created_at":"2025-11-06 15:51:57","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":366271,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative view during rigid bronchoscopy.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8034289/v1/38d7084ea2af2875e75c4e65.png"},{"id":95313257,"identity":"37fee747-67fe-4405-8c3d-3ac443b81848","added_by":"auto","created_at":"2025-11-06 15:51:11","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":419024,"visible":true,"origin":"","legend":"\u003cp\u003e(A) Retrieved fractured metallic inner tracheostomy tube; (B) external intact and broken internal pieces.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-8034289/v1/78d07228aaa2c821f39e62fa.png"},{"id":95313438,"identity":"7ade0a3f-2d51-4c93-bc0a-96312275b3ec","added_by":"auto","created_at":"2025-11-06 15:51:25","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":364717,"visible":true,"origin":"","legend":"\u003cp\u003eNewly placed non-metallic tracheostomy tube securely positioned in a mature tracheostomy stoma.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-8034289/v1/e49fe8e0abeb1a9686a3efcb.png"},{"id":95267901,"identity":"3567dc1c-16f6-40ea-b46b-f2a45b5b62f4","added_by":"auto","created_at":"2025-11-06 06:24:19","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":62930,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart showing literature search and selection of fractured metallic tracheostomy tube cases.\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-8034289/v1/e0d4c4e09af6cf19757c9a7a.png"},{"id":95315767,"identity":"bfe2e7d1-4238-4623-9949-2e12c323a1e9","added_by":"auto","created_at":"2025-11-06 15:57:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3148356,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8034289/v1/3afae91c-d520-4b23-9f95-02d93e5b2bae.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eFracture and migration of a metallic tracheostomy tube: anesthetic considerations and case review\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eTracheostomy is a commonly performed procedure in both emergency and elective settings to secure the airway or provide prolonged ventilatory support. Its main indications include upper airway obstruction or respiratory failure\u003csup\u003e1\u003c/sup\u003e. In recent years, tracheostomy rates in the pediatric population have increased due to advancements made 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\u003csup\u003e2\u003c/sup\u003e. 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\u003csup\u003e3\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eAlthough tracheostomy offers clear benefits in 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\u003csup\u003e4\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eIncidence of fractured tracheostomy tube is low with an incidence rate of \u0026lt;\u0026thinsp;1/1000 \u003csup\u003e5\u003c/sup\u003e. Management of a fractured tracheostomy tube and retrieving a dislodged fragment can be challenging. The mode of ventilation proposed includes either controlled or spontaneous ventilation. Studies suggest that the choice of anesthetic technique is often individualized based on the patient\u0026rsquo;s airway condition and surgical requirements, and may be modified as needed during the procedure\u003csup\u003e67\u003c/sup\u003e. 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.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 27-year-old male with a history of 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, and continued using the same pediatric metallic tracheostomy tube, which he cared for independently.\u003c/p\u003e\u003cp\u003eOne day before the presentation, he noticed that the inner 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.\u003c/p\u003e\u003cp\u003eOn pre-anesthetic evaluation, the patient was alert and cooperative. His vital signs were: pulse rate 88/min, SpO₂ 93% on room air, and blood pressure within normal limits. Airway examination revealed a mature tracheostomy stoma with the outer metallic tracheostomy tube in situ, secured with elastic strap, but the inner tube was missing (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). 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).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003ePreoperative investigations included comprehensive metabolic profile which were within normal reference range. Chest X-ray revealed a foreign body in the right main bronchus (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Patient was immediately shifted to the operating room for emergency rigid bronchoscopy and foreign body removal under general anesthesia.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003ePatient was premedicated with intravenous glycopyrrolate 0.2 mg, 100mg of hydrocortisone, and nebulization with 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. Anesthesia was planned under general anesthesia with preservation of spontaneous ventilation to preserve the airway. Then, 2ml of 2% lignocaine was injected locally at the stoma site, and 3ml of 2% lignocaine with adrenaline was given via the transtracheal route to anesthetize the airway and prevent coughing and tendency to breath-hold when using the volatile agent.\u003c/p\u003e\u003cp\u003eInduction was achieved with sevoflurane (6%) followed by bolus intravenous fentanyl 100 µg, propofol 50 mg (repeated once). Sedation was maintained with a propofol infusion at 25mg/kg/min, titrated as required. The metallic tracheostomy outer 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 was attempted via the tracheostomy stoma; however, the cough reflex persisted during the first attempt. To deepen anesthesia, an additional 50 mg of propofol and 20 mg of ketamine were administered. Then for muscle relaxation became necessary, succinylcholine 100 mg was given, and with the addition of ketamine 20 mg intraoperatively, rigid bronchoscopy was reattempted (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). On the third attempt, the foreign body was successfully retrieved (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eSubsequently, flexible bronchoscopy was performed to inspect the airway, confirming no mucosal injury or retained fragments. Throughout the procedure, vital signs remained stable. After securing the non-metallic tracheostomy tube of 6.0mm ID (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e), adequate ventilation was confirmed, thorough suctioning of the tracheostomy tube was done, and the patient was awakened at the end of surgery.