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 Table of Contents  
Year : 2019  |  Volume : 8  |  Issue : 1  |  Page : 60-63

A novel way of removing an endotracheal suction catheter foreign body in a preterm neonate: A case report and review of literature

1 General Paediatric Department, Neonatal Intensive Care Unit, The Royal Hospital, Muscat, Oman
2 General Paediatric Department, Acharya Shri Chander College of Medical Science and Hospital, Jammu, Jammu and Kashmir, India

Date of Web Publication29-Jan-2019

Correspondence Address:
Dr. Khalid Ali Aman Bait Jamil
Neonatal Intensive Care Unit, The Royal Hospital, Muscat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcn.JCN_91_18

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Airway obstruction by foreign bodies (FBs) in preterm neonates is a rare occurrence. Most of these FBs are iatrogenic and related to medical devices used in the neonate. We describe a case of an endotracheal FB resulting from the cut end of an in-line closed suction catheter. The FB caused collapse/consolidation of different lung lobes with changes in its position. It was missed for a long period of about 3 weeks and was removed by applying direct suction through an endotracheal tube. Different innovative devices have been used to retrieve endotracheal FBs in small preterm neonates; however, this method is not reported in literature to our knowledge.

Keywords: Endotracheal foreign body, endotracheal suction catheter, endotracheal tube, premature infant

How to cite this article:
Jamil KA, Ahmed UB, Itoo BA. A novel way of removing an endotracheal suction catheter foreign body in a preterm neonate: A case report and review of literature. J Clin Neonatol 2019;8:60-3

How to cite this URL:
Jamil KA, Ahmed UB, Itoo BA. A novel way of removing an endotracheal suction catheter foreign body in a preterm neonate: A case report and review of literature. J Clin Neonatol [serial online] 2019 [cited 2022 Jan 16];8:60-3. Available from: https://www.jcnonweb.com/text.asp?2019/8/1/60/250988

  Introduction Top

Tracheobronchial foreign bodies (FBs) are extremely rare in preterm neonates. In a study of 1060 cases of tracheal FBs in children below 12 years of age, 92.5% were recorded in children below 3 years of age; however, no case was reported in children below 6 months of age.[1] However, there are numerous case reports of tracheal FBs in newborns.[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13] The majority of the reported cases are iatrogenic resulting from medical devices such as detached endotracheal intubation stylet sheath,[2],[3],[4],[5] fractured or cut suction catheters,[6],[7],[8],[9],[10] cut end of endotracheal tube (ETT),[11] and fractured end-tidal carbon dioxide catheter.[12] FBs may also be introduced by others such as an elder sibling inadvertently.[13]

Potential serious complications such as acute respiratory compromise and even death may occur. Pneumonia and lobar collapse are common. Lung perforation and pneumothorax is reported in a case report of broken suction catheter in the tracheobronchial tree.[10] To prevent these complications, early identification and removal of the FBs is very important. Many times, the diagnosis is delayed for quite some time.[2],[7],[11],[12] The limitations created by the small anatomical structures, nonavailability of appropriate equipment, and sick newborn babies pose special challenges for removing these FBs. Many times, innovative equipment is used to remove the tracheobronchial FBs.[6],[11]

We describe a broken suction catheter that migrated into the tracheobronchial tree, went unnoticed for about 3 weeks causing migratory lung collapse corresponding to its position. We used a novel method of retrieving this FB that is the least invasive.

  Case Report Top

A preterm baby born by spontaneous vaginal delivery at a gestational age of 32 weeks and birth weight of 1.560 kg was referred to our unit at the age of 68 h with a history of feeding intolerance, recurrent bilious vomiting, distended abdomen, and possible intestinal obstruction. The baby was being managed with nasal-continuous positive airway pressure for respiratory distress.

The child was assessed by the pediatric surgical team, and on the same day, laparotomy was done that revealed multiple intestinal atresia (membranous type) needing multiple resections and anastomosis. Postoperatively, the baby was gradually started on feeds.

The baby was electively intubated in the operation theater and an X-ray of the chest was taken immediately after surgery [Figure 1]. The child was connected to ventilator with in-line closed suction catheter, and the ETT was resized to decrease dead space. Child stayed ventilated for nearly 3 weeks and was difficult to wean. Over this period, he developed recurrent lung collapses of the left upper lobe [Figure 2], and the right upper and middle lobes [Figure 3] with excessive endotracheal secretions.
Figure 1: Anteroposterior chest X-ray showing normal lung with endotracheal tube and nasogastric tube in place

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Figure 2: Anteroposterior chest X-ray showing double laminar tube in the left main bronchus (arrow) with left upper lobe collapse

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Figure 3: Anteroposterior chest X-ray showing doubles laminar tube in the right main bronchus arrow with right upper lobe collapse

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On the 19th postoperative day, the baby needed reintubation for not maintaining saturations and suspicion that the ETT being blocked. The postintubation X-ray to confirm the position of the ETT showed a tubular shadow about 3 cm-long in the right main bronchus; this was thought to be the distal part of the endotracheal suction catheter.

