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Table of Contents
LETTER TO EDITOR
Year : 2019  |  Volume : 35  |  Issue : 4  |  Page : 564-566

An unexpected cause of endotracheal tube obstruction after routine tracheal suctioning


1 Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
2 Department of Anaesthesiology and Critical Care, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India

Date of Web Publication13-Dec-2019

Correspondence Address:
Dr. Mritunjay Kumar
Department of Anaesthesiology and Critical Care, 3rd Floor, OPD Block, All India Institute of Medical Sciences, Basni Industrial Area, Phase II, Jodhpur - 342 005, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joacp.JOACP_100_18

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How to cite this article:
Chouhan RS, Kumar M, Saran A, Mohammed S, Gupta S, Chopra K. An unexpected cause of endotracheal tube obstruction after routine tracheal suctioning. J Anaesthesiol Clin Pharmacol 2019;35:564-6

How to cite this URL:
Chouhan RS, Kumar M, Saran A, Mohammed S, Gupta S, Chopra K. An unexpected cause of endotracheal tube obstruction after routine tracheal suctioning. J Anaesthesiol Clin Pharmacol [serial online] 2019 [cited 2020 Apr 4];35:564-6. Available from: http://www.joacp.org/text.asp?2019/35/4/564/272921



Madam,

Endotracheal suctioning is a commonly done procedure in perioperative period and intensive care units to clear pulmonary secretions, to optimize oxygenation and to prevent complications related to retention of secretions such as atelectasis, pneumonia, blockade of tube, etc. The obstruction of an endotracheal tube is a potentially life-threatening complication. We report a case, where we found a totally unexpected cause of desaturation after routine tracheal suctioning.

A 45-year-old, male patient, a postoperative case of Whipple's procedure was on elective ventilation with assist control mode in intensive care unit. The patient was generating more than 8 ml/kg of tidal volume with peak airway pressure of 12–14 cm of H2O and 100% saturation with FiO2 of 0.3. Five minutes after one of the routines suctioning by the attending nurse, patient developed tachycardia, desaturation, with a simultaneous rise in peak airway pressure up to 35 cm of H2O.

The duty doctor immediately attended him. He first increased the FiO2 to 100% and then checked all connections, any kinking or external pressure on endotracheal tube ETT or ventilator circuits. Chest auscultation revealed decreased air entry without any rhonchi or rales. Repeat ETT suctioning done to remove any secretions or mucus plug, with some resistance but saturation continued to fall. Ventilation with Bain's circuit was also attempted without improvement. Finally, a decision was made to change the ETT. After re-intubation with the same size tube, ventilation compliance and saturation improved.

On careful examination of the removed ETT, we found the torn end of a glove finger occluding the distal end of the tube [Figure 1] and [Figure 2]. On further enquiry, attending nurse revealed that her distal glove part of index finger had got stuck in between the tube mount and ETT connector while doing tracheal suctioning, which she had pulled out in hurry. Torn part of the glove was probably displaced distally because of positive pressure ventilation and was finally stuck at the tip of the tube leading to its partial occlusion, which manifested as rise in the peak airway pressure and desaturation.
Figure 1: Torn end of the glove causing partial obstruction of the distal end of the ETT (Arrow)

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Figure 2: Torn part of the glove finger

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After successful endotracheal intubation, difficulty in ventilation through ETT may occur owing to variety of reasons[1] such as malfunction of the gas delivery system, obstruction of the breathing circuit (anywhere from common gas outlet to the distal end of ETT), esophageal intubation, poor pulmonary compliance caused because of extrinsic (e.g., chest wall rigidity) or intrinsic factors (such as acute severe bronchospasm, tension pneumothorax, and endobronchial mass), overinflated tracheal cuff, and plugging of the ETT by desiccated secretions or blood clot. Several manufacturing defects of the ETT like herniation of the cuff, elliptical defects in the tube wall at the level of the notch cut for insertion of the pilot tube causing air leak, intraluminal plastic films, and meniscus, etc. have also been observed during clinical use.[2] Sheared off parts of the plastic tip of the stylet[3] or tube,[4] temperature probe,[5] and tegaderm[6] have also been reported to cause partial or complete obstruction.

Inspection of ETT prior to use for patency of the lumen along with the pilot balloon cuff assembly, use of appropriate size of the ETT, checking of the integrity of the intubation aid devices like stylet before and after intubation, avoiding use of plastic coating of the stylet altogether, continuous monitoring of ventilator pressures, saturation, and end-tidal CO2 are some of measures that can be taken for prevention and early detection of airway obstruction.

When complete obstruction of the airway is encountered in an intubated patient, it is important to consider both mechanical and pathological factors mentioned above and simultaneously act to resolve it quickly. The passing of suction catheter or fiberoptic bronchoscope can help us in identifying and solving a few of the causative factors. In cases where we are unable to find cause for inadequate ventilation, it is imperative to replace the ETT.

Our case highlights the importance of vigilance and communication while taking care of intubated patients. We also recommend the use of well-fitting gloves and closed suction system to avoid this kind of incidence.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Barst S, Yossefy Y, Lebowitz P. An unusual cause of airway obstruction. Anesth Analg 1994;78:195.  Back to cited text no. 1
    
2.
Hajimohammadi F, Taheri A, Eghtesadi-Araghi P. Obstruction of endotracheal tube; a manufacturing error. Middle East J Anaesthesiol 2009;20:303-5.  Back to cited text no. 2
    
3.
Bhargava M, Pothula SN, Joshi S. The obstruction of an endotracheal tube by the plastic coating sheared from a stylet: A revisit. Anesthesiology 1998;88:548-9.  Back to cited text no. 3
    
4.
Choi YH, Lee DH. A rare airway obstruction caused by dissection of a reinforced endotracheal tube. J Emerg Med 2018;54:e73-5.  Back to cited text no. 4
    
5.
Palta S, Saroa R, Saini V. El tubo endotraqueal no protégé contra la aspiración de un cuerpoextra˜nohaciaadentro de la tráquea: Reportede caso. Rev Colomb Anestesiol 2014;42:129-31.  Back to cited text no. 5
    
6.
PatakLS. Iatrogenic endotracheal tube obstruction by tegaderm. A A Case Rep 2017;9:332-3.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2]



 

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