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe patient was transferred to the high-dependency unit (HDU) for observation. His postoperative course over 24 hours 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.\u003c/p\u003e\u003cp\u003eTo 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.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Methods","content":"\u003cp\u003eWe conducted a literature search in MEDLINE without time restrictions using the terms (\u0026ldquo;tracheostomy\u0026rdquo;[MeSH Terms] OR \u0026ldquo;tracheostomy tube\u0026rdquo;[All Fields]) AND (fracture OR breakage OR migration OR complication) AND (metallic OR metal). The search identified 73 articles, of which 41 were case reports. After excluding non-English articles, those without 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 [Figure 5].\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this case, we report a fracture and migration of a metallic tracheostomy tube inner 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. 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 (\u003csup\u003e24\u003c/sup\u003e,\u003csup\u003e25\u003c/sup\u003e). 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. Removal required rigid or flexible bronchoscopy under either local or general anesthesia \u003csup\u003e26\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eIn 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, where seven cases had localization of fractured metallic tube in right main bronchus Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. 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 \u003csup\u003e27\u003c/sup\u003e. 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.\u003c/p\u003e\u003cp\u003eSeveral factors contribute to tracheostomy tube fracture. These include prolonged wear-and-tear and aging \u003csup\u003e28\u003c/sup\u003e, as well as patient noncompliance with regular tube changes. Mechanical stress from repeated removal and reinsertion can lead to early erosion\u003csup\u003e29\u003c/sup\u003e, while repeated sterilization may cause corrosion due to exposure to oxygen, moisture, and temperature, creating internal stresses that promote alkali-mediated corrosion [\u003csup\u003e30\u003c/sup\u003e, \u003csup\u003e28,29,31\u003c/sup\u003e]. Design defects of the tubes have also been reported as a contributing factor [\u003csup\u003e3028,29,31,32\u003c/sup\u003e]. 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.\u003c/p\u003e\u003cp\u003eAnesthetic 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\u0026rsquo;s clinical condition and procedural requirements \u003csup\u003e6\u003c/sup\u003e. In our case, we had to switch from spontaneous ventilation to controlled ventilation during the retrieval of a foreign body.\u003c/p\u003e\u003cp\u003eIn 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\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). 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\u003csup\u003e7\u003c/sup\u003e.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eLong-term use of metallic tracheostomy tubes may predispose to fracture and migration. Regular tube replacement and follow-up are essential to prevent such late complications. Individualized and flexible anesthetic planning ensures safe management when such rare events occur.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eY.K., R.G., and P.G. contributed equally to the conception, data collection, and drafting of the manuscript. R.G. and P.G. also performed data analysis and literature review. R.S. and S.O. assisted in manuscript editing and formatting. L.N. contributed to figure preparation and critical revision of the manuscript. All authors reviewed and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data sets are available from the corresponding author on request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis case report was approved by institution ethics committee of Institute of Medicine, Tribhuwan University Teaching Hospital. The patient has signed the informed consent for the surgical and anesthetic management.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten consent was obtained from the patient for publication and any accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eWilkinson KA, Freeth H, Martin IC. Are we \u0026ldquo;on the right trach?\u0026rdquo; The National Confidential Enquiry into Patient Outcome and Death examines tracheostomy care. J Laryngol Otol. 2015 Mar;129(3):212\u0026ndash;6.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eKomori M. Update on pediatric tracheostomy. Auris Nasus Larynx. 2024 Jun;51(3):429\u0026ndash;32.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMitchell RB, Hussey HM, Setzen G, Jacobs IN, Nussenbaum B, Dawson C, et al. Clinical consensus statement: tracheostomy care. Otolaryngol Head Neck Surg. 2013 Jan;148(1):6\u0026ndash;20.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eFernandez-Bussy S, Mahajan B, Folch E, Caviedes I, Guerrero J, Majid A. Tracheostomy Tube Placement: Early and Late Complications. J Bronchology Interv Pulmonol. 2015 Oct;22(4):357\u0026ndash;64.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eHosur B, Ahuja CK, Virk RS, Singh P. Unusually dislodged tracheostomy tube with intact airway. BMJ Case Rep. 2020 Jul 16;13(7).\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eLiu Y, Chen L, Li S. Controlled ventilation or spontaneous respiration in anesthesia for tracheobronchial foreign body removal: a meta-analysis. Paediatr Anaesth. 2014 Oct;24(10):1023\u0026ndash;30.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eFarrell PT. Rigid bronchoscopy for foreign body removal: anaesthesia and ventilation. Paediatr Anaesth. 2004 Jan;14(1):84\u0026ndash;9.