Fatal endotracheal tube obstruction due to the ball valve effect

Endobronchial hydatid cyst causing variable intrathoracic airflow limitation selectively during expiration acting as a ball valve

Lung hydatid cyst is a frequently encountered site of echinococcus infection after the liver. Rupture of endobronchial hydatid cyst may lead to hydatemesis or may spread to the normal lung or can cause anaphylactic reactions. Performing bronchoscopy in cases with bronchial hydatid is controversial. The thoracic hydatid cyst may destroy the native lung parenchyma or may cause mass effect on the surrounding structures. Ball valve obstruction of the bronchial hydatid cyst is not documented in the literature and here the authors present such a case as the recognition of the ball valve mechanism is important as it may cause tension pneumothorax.

Supplementary information

The online version contains supplementary material available at 10.1007/s12055-023-01541-4.

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

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