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Intratracheal kinking of endotracheal tube

Taipei, Taiwan

To the Editor:

Obstruction of the endotracheal tube (ETT) can occur in various forms while the patient is intubated.^1–3 We would like to report a rare case of intratracheal kinking of the ETT during nasotracheal intubation.

A 20-yr-old man with right mandibular fracture was scheduled for internal fixation of the fracture. He was healthy without any systemic disease. Anesthesia was induced with fentanyl, thiopental, and succinylcholine. Nasotracheal intubation was attempted with an internal diameter (ID) of 7.0 mm ETT. The tube could not pass through the patient’s nasal cavity even with force and was changed for an ID 6.5 mm ETT. After soaking the tube in warm water, it could barely pass through the nasal cavity. At laryngoscopy, the tube was inserted past the vocal cords. Manual ventilation showed a peak airway pressure of 50 cm H₂O and no CO₂ waveform was observed. Auscultation revealed no breath sounds over both lung fields and no gurgling sounds over the epigastrium. The ventilation equipment was checked and found to be normal, so we withdrew the ETT into the oropharynx and reinserted the tube again. The tube was reinserted smoothly but manual ventilation was still difficult. After treatment for a suspected bronchospasm, breath sounds were still not heard and SpO₂ dropped from 99% to about 70%. We checked the tube a second time with a flexible fibreoptic bronchoscope, which, however, could not pass through the tube. Occlusion of the ETT was diagnosed and the tube was removed. We found a kink in the intracuff portion of the ETT (Figure). We then used an ID 6.0 mm ETT for nasotracheal intubation, which was inserted successfully without difficulty. The subsequent anesthetic course was uneventful.

View larger version (111K): [in this window] [in a new window]   FIGURE The endotracheal tube removed from the patient. Arrow A indicates that kinking occured at the site where the inflating lumen opens into the cuff. Arrow B points to the Murphy eye.

It is important for us to consider both mechanical and pathologic factors when airway obstruction is encountered in an intubated patient. Kinking of the ETT inside the trachea is an uncommon problem but must be kept in mind as one of the differential diagnoses.

References

1 Szekely SM, Webb RK, Williamson JA, Russell WJ. Problems related to the endotracheal tube: an analysis of 2000 incident reports. Anaesth Intensive Care 1993; 21: 611–6.[Medline]

2 Gottschalk SK, Schuth CR, Quinby GE Jr. A complication of tracheal intubation: distal kinking of the tube. J Pediatr 1978; 92: 161–2.[Medline]

3 Singh B, Gombar KK, Chhabra B. Tracheal tube kinking (Letter). Can J Anaesth 1993; 40: 682.[Medline]

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