Case report: complete pilot balloon detachment in a ventilator-dependent patient with high-risk tracheostomy exchange

Complete detachment of a pilot balloon and one-way valve eliminates the standard route for tracheostomy-cuff inflation and pressure measurement. Definitive tube exchange may be hazardous in selected patients.

A 74-year-old ventilator-dependent woman with a long-term tracheostomy developed an audible upper-airway leak, a ventilator leak alarm, and reduced displayed tidal volume. Inspection showed complete loss of the pilot balloon and one-way valve, while the residual inflation line remained attached to the tube. Computed tomography documented post-tracheostomy changes but did not report peri-tracheostomy granulation. Otolaryngology bedside examination identified granulation tissue below the stoma and considered tube removal and exchange difficult, with risks of bleeding, aspiration, respiratory difficulty, and loss of the airway. After multidisciplinary assessment and informed shared decision-making, the existing tube was retained and an exceptional bridge manoeuvre was used to access the residual inflation-line lumen, inject approximately 3 mL of air, and occlude the line. Because the pilot balloon and one-way valve were absent, the standard connection for a cuff manometer no longer existed; intracuff pressure was not measured. The reported volume was case-specific, was not a target, and did not establish a safe cuff pressure, efficacy, or safety. Routine hourly observations near the event were not immediate pre-/post-intervention measurements and cannot demonstrate an intervention-related physiological effect. Intermittent leakage persisted, and the defective tube remained in situ at family-requested discharge.

This case highlights recognition of cuff-system failure, specialist escalation, shared risk assessment, and surveillance when exchange is hazardous. This case-specific manoeuvre should not be interpreted as a recommended bedside procedure. Definitive management remains replacement of the defective tracheostomy tube whenever safely feasible.