Incidental tracheal cuff rupture during placement of double-lumen tubes, What to do?

Sir,

A 60 years male who was taking anti-tubercular treatment presented in emergency for severe breathlessness. He was managed and investigated found to having upper and middle lobe right lung aspergillosis. Patient was planned for right thoracotomy and upper and middle lobe pneumonectomy in General Anesthesia with double lumen tube. First of all thoracic epidural catheter is placed and general anesthesia given as per protocol. The height of the patient was 170 cm, so 39 F size double lumen tube of disposable polyvinyl chloride (Broncho Cath DLT, Mallinckrodt Medical, Inc. St. Louis, MO) was selected and checked for any manufacturer defect. Patient trachea was intubated after direct laryngoscopy guided well lubricated left sided 39 F, DLT and tube fixed at 29 cm mark. On ventilation there stared gargling sound showing leak from trachea. On again checking rupture tracheal cuff was confirmed. After removal of first DLT showing ruptured tracheal cuff [Figure 1]. Another same size 39F left sided DLT was placed with help of Glideoscope video laryngoscope under vision with all precaution. Tube position was again confirmed by fiberscope and secured. After the surgery DLT was changed to 8.5 size cuffed normal PVC endotracheal tube.

Figure 1.

showing ruptured tracheal cuff of DLT

The cuffs of plastic DLTs are fragile and easily torn by the teeth, usually during a “difficult” laryngoscopy. In a study done on for left sided DLT placement 1,169 attempted intubations the bronchial cuff was torn once and the tracheal cuff 11 times (0.9%).[1] As our patient airway was Mallampati Grading –I and no buck teeth and, the possible causes of tracheal cuff rupture may be either from teeth or larangoscope blades while negotiating DLT tube in trachea. The patient due to his intrinsic pathology having fibrosis of upper and middle lobe may have presented altered angulation of the tracheobronchial tree.

On reviewing the literature, we found that if a difficult intubation is anticipated, the tracheal cuff of a DLT can be protected by various methods. Both cuffs of a modern plastic DLT can be damaged by teeth or by the laryngoscope blade during intubation of the airway. The larger tracheal cuff is usually at greater risk than the bronchial cuff. When a cuff tear occurs, the tube must be replaced with an intact DLT. This is not only expensive, but requires additional time and may place the patient at increased risk while the airway is being secured. To protect the tracheal cuff of DLTs from rupture, a tape cuff protector can be used for either or both cuffs of a DLT or for the cuff on a conventional endotracheal tube.[2] A more simple method to protect the cuff of a double-lumen tube, especially if prominent teeth's, is to use a well lubricated teeth guard and also to lubricate the cuffs of the DLT. This provides a smooth gliding surface, thereby minimizing the risk of cuff damage while making it much easier to advance the double-lumen tube and assuring adequate tooth protection.[3] Fortier et al, told two other methods to protect the tracheal cuff.[4] First increase the curve of the endobronchial part of the DLT with the aid of the stylet included, such as a hockey stick, as for a difficult intubation. Thus, during the laryngoscopy, the DLT is placed in the airway, and the tracheal cuff is inserted inside the mouth without touching the teeth or the laryngoscope blade. Another method consists of first inserting the DLT until the tracheal cuff is placed inside the mouth, then visualizing the anatomy and intubating after the laryngoscope is inserted.

We conclude that there are rare but fatal chances of tracheal cuff rupture while placing DLT, chances are further increased in difficult airway. We used Glideoscope videolaryngoscopy to put DLT under vision to better see airway structures and passing of tube throw vocal cord.[5] Always try to consider and prevent things that can rupture tracheal cuff while tube placement.[6] If however tracheal cuff ruptures occur it should be replaced with a new one to avoid any intraoperative problem.