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAfiadigwe EE, Umeh US, Obasikene G, Chukwuanukwu TO, Ezeanolue BC. Fractured Metallic Tracheostomy Tube: A Rare Presentation of Bronchial Foreign Body. Niger J Clin Pract. 2024 May 1;27(5):678\u0026ndash;81.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSo-Ngern A, Boonsarngsuk V. Fractured metallic tracheostomy tube: A rare complication of tracheostomy. Respir Med Case Rep. 2016;19:46\u0026ndash;8.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eVakili Ojarood M, Samady Khanghah A. Successful removal of an aspirated broken metal tracheostomy tube from the right main bronchus: a case report. Ann Med Surg (Lond). 2023 Sep;85(9):4547\u0026ndash;52.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eLoh TL, Chin R, Flynn P, Jayachandra S. Fracture and aspiration of a tracheostomy tube. BMJ Case Rep. 2014 Feb 19;2014.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eBo LJ, Yu PX, Qi X, Kang RT. Anesthetic management of a patient with an unusual broken tracheostomy tube: a case report. J Int Med Res. 2019 Feb;47(2):718\u0026ndash;21.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eFityani M, Juma Y, Omari M, Tayyem I, Sweity R, Deeb M, et al. Fractured Metallic Tracheostomy Tube as an Unusual Foreign Body in The Left Main Bronchus: A Case Report. Clin Med Insights Case Rep. 2025;18:11795476251346992.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eOtto RA, Davis W. Tracheostomy tube fracture: an unusual etiology of upper respiratory airway obstruction. Laryngoscope. 1985 Aug;95(8):980\u0026ndash;1.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eHajipour A, Khan ZH. Fracture and aspiration of metallic tracheostomy tube. Saudi Med J. 2007 Mar;28(3):468.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eGupta SC, Ahluwalia H. Fractured tracheostomy tube: an overlooked foreign body. J Laryngol Otol. 1996 Nov;110(11):1069\u0026ndash;71.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eJensen O V, Pedersen U. Fractures in polyvinyl chloride tracheostomy tubes. J Laryngol Otol. 1988 Apr;102(4):380\u0026ndash;1.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eBhargava SK, Bhat N, Bhargava KB. Broken tracheostomy introducer--an unusual tracheobronchial foreign body. J Laryngol Otol. 1993 May;107(5):463\u0026ndash;4.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003ePiromchai P, Lertchanaruengrit P, Vatanasapt P, Ratanaanekchai T, Thanaviratananich S. Fractured metallic tracheostomy tube in a child: a case report and review of the literature. J Med Case Rep. 2010 Aug 2;4:234.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eWilliams MA. Tracheotomy tube failure. Int J Pediatr Otorhinolaryngol. 1987 Jun;13(1):57\u0026ndash;60.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eKantar B; UF; YAA; NO; ST; KM. Emergency management of aspirated tracheostomy cannula. Vol. 31. 2014. p. 269.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eKadasah SK, Alshammari AM, Alharbi NS, Alshehri IS, Alasiri RY, Al Qahtani A, et al. Fractured tracheostomy tube as a foreign body in a pediatric patient: a case report and review of literature. J Surg Case Rep. 2025 Apr;2025(4):rjaf194.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eKashoob M, Al Washahi M, Tandon R. Aspiration Pneumonia Due to Migration of Fracture Tracheostomy Tube after 14 Years of Use. Oman Med J. 2020 Mar;35(2):e113.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAgarwal N, Agarwal R. Fractured tracheostomy tube migrating into the tracheobronchial tree: a rare complication. Indian J Chest Dis Allied Sci. 2011;53(2):111\u0026ndash;2.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSo-Ngern A, Boonsarngsuk V. Fractured metallic tracheostomy tube: A rare complication of tracheostomy. Respir Med Case Rep. 2016;19:46\u0026ndash;8.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMahattanasakul P, Kaewkongka T, Sriprasart T, Kerekhanjanarong V. Fracture Outer Metallic Tracheostomy Tube as an Airway Foreign Body. Indian J Otolaryngol Head Neck Surg. 2022 Oct;74(Suppl 2):1752\u0026ndash;6.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eKarakoc F, Cakir E, Ersu R, Uyan ZS, Colak B, Karadag B, et al. Late diagnosis of foreign body aspiration in children with chronic respiratory symptoms. Int J Pediatr Otorhinolaryngol. 2007 Feb;71(2):241\u0026ndash;6.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eParida PK, Kalaiarasi R, Gopalakrishnan S, Saxena SK. Fractured and migrated tracheostomy tube in the tracheobronchial tree. Int J Pediatr Otorhinolaryngol. 2014 Sep;78(9):1472\u0026ndash;5.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eBhargava SK, Bhat N, Bhargava KB. Broken tracheostomy introducer--an unusual tracheobronchial foreign body. J Laryngol Otol. 1993 May;107(5):463\u0026ndash;4.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eBASSOE HH, BOE J. Broken tracheotomy tube as a foreign body. Lancet. 1960 May 7;1(7132):1006\u0026ndash;7.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eLynrah ZA, Goyal S, Goyal A, Lyngdoh NM, Shunyu NB, Baruah B, et al. Fractured tracheostomy tube as foreign body bronchus: our experience with three cases. Int J Pediatr Otorhinolaryngol. 2012 Nov;76(11):1691\u0026ndash;5.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAl-Momani HM, Alzaben KR, Mismar A. Upper airway obstruction by a fragmented tracheostomy tube: Case report and review of the literature. Int J Surg Case Rep. 2015;17:146\u0026ndash;7. \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table","content":"\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Summary of reported cases of fractured tracheostomy tubes with dislodgement, anesthetic management, and outcomes.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003eNo.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eAuthor (Year)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003eAge/Sex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003eTube Type / Fracture Site\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eDislodged Location / Presenting Signs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eAnesthetic Technique / Management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eOutcome\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e1.