Tubercular mediastinal lymphadenopathy: An unusual cause of failed decannulation and tracheostomy

Literature has described many causes of failed decannulation and weaning. However, failed decannulation and weaning from ventilator due to a hilar lymph node compressing upon a bronchus has not been described. We report a case of a 30-year-old man with Guillain-Barré syndrome who had quadriparesis and respiratory distress. After 1 year of intensive care unit admission, he was ambulatory, haemodynamically stable, devoid of sepsis, had effective cough with tracheostomy in situ. Every attempt of decannulation led to pooling of secretions in left side of chest, hypercarbia and altered sensorium. This was followed by re-institution of ventilator support. Chest x-ray was unremarkable, but computed tomography (CT) chest done during this time showed a mass compressing upon left lower lobe bronchus. Flexible fibre-optic bronchoscopy and transbronchial biopsy confirmed the diagnosis to be tubercular lymph node. After 1 month of starting of anti-tubercular treatment, there was resolution of the mass with relief of the bronchial compression and a successful decannulation thereafter. Role of CT in difficult cases of weaning is emphasized, and role of bronchoscopy is highlighted in difficult cases of weaning and decannulation.