Failure to deflate an endotracheal cuff

Challenges in Extubation: A Case of a Non-removable Tracheal Tube Following Surgery

This report details a challenging case of difficult extubation due to a lodged tracheal tube following surgery, presenting an unexpected and complex clinical situation. An inspection of the airway using videolaryngoscopy revealed an over-inflated cuff beneath the vocal cords. Initial efforts to deflate the cuff with various methods were unsuccessful. The situation was ultimately resolved through the intervention of an otolaryngology surgeon. This case not only reviews various mechanisms of difficult endotracheal tube removal reported in the literature, but also underscores the potential for serious complications and highlights the critical role of multidisciplinary collaboration in managing extubation challenges. Additionally, our manuscript discusses alternative strategies that can be employed in scenarios where an otolaryngology surgeon is not available, offering practical guidance for anesthesiologists confronted with similar situations.

Surgical tracheostomy in a patient with a stuck tracheal tube in situ

The inability to extubate a patient's trachea due to a mechanical complication is rarely encountered in clinical practice. The risks of attempting to remove a stuck tracheal tube include laryngeal trauma, vocal cord injury and arytenoid dislocation, all of which have significant implications. Here, we report the case of a patient who was admitted to the intensive care unit for mechanical ventilation following liver transplant surgery. Her trachea was initially extubated on the second postoperative day, but she required further mechanical ventilation the following day and her trachea was re-intubated. Five days later, she was deemed suitable for tracheal extubation, but the formation of granulation tissue around the tracheal tube prevented its removal. A multi-disciplinary decision-making approach was taken when deciding to site a surgical tracheostomy. A flexible bronchoscope was used as an aid for safe placement. This facilitated safe extrication of the tracheal tube, which was freed by gentle manipulation both proximally and distally. We suspect that tracheal tube size may have been a factor in the development of the granulation tissue in this case. It is important to consider tracheal tube size in all patients, particularly if they require tracheal re-intubation or are likely to require mechanical ventilation for a prolonged period.

Unexpected difficult extubation of double lumen bronchial intubation: a case report

Background

The anesthetist and other members of the perioperative team need to be extremely cautious for successful completion of any surgery. If the final step of any general anesthetic-extubation is not sufficiently well planned, it can lead to critical airway incidents during the extubation and hinder transportation of the patient to the post-anesthesia care unit.

Case presentation

A 48-year-old female underwent video-assisted thoracoscopic surgery (VATS) combined with left lower lobectomy. The distal end of the left branch of the tracheal tube was lodged by surgical sutures. In this case, the respiratory physician burned the sutures using an argon electrode, after discussion with the thoracic surgery experts.

Conclusions

Teamwork is essential when caring for a patient with a shared airway. The anesthetist and surgeon must communicate well with each other to achieve optimal surgical outcomes. Importantly, testing the patency of the ETT prior to extubation should be a regular procedure, which is practical significance to guide safe extubation.

Insertion of cuff inflation line into pediatric tracheal tubes related to oral and nasal tracheal intubation depth

BACKGROUND

In clinical practice, the cuff inflation line of cuffed pediatric tracheal tubes often interferes with securing tracheal tubes.

METHODS

The insertion site of the cuff inflation lines and the lengths of four different brands and nine sizes of commonly used cuffed pediatric tracheal tubes were measured and compared in vitro with oral and nasotracheal intubation depths as calculated by different formulas for pediatric patients aged from birth to 16 years. Motoyama's recommendation was used for age-related size selection of cuffed pediatric tracheal tubes.

RESULTS

The proportion of the distance from the tracheal tube tip to the insertion site of the cuff inflation line varied considerably between the tracheal tubes (Microcuff: 48.5-60.7%; Parker: 48.7-73.2%; Ruesch: 59.1-77.8%; and Shiley: 46.0-60.3%). Using different formulas for oral or nasotracheal intubation depth, the insertion site of the cuff inflation line was placed within the oral or nasal cavity or within an area 1 cm beyond the teeth or the nostrils in almost all tracheal tubes tested. Positioning the insertion site 2 cm from the proximal end of the tracheal tubes resulted in a cuff line-free tube area of ≥1 cm in all orally and almost in all nasally inserted tracheal tubes, considering maximum recommended tracheal intubation depths.

CONCLUSION

The cuff inflation line in almost all commonly used cuffed pediatric tracheal tubes interferes with securing the tracheal tube due to its insertion site into the tracheal tube. This potentially carries the risk of kinking, obstruction, or damage to the cuff inflation line with ensuing failure to deflate or inflate the cuff. The proposed position of the insertion of the cuff inflation line 2 cm from the proximal end of the tracheal tube would ensure a 1-cm-wide cuff line-free circular area beyond the oral or nasal cavity in nearly all assessed tracheal tube sizes.

Inappropriate fixation of an endotracheal tube causing cuff malfunction resulting in difficult extubation

We discuss a case of difficult extubation, due to inadequate deflation of the tracheal tube cuff, despite collapse of the pilot balloon, on its aspiration. This was caused by inadvertent kinking of the pilot balloon tubing due to inappropriate tape fixation of the endotracheal tube.

Inappropriate fixation of an endotracheal tube causing cuff malfunction resulting in difficult extubation

We discuss a case of difficult extubation, due to inadequate deflation of the tracheal tube cuff, despite collapse of the pilot balloon, on its aspiration. This was caused by inadvertent kinking of the pilot balloon tubing due to inappropriate tape fixation of the endotracheal tube.