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eAfiadigwe EE, et al (2024)\u003csup\u003e8\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e56/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003eMetallic, shaft\u0026ndash;flange junction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eTrachea at carina; cough, choking, dyspnea (4 h), RR 46, mucus via stoma, fever, SpO₂ 90%\u003c/p\u003e\n \u003ctable border=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eEmergency bronchoscopy under GA via tracheostomy stoma; fragment retrieved with forceps\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eUneventful recovery; discharged stable\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e2.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eSo-Ngern A, et al (2016)\u003csup\u003e9\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e65/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003eMetallic, outer tube\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eLeft main bronchus; fever, purulent cough, tachypnea\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eGA; flexible bronchoscopy with balloon catheter; fragment removed through stoma with rigid bronchoscope\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eUneventful recovery; discharged stable\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e3.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eVakili Ojarood M, et al (2023)\u003csup\u003e10\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e11/F\u003c/p\u003e\n \u003ctable border=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003eMetallic, neck plate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eRight main bronchus; respiratory distress\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eDeep sedation; rigid bronchoscopy via tracheostomy; fragment removed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eUneventful recovery; discharged stable\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e4.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eLoh TL, et al (2013)\u003csup\u003e11\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e70/F\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003ePVC, mid-shaft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eRight main bronchus; right-sided pneumonia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eSedation with intermittent ventilation; flexible bronchoscopy; new tube inserted\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eRecovered from pneumonia; stable follow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e5.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eBo LJ, et al (2018)\u003csup\u003e12\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e77/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003eMetallic, junction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eLeft main bronchus; cough, bleeding at stoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eGA with spontaneous respiration (dexmedetomidine, sufentanil, midazolam, tetracaine, propofol); fragment removed; new tube placed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eUneventful recovery; discharged stable\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e6.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eFityani M, et al (2025)\u003csup\u003e13\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e43/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003eStainless steel, distal end\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eLeft main bronchus; asymptomatic; SpO₂ 88% RA \u0026rarr; 95% on 2 L NC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eGA; initial flexible bronchoscopy failed; rigid bronchoscopy with standby ECMO; fragment removed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eUneventful recovery; discharged stable\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e7.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eOtto RA, et al (1985)\u003csup\u003e14\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e3/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003eMetallic, junction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eRight main bronchus; respiratory distress\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eRigid bronchoscopy under GA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eUneventful recovery; discharged stable\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e8.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eHajipour A, Khan ZH (2007)\u003csup\u003e15\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e30/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003eMetallic (zinc\u0026ndash;copper alloy), shield\u0026ndash;tube junction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eRight main bronchus; aspiration during suctioning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eGA; IV sufentanil, midazolam, lidocaine; halothane induction; rigid bronchoscopy; plastic tube inserted\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eUneventful recovery; discharged stable\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e9.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eGupta SC\u0026nbsp;(1996)\u003csup\u003e16\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e10/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003eFuller\u0026apos;s biflanged metallic tube; flanges fractured\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eRight main bronchus and left lung; asymptomatic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eBronchoscopy under GA; partial retrieval; thoracotomy deferred\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eAsymptomatic on follow-up; stable\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e10.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eJensen OV\u0026nbsp;(1988)\u003csup\u003e17\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e14 mo/M\u003c/p\u003e\n \u003ctable border=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003ePVC, junction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eTrachea; mild respiratory distress\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eGA; rigid bronchoscopy via tracheostoma; new tube inserted\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eSuccessful removal; stable recovery\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e11.