TRANSTRACHEAL OXYGEN CATHETERIZATION WITH PNEUMOMEDIASTINUM AND SUDDEN-DEATH

A 69-year-old man with hypoxemic COPD underwent placement of a transtr acheal oxygen (TTO) catheter, At 3 months, the catheter tract appeared mature with minimal erythema and no evidence of infection at the cath eter site. The patient and his spouse were taught to remove and reinse rt the catheter but were told to delay beginning the procedure due to erythema at the stoma site. Despite instructions not to remove the cat heter for cleaning, the spouse removed the TTO catheter and attempted to reinsert it using the flexible metal cleaning rod. Subsequently, th e patient suffered an acute episode of subcutaneous air and hemodynami c collapse resulting in death. Necropsy revealed a false catheter trac t occluded by clotted blood and a defect in the platysma muscle where oxygen had dissected into the mediastinum. The patient died due to pne umomediastinum and cardiac tamponade.