The suction catheter used was the closed endotracheal suction System with Lock, size 06F, manufactured by Saudi Mais Medical Pharmaceuticals, Riyadh, KSA. Ref: 562-6275.

It was planned to remove the FB by applying direct suction through an ETT, and in the meantime, arrangements were made to involve the pediatric pulmonologist to remove the FB through bronchoscopy if needed.

After confirming the position of the FB in the trachea, a new ETT size 3.5 mm ID was inserted, and this was connected to the wall suction directly after cutting the suction tube square and holding it pressed with the ETT adapter with two hands the ETT being used as a suction tube.

On applying suction, the FB along with a lot of secretions came out and got stuck in the ETT at its junction with the ETT adaptor. The ETT was removed, detached from the adopter, and the F B milked out of it. It was confirmed to be the distal 3.4 cm of the in-line endotracheal suction catheter that had changed the color to yellow [Figure 4] and [Figure 5]. The proximal end was cut obliquely indicating that it was cut along with the ETT.
Figure 4: Foreign body aspirated from the main bronchus measuring 3.5 cm in length

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Figure 5: Foreign body color changed to yellow compared to the normal transparent color of the suction catheter

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After removal of the FB, the child was connected to nasal-IMV. He did well and was weaned gradually.

  Discussion Top

Tracheobronchial FB in neonates are rare and mostly iatrogenic. In a study of 1060 cases of trachea-bronchial FBs, no case of FB was reported in children below 6 months of age.[1] However, there are multiple anecdotal case reports of tracheal FBs.[1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13] Literature reviews reveal that the majority of the FBs are derived from medical devices.[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12] Reported objects include sheared ETT stylet sheath,[2],[3],[4],[5] fractured suction catheter tip,[6],[7],[8],[9],[10] severed end of an ETT,[11] and end-tidal carbon dioxide catheter.[12] There is a report of FB being put into the respiratory passage of two newborn babies by their elder siblings.[13] The tracheobronchial FBs can cause respiratory obstruction, lobar collapse, and even lung perforation and pneumothorax.[10]

In our case, the FB retrieved from the trachea was the distal segment of a closed ETT suction catheter [Figure 4]. The diagnosis was made on the 19th postoperative day. On reviewing the serial X-rays, this FB was noted in all the X-rays taken from the 1st postoperative day. However, the FB was not seen in the immediate postoperative X-ray which was taken immediately after arrival from the OT. After this X-ray, the ETT had been cut to decrease dead space, and the next X-ray was taken about 34 h later.

Since the FB was not present in the first postoperative X-ray but was present in the next one, the FB inhalation occurred after the first postoperative X-ray and before the next X-ray. This timing of occurrence and the beveled shape of the cut end indicates that the tube was accidentally cut while the ETT was being resized without pulling the suction catheter out of the ETT completely. The catheter was cut along with the ETT and the severed end dropped into the ETT. Since the catheter is not completely radiopaque, it was not noticed in the subsequent X-rays. Another possibility is that the suction catheter got stuck in the ETT and broke on pulling it out forcibly. In such an event, the cut end would not be so sharp and beveled.

When the cut catheter was withdrawn, the deficient cut end was not noted as the catheter does not have any marker at the distal end. We recommend that the suction catheter should be withdrawn completely before cutting the ETT, or the ETT should be detached from the suction catheter, and the distal end should be distinctly color coded and should be examined for completeness. Similar recommendations have been made by other authors to make early diagnosis.[8],[9] Alternatively, the ETT should be cut to resize immediately after insertion and before connecting to the in-line suction catheter.

The FB was not noted on the chest X-rays for about 20 days in our case like other reports, and the diagnosis was delayed due to difficult or nonvisualization of the catheter in the initial radiographs and a closer look on review revealed that the FB was there but missed.[2],[4],[7],[11],[12] In two of the case reports, the FB was lodged inside the ETT and was missed on the first X-ray.[4],[12] This indicates that the clinician and the radiologist should be more careful in studying the X-rays in such cases. In addition, if the suction catheter is made more radio opaque it could be visualized easily.

