“The patient had a cardiac arrest due to airway obstruction because of airway bleeding the night before. After handover the thoracic surgeons were asked to assess patient and perform a bronchoscopy... It was thought that the source of bleeding was above the tip of the tube as clot was seen tracking down beside the tube. On inspection of the oral cavity it was occupied with clot that kept reaccumulating.

ENT were asked to attend. Further inspection of the trachea did not allow the existing clots to be cleared. [Another surgeon] suggested a rigid bronchoscopy but because of fear of losing the airway to upper airway bleeding at this time, this was deferred until ENT arrival and inspection. The ETT tube was advanced as distal as possible to prevent any further clot migration into the lumen but ultimately ventilation was only possible with suction catheter down the ETT beyond the tip. A decision was made to do the rigid bronchoscopy
to clear the clots and this was successfully performed with jet ventilation. A partial tear to the back wall of the trachea was found. The patient was reintubated and on ENT inspection a tear to the soft palate and the pharynx were identified. The patient was kept asleep, paralysed with good gas exchange.”

Blood clot in the airway can be very difficult to remove because of its adherence; using the suction on a flexible bronchoscope may not be sufficient. Although the mechanism of injury is not specified in this story, it seems likely that separate injuries to the soft palate and trachea were caused at laryngoscopy and intubation of the trachea. In any event, this story is a reminder of the hazards that exist. Intubation is not a benign procedure. Airway bleeding should always be investigated. Endoscopy is universally available and should not be delayed. If the source of the bleeding cannot be easily identified then evaluation of the airway without the tracheal tube should be considered. This requires careful planning, as in this case, but again, this should not be delayed if bleeding is significant.