removal of tracheobronchial secretions to maintain airway patency is a standard of care in mechanically ventilated patients . since the endotracheal tube ( ett ) cuff abruptly stops the mucociliary escalator , endotracheal suctioning is essential to physically remove the secretions this can be achieved by the conventional open system or closed circuit suction system ( ccss ) . the advantages of ccss include limiting environmental , personnel and patient contamination and preventing the loss of lung volume as well as the alveolar de - recruitment associated with standard suctioning in the severely hypoxemic patients . we report an unusual case of an airway foreign body blocking the ccss , the like of which has never been reported before . a 57-year - old farmer presented with a history of fall from a tractor while working in the fields . he sustained head injury , multiple rib fractures on the right side and fracture of the right leg . at the time of presentation he was agitated and tachypnoeic . computed tomography ( ct ) head showed small right sided subdural hematoma contrast enhanced ct chest showed multiple rib fractures , hemo - pneumothorax , basal consolidative changes and surgical emphysema on the right side . the patient 's clinical condition remained stable for 3 days while he was treated with analgesics , antibiotics and 5 l / min oxygen ( o2 ) inhalation by face mask . glasgow coma score remained 15 , arterial blood gas ( abg ) and chest x - rays showed no deterioration . on the 4 day he became drowsy and tachypnoeic . his heart rate ( hr ) increased from 76 to 104 bpm , blood pressure ( bp ) increased from 130/80 to 150/100 mmhg , respiratory rate ( rr ) increased from 18 to 35/min and spo2 dropped to 89% despite increasing inspired o2 concentration . he was intubated and put on ventilator on bi - level mode , following which his condition stabilized within 5 min . hr settled to 88 bpm , rr to 20/min , bp 140/84 mmhg and spo2 97% . as a protocol , ccss ( 14 french ) was attached and suctioning done every 2 h and as and when required . 6 h after putting on ventilator , he again developed tachypnoea ( rr increased from 20/min to 45/min ) , tachycardia ( 110 bpm ) , hypertension ( 150/110 mm hg ) , and de - saturation ( spo2 dropped from 97% to 90% ) . anticipating secretions ccss catheter was passed through the ett but nothing could be sucked out . auscultatory findings ( conducted sounds all over the chest ) and spirometry findings ( decreased inspiratory and expiratory peak flows , low tidal volume ) suggested retained secretions . the ccss was disconnected and on close inspection a tiny stone blocking its tip could be seen [ figure 1 : blocked tip of ccss ] ; [ figure 2 : on close observation tiny stone foreign body blocking the tip of catheter ] which the patient probably inhaled / aspirated at the time of accident . later a large volume of secretions was sucked out using a different suction catheter ; following that the patient 's condition stabilized . a bronchoscopy was performed immediately to rule out the presence of any other foreign body . the patient was managed on the ventilator and tracheostomy done on the 5 day of intubation . he was weaned off the ventilator on the 11 day , operated upon for fracture tibia on the 16 day and discharged on the 23 day following admission in satisfactory condition . ccss has become popular in the recent past because of certain advantages over the traditional open system . it prevents problems associated with ventilator disconnection like hypoxemia , hemodynamic instability , alveolar derecruitment , loss of lung volume and ventilator malfunction . it has also been reported to have some role in protecting against ventilator associated pneumonia and in decreasing environmental contamination with patient 's secretions . it has been found to be more cost effective in patients requiring prolonged ventilation . despite all these benefits it has been postulated to have lower efficacy in removing endotracheal secretions . in our case , it got totally blocked by an airway foreign body ; leading to its failure to remove secretions . since there are chances of the catheter tip , which is not visible in the ccss , getting blocked by inspissated secretions , blood clot or in rare cases like authors by an aspirated small foreign body , the authors suggest that one should be watchful for other signs of retained secretions ; particularly if a closed - suction system is being used . to conclude , closed - suction system has many proven benefits , but the invisibility of its tip can pose serious problems . hence while using ccss , it is advisable to be extra cautious about the signs - symptoms of retention of tracheal secretions .
closed circuit suction system ( ccss ) has become a standard of care for the tracheal suctioning of mechanically ventilated patients . 
 the advantages of ccss over the open suction system include decreased environmental , personnel and patient contamination , preservation of lung volumes and oxygenation especially in the severely hypoxemic patients . on the other hand , ccss has lower efficacy in removal of secretions and it may have certain other disadvantages due to the invisibility of its tip . 
 we report an unusual case of an airway foreign body causing blockage of the ccss leading to retained secretions and deterioration of patient . 
 timely changing over to open suction system helped in its detection and improvement of patient .