Persistent refractory hypercapnia following tracheostomy decannulation in a patient with brainstem hemorrhage: a case report

Background In tracheostomy decannulation decisions for patients with brainstem injury, clinicians typically focus on airway patency, swallowing, and overall respiratory status. However, some patients may remain at risk of chronic hypoventilation after decannulation because of impaired central ventilatory drive and other concomitant factors, even when anatomical airway patency has been restored. Case presentation An elderly male with brainstem hemorrhage underwent decannulation after excision of granulation tissue in January 2024, with no immediate complications. During follow-up, he developed persistent carbon dioxide (CO₂) retention and was readmitted nine times for hypercapnic respiratory failure over the subsequent 19 months, with a peak arterial partial pressure of carbon dioxide of 172 mmHg. Despite repeated medical therapy and noninvasive ventilation, long-term ventilatory stability was not achieved, and a repeat tracheostomy was performed in August 2025. Conclusions This case suggests that decannulation in brainstem-injury patients can be followed by a prolonged compensated phase—chronic compensated hypercapnia was clinically well tolerated for 19 months in this patient—before late, event-triggered decompensation. FEES performed during follow-up confirmed bilateral vocal cord paralysis with severe (penetration–aspiration scale level 7) aspiration, identifying a more direct mechanism for recurrent pneumonia and progressive ventilatory load than central drive impairment alone. The pre-decannulation PaCO₂ was normal, confirming that central ventilatory drive was sufficient at the time of decannulation; chronic compensated hypercapnia is not, in itself, an indication for recannulation. Longitudinal assessment of ventilatory stability is warranted, and the clinical course was likely multifactorial. Pre-decannulation FEES or flexible laryngoscopy should be considered in every brainstem-injury patient—not only those with documented dysphagia—and post-decannulation CO₂ monitoring should be targeted to selected high-risk patients in whom the results would alter management.