The FB was removed in most of the cases by innovative devices as the appropriately small equipment is not available. In many cases, the FB was retrieved by rigid bronchoscopy.[5],[6],[7],[8],[10],[12] In a reported case, a cupped biopsy forceps was used to retrieve the FB.[6] An optical grasping forceps was used to remove the FB in two cases.[2],[10] In another case, the severed end of the ETT was retrieved by a Fogarty embolectomy catheter.[11] Even a gooseneck snare has been used to retrieve a tracheal FB in a small preterm baby.[3] If on direct laryngoscopy, the FB is visible at the glottis it can be removed by a FB forceps or a McGill forceps.[5],[13] In case, a FB is discovered to be in the ETT; it may come out with it when the ETT is removed.[4] In an unusual case, the severed end of a suction catheter was noted in the right main bronchus but is traveled spontaneously to get access to the stomach and was passed per rectum after 14 days.[9]

We report a novel, simple, and less invasive method of retrieving the FB. We re-intubated the baby with a bigger ETT and applied direct suction to the ETT and retrieved the FB easily. Although we applied pressure with the suction tube cut square and held tightly with the ETT adaptor, it would be easier to use a meconium aspirator to apply direct suction to the ETT. This method saved the patient from transfer to operating room, the use of anesthesia, and rigid bronchoscopy. Our success with this method may be related to the small diameter of the FB related to the size of the trachea. We recommend this least invasive method to be tried with all cases of tracheobronchial FBs before other invasive procedures are tried in neonatal FB inhalation.

The respiratory condition of our patient after removal improved remarkably, and there was no sign of any complication, and the child was weaned to room air and discharged home in a stable general condition.

  Conclusion Top

We describe our experience in managing a preterm neonate with iatrogenic suction catheter inhalation after shortening of the ETT. The FB was missed in repeated X-rays. We recommend that the suction catheter should be removed completely from the ETT before shortening it, and whenever, the suction catheter is removed it should be inspected for completeness. The distal end of the suction catheter should ideally be brightly colored so that it can be checked for completeness on removal. We also suggest to the manufacturer to make the catheter more radiopaque. In addition, the clinicians and the radiologists should study all the X-rays more carefully.

We removed the FB from the trachea by applying direct suction to the ETT and recommend this method to be given a trial before using other invasive techniques to retrieve endotracheal FBs.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Xu Y, Liu L, Zhang XR, Chen WB, Zhu Z, Qi L. Tracheobronchial foreign body aspiration in pediatric patients: An experience on 1060 cases in 2015. Eur J Inflamm 2017;15:267-71.  Back to cited text no. 1
Chiou HL, Diaz R, Orlino E Jr., Poulain FR. Acute airway obstruction by a sheared endotracheal intubation stylet sheath in a premature infant. J Perinatol 2007;27:727-9.  Back to cited text no. 2
Boyd RL, Bradfield HA, Burton EM, Carter BS. Fluoroscopy-guided retrieval of a sheared endotracheal stylet sheath from the tracheobronchial tree in a premature infant. Pediatr Radiol 1999;29:575-7.  Back to cited text no. 3
Shetty S, Power S, Afshar K. A sheared stylet. BMJ Case Rep 2010;2010. pii: bcr0220102725.  Back to cited text no. 4
Stevens DC, Merk PF, Fenton LJ, Schreiner RL. Airway foreign body: A complication of neonatal endotracheal intubation. Clin Pediatr (Phila) 1982;21:510-1.  Back to cited text no. 5
Wei JM, Chang ET, Arnold R, Cable BB. Airway foreign body in a premature neonate. JAMA Otolaryngol Head Neck Surg 2017;143:954-5.  Back to cited text no. 6
Verghese S, Hannallah R, Powell D, Pena M. Delayed retrieval of a hollow foreign body from the trachea of an 850-g newborn. Anesth Analg 2009;108:1720.  Back to cited text no. 7
Shah DM, Sinn J. Endotracheal suction catheter as a foreign body in a neonate. J Paediatr Child Health 2010;46:209.  Back to cited text no. 8
Leung L, Chung PH, Wong KK, Tsoi NS, Lee RS. An unexpected journey of a suction catheter in a preterm neonate. J Pediatr Surg Case Rep 2015;3:364-6.  Back to cited text no. 9
Arda MS, Hamrick MC, Kane TD. Conservative treatment of lung perforation secondary to retained catheter in an extremely low-birth-weight premature infant. European J Pediatr Surg Rep 2015;3:68-70.  Back to cited text no. 10
Horimoto Y, Kasuya T, Yoshizawa M, Okazaki A, Itoh H, Shimura K, et al. An unusual tracheal foreign body in a neonate. Pediatr Radiol 1986;16:420-1.  Back to cited text no. 11
McNamara PJ, Al-Nabhani D, Finelli M. Endotracheal tube with end-tidal carbon dioxide port. Anesthes 2008;108:337-8.  Back to cited text no. 12
Singh I, Gathwala G, Yadav SP, Sharma A. Foreign body airway in neonates. Indian J Pediatr 1999;66:288-9.  Back to cited text no. 13


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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