Poorly Placed Tracheostomy Tube Causes Patient Death

Cody Porcoro

Written by
— Updated on December 22, 2017

This case involves a young man who was involved in a severe car accident and needed to be placed on a tracheostomy tube. After a day of being on the tracheostomy tube, the respiratory therapist noticed his oxygen saturation started to decline. The respiratory therapist attempted to readjust the tube, but was immediately met with resistance. The respiratory therapist continued to push the tube in, and finally succeeded on the third attempt. However, the patient’s oxygen saturation rapidly dropped. Further attempts were made at readjusting the tube, but a code was called in. He died soon after and it was found that he had suffered from tension pneumothorax.

Question(s) For Expert Witness

  • 1. How often do you see patients with tension pneumothoraces?
  • 2. Have you ever reviewed a similar case or seen this complication?
  • 3. What is the correct protocol to replace and confirm placement of an tracheostomy tube?

Expert Witness Response E-007983

As a professor of medicine and pulmonary and critical care specialist, I typically treat tension pneumothoraces multiple times a year. In regards to replacing a tracheostomy tube, it is very important to be careful. Verification can be done visually via bronchoscopy or clinically by assessing breath sounds and oxygen saturation.

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