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Canadian Journal of Anesthesia 49:527-528 (2002)
© Canadian Anesthesiologists' Society, 2002

Correspondence

Diagnosing endotracheal tube partial withdrawal vs cuff puncture

Atul Gaur, MD, Anil Agarwal, MD and Garima Garg, MD

Lucknow, India

To the Editor:

Partial withdrawal of the endotracheal tube (ET) and cuff puncture are not rare occurrences.1,2 This in vitro study was performed to differentiate these two conditions. Forty intubations were performed in mannequins with 8 mm high-volume low-pressure cuffed ET, divided into four groups of ten. The ET cuffs were inflated with 10 mL of air in Groups I and II; and with 10 mL of normal saline (NS) in Groups III and IV. In Groups I and III, ET cuffs were intact and allowed to protrude partly above the vocal cords. In Groups II and IV, ET cuffs were punctured with a 22 gauge needle and placed properly in the trachea.

The feel of the pilot balloon was graded by an anesthesia technician blinded to group allocation and found to be similar in all groups. Air or NS was then aspirated from the ET cuffs. The volumes injected and the volumes retrieved were compared by Student's t test (TableGo).


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  		TABLE Volume of air/normal saline (NS) injected and aspirated from the pilot balloon.
 
In intact ET cuffs protruding partially above the vocal cords, there was no significant difference between the volume of air injected and the volume of air aspirated from the cuffs (Group I). There was a significant increase in the volume of air aspirated compared to the volume injected in punctured ET cuffs placed properly inside the trachea (Group II).

In intact ET cuffs protruding partially above the vocal cords, there was no significant difference between the volume of NS injected and the volume of NS aspirated (Group III). There was a significant decrease in the volume of NS aspirated compared to the volume injected in punctured ET cuffs placed properly inside the trachea (Group IV).

Therefore, we suggest that the volume of aspirate from the ET cuff provides important clues regarding ET displacement or cuff injury. When the volume of aspirate is similar to the one injected, this indicates that there is no injury to the ET cuff and partial dislodgement is a likely explanation. When the volume of aspirate differs from what was injected into the ET cuff, injury to the ET cuff is probable. Further, when NS is used, volume is lost through the injured ET cuff, hence the volume of aspirate is less then what was injected. However, when air is used to inflate the ET cuff, gas may be aspirated from the injured cuff, increasing the volume retrieved. We recommend that this test be performed to differentiate tube misplacement from ET cuff injury in the presence of an air leak in the intubated patient.

References

1 Dorsch JA, Dorsch SE. Tracheal tubes. In: Retfort DC (Ed.). Understanding Anaesthesia Equipment Construction, Care and Complications. Baltimore: Williams and Wilkins, 1994.

2 Munshon ES, Lee R, Kushing LG. A new complication associated with the use of wire-reinforced endotracheal tubes. Anesth Analg 1979; 58: 152.[Abstract/Free Full Text]





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