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Severe pneumonia,kidneys not functioning,cardiopulmonary arrest due to mucus plug

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General & Family Physician
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My mother was on a ventilator due to sever pneumonia. They attempted to wean her off after a few days and although her blood pressure, oxygen levels, etc. were good, they doctors said she feel asleep and they could not wean her off unless she was fully awake. They told us her kidneys were not functioning properly and were going to do a dialysis for up to 3 days. They said the dialysis would also help losen some of the volume around her lungs and she will be stronger to breath on her own. After her first day of doing dialysis, a mucus plug caused cardiopulmonary arrest and she passed. We did not know it was a mucus plug until after she passed and they removed the tubes (we were called to the hospital at 3am and just told her pressure and heart were dropping) We were in such shock when all of this happened so I was unable to ask the physicians any questions. I am curious to know: 1.) Could the mucus plug have been cleared, preventing death 2.) Shouldn't they have removed the tube once her numbers starting decreasing, being a mucus plug is a risk for ventilator patients? 3.) How long does a mucus plug take to build up...hours, days, minutes?

Any answers were be greatly appreciated.
Posted Sun, 29 Apr 2012 in Hypertension and Heart Disease
Answered by Dr. Deepak Anvekar 29 hours later
Hello Mellissa,

I am very sorry to know about the sad demise of your mother.

Here are the answers to your specific questions:

1.) Could the mucus plug have been cleared, preventing death?

Answer: YES, mucus plugs within the ETT (endotracheal tube) can be cleared by regular suctioning.

But Plugs in the branches of the bronchioles and XXXXXXX lung segments cannot be removed, and might need invasive procedures such as bronchoscopy, which are difficult to do in a patient already on mechanical ventilation.

Mucus plugs are the most common complication, that occur in a patient on mechanical ventilation and entotracheal tube intubation.

Mucoid impaction results from the inspissation of mucus and other secretions within the airway and can cause the partial or even complete airway obstruction. It often occurs in the bronchi and bronchiole, but may also appear in the ETT.

In a Intubated patient, Usually small plugs within the ETT, can be cleared by regular suctioning.

Several factors can increase the risk for developing thick secretions within the trachea and lower respiratory tract.
1. Dehydration by the fasting and low inspired humidity can increase the viscosity of secretions, leading to inspissation and a reduction in mucociliary flow.
2. Atropine and inhalational anesthetic drugs may cause mucus to become viscid and impair mucous transport.
3. The inflation of an ETT cuff may not only decrease mucous velocity in the trachea, but also can prevent normal effluence of secretions within the trachea and cause the aggregation of secretions in the upper trachea.

Hence once such plugs are formed, it causes respiratory tract obstruction and respiratory failure.

After the diagnosis of an mucus plug obstruction is established, it is necessary to reopen the airway. Although different methods are available to remove the obstructed materials from the ETT, such as suction, forceps extraction, balloon embolectomy, Reintubation is the most appropriate next step to establish a patent airway if direct laryngoscopy is not difficult.

2.) Shouldn't they have removed the tube once her numbers starting decreasing, being a mucus plug is a risk for ventilator patients?
ANSWER: From the available history, it seems that your mother had developed multiorgan failure, as a result of the pneumonia. The pulmonary edema, (Fluid overload in the lungs, which does not allow proper lung function to occur) which developed as a result of the kidney dysfunction, would have increased the work of breathing, if the tube had been removed before dialysis was done, and the kidney dysfunction rectified. In case the tube was removed earlier, the chances of deterioration would have been very high.

3.) How long does a mucus plug take to build up...hours, days, minutes?
ANSWER: It takes a few hours for a mucus plug to develop. Hence it is very difficult to reach or rectify them.

Hope I have answered your query.

I will be available to answer your follow up queries.
Above answer was peer-reviewed by
Follow-up: Severe pneumonia,kidneys not functioning,cardiopulmonary arrest due to mucus plug 13 days later
Thank you for your detailed response, Dr. Anvekar. I have been doing much research and I have just requested her medical records. My mother was in ICU in one of the best lung centers in the country so I am having a hard time understanding how a mucus plug could cause her death.

When I asked if they should have removed her tube, I understand that if done, they most likely would have to intubate her again. Because her airways were being blocked, I'm sure the ventilator machine had to be beeping (a sound we knew well from when she would bite down on the tubing or she needed to be suctioned) If her machine was beeping, her oxygen was decreasing and her blood pressure going down, is there any reason for them not to be able to either clear the tube via suctioning or remove the tube, clear the plug, then re-intubate? They didn't know it was a mucus plug until after she was pronounced dead and they only knew because they removed the tube and saw it. Is there any reason they wouldn't have known this until it was too late? They stated that the dialysis would loosen her secretions around her lungs; shouldn't they have been prepared for a mucus plug or have done extra suctioning being she wasn't able to cough up the mucus on her own? If they removed the tube and then she passed, I would understand better but I feel not everything was done to save her.

Prior to this second intubation, she was off the ventilator for about one week. During that time, she claimed her body was numb and she had no pain. My mother suffered with severe rheumatoid arthritis and was in constant pain all her life. She had little mobility and was not quiet when she hurt. The week between ventilators, she was moving more, showed no signs of pain and even refused pain medication, saying she didn't need it. Is there any medical reason for this? She was also very lucid the entire time and knew everything that was going on. She was very sharp and even when on the ventilator, would mouth words to communicate with us, making perfect sense and asking important questions.

I greatly appreciate you taking the time to answer my questions and better understand.

Best regards,
Answered by Dr. Deepak Anvekar 11 hours later
Hello Mellissa,

Usually the protocol in a intubated patient is to perform suction on the tube at regular intervals so as to remove any secretions that can later result in a mucus plug. This is regularly followed in any major medical institute, and must have been followed in the concerned hospital as well.

In case that was not done, then this might have resulted in complications and hence formation of mucus plugs in the tubes.
The ventilator beeps when the vitals become abnormal. But it is difficult to differentiate the presence of mucus plugs in the tube, and that of sudden cardio-respiratory depression that can occur due to the medical conditions that your mother had. The medical staff must have determined that the onset of her sudden deterioration was due to her pneumonia and not due to the plugs, as they might have not anticipated the plugs forming inspite of them following the predetermined precautionary measures.
Since your late mother, was on a ventilator, removal of the Endotracheal tube would have caused the collapse of her status further, and hence removal and re-intubation with a different tube was not tried.

The cause of your mother being in a painless state, could be due to the fact that she was being given painkillers (parenteral) and anesthetics that reduce her sensation and discomfort to presence of the endotracheal tube and other procedures.

I hope this helps.
Above answer was peer-reviewed by
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