Polythene predicament

Abstract

Background: Hypoxemia complicating care during ventilation is a common problem.

Objective: To describe an unusual cause of hypoxemia with fluctuating airway pressures in an invasively ventilated, organophosphate-poisoned patient.

Case report: A 40-year-old man being treated for organophosphate poisoning developed episodes of high airway pressure during mechanical ventilation. These episodes initially settled spontaneously. Detailed evaluation failed to reveal any patient-, airway-, or ventilator-related cause for the high airway pressures. On the fourth hospital day, one such episode of high peak airway pressures persisted and was associated with low tidal volumes and oxygen desaturation. Several attempts at suctioning were unsuccessful and the suction catheter could not be advanced. When the endotracheal tube was removed, a piece of polythene was found at the lower end of the endotracheal tube. This polythene probably resulted in this unusual problem by behaving like a flap valve, causing fluctuating airway pressures initially, and high airway pressures subsequently. There were no further episodes of high airway pressure, and a bronchoscopy did not reveal any residual pieces of polythene. On subsequent questioning, it was revealed that the patient was discovered unconscious with a stuffed polythene cover containing the poison in his mouth. It was likely that the polythene was aspirated when the patient was drowsy, or it was pushed into the airway during intubation.

Conclusion: The importance of careful visualization of the oral cavity before intubation is illustrated in this report. A bronchoscopy may aid in the evaluation of intermittent high airway pressures once pneumothorax and bronchospasm are excluded and should be considered early if an obvious cause for the high airway pressure is not evident.