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eBhargava SK\u0026nbsp;(1993)\u003csup\u003e18\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e55/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003eMetallic, introducer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eRight main bronchus; dyspnea\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eRigid bronchoscopy under local anesthesia; fragment removed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eUneventful recovery\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e12.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003ePiromchai P (2010)\u003csup\u003e19\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e14/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003eMetallic, inner tube \u0026amp; connector\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eRight main bronchus; cough \u0026times;2 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eGA; bronchoscopic removal via tracheostomy stoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003ePneumonia treated; full recovery at 1-month follow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e13.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eWilliams MA (1987)\u003csup\u003e20\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e2.5/F, 3/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003ePVC, junction / footplate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eNone / cyanosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eSedation; spontaneous ventilation; tracheostomy tube exchanged over Frova catheter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eUneventful postoperative course\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e14.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eKantar B et al. (Year not specified)\u003csup\u003e21\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e9/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003eTracheostomy cannula; inner tube\u0026ndash;connector junction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eLeft main bronchus; acute respiratory distress, SpO₂ 78%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eMask ventilation; propofol + rocuronium; rigid bronchoscopy; new tube inserted\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eUneventful recovery\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e15.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eKadasah SK et al. (2025)\u003csup\u003e22\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e10/F\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003eMetallic; fracture site not specified\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eRight main bronchus; desaturation to 65\u0026ndash;70%, chest tightness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eInitially spontaneous; converted to controlled; fragment removed with forceps; new Shiley tube inserted\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eUneventful recovery; stable\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e16.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eKashoob M et al. (2020) \u003csup\u003e23\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e20/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003eMetallic double-lumen, shaft\u0026ndash;flange junction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eRight main bronchus; fever, respiratory distress, altered consciousness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eGA; rigid ventilating bronchoscope (8.5 mm); fragment removed; new cuffed tube inserted\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eICU stay for pneumonia; stable recovery\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations: GA: general anesthesia; PVC: polyvinyl chloride; RA: room air; NC: nasal cannula; ECMO: extracorporeal membrane oxygenation; ET: endotracheal tube; SpO₂: peripheral oxygen saturation; RR: respiratory rate.\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Tribhuwan University","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"tracheostomy, airway management, foreign body, anesthesia, bronchoscopy, tracheostomy tube fracture","lastPublishedDoi":"10.21203/rs.3.rs-8034289/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8034289/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003cbr\u003e\nTracheostomy 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 are 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase Presentation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe report a 27-year-old male with a tracheostomy placed 18 years ago for prolonged ventilation after a road accident. He had used the same metallic tube without replacement or follow-up. Presenting 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 inner tube through the tracheostomy stoma. Recovery was uneventful.\u003c/p\u003e\n\u003cp\u003eLiterature review identified 16 similar case reports of fractured tracheostomy tubes. Both spontaneous and controlled ventilation techniques were used in these cases, emphasizing that anesthetic management should be individualized based on patient stability, airway conditions, and procedural requirements.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFracture 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.\u003c/p\u003e","manuscriptTitle":"Fracture and migration of a metallic tracheostomy tube: anesthetic considerations and case review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-06 06:24:14","doi":"10.21203/rs.3.rs-8034289/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"47c7dd5e-bd3d-4afa-acd4-02490190b759","owner":[],"postedDate":"November 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":57457345,"name":"Anesthesiology \u0026 Pain Medicine"}],"tags":[],"updatedAt":"2025-11-06T06:24:14+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-06 06:24:14","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8034289","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8034289","identity":"rs-8034289","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}