Severed cuff inflation tubing of endotracheal tube: A novel way to prevent cuff deflation

Abstract

A well-secured endotracheal tube (ETT) is essential for safe anesthesia. The ETT has to be fixed with the adhesive plasters or with tie along with adhesive plasters appropriately. It is specially required in patients having beard, in intensive care unit (ICU) patients or in oral surgeries. If re-adjustment of the ETT is necessary, we should be cautious while removal of the plasters and tie, as there may be damage to the cuff inflation system. This can be a rare cause of ETT cuff leak, thus making maintenance of adequate ventilation difficult and requiring re-intubation. In a difficult airway scenario, it can be extremely challenging to re-intubate again. We report an incidence where the ETT cuff tubing was severed while attempting to re-adjust and re-fix the ETT and the patient required re-intubation. Retrospectively, we thought of and describe a safe, reliable and novel technique to prevent cuff deflation of the severed inflation tube. The technique can also be used to monitor cuff pressure in such scenarios.

INTRODUCTION

One of the dangerous complications of improper endotracheal tube (ETT) fixation is tearing of cuff inflation tube while removing plaster/tie during ETT re-adjustment.[1] We report an incidence, where the cuff tubing was accidentally cut along with the ETT tie while trying to re-adjust the ETT and the patient had to be re-intubated. ETT fixation or re-adjustment must be done in an appropriate manner to avoid complications like kinking or detachment of cuff tube from ETT. It can have grave consequences if unnoticed or in cases of difficult airway. If there is a tear of the cuff tubing leading to cuff deflation in such cases, there are various techniques which will be useful to keep the cuff inflated. However, these techniques have their own drawbacks. We wanted to illustrate a safe, secure, reliable and novel technique to prevent cuff deflation of the severed inflation tube and also monitor cuff pressure in such scenarios.

CASE REPORT

The present case report is about a 28-year-old male patient who was brought into our ICU after a road traffic accident, with an ETT secured in the casualty. He had a head trauma, with a Glasgow Coma Score 8, stable vitals but shallow respiration. The patient required mechanical ventilation and was connected to a ventilator on Synchronized Intermittent Mandatory Ventilation mode. We noticed that the ETT was fixed at 24 cm using tie and plasters and breath sounds were lesser on the left side on auscultation. Hence, the plan was to re-fix the tube after slight withdrawal once bilateral equal breath sounds were heard on auscultation. After thorough oral suctioning, while the ETT tie was being cut, it leads to cutting of the ETT cuff tubing as well. Following this, we noticed a leak and inadequate ventilation. The patient was mask ventilated with 100% oxygen, using Artificial Manual Breathing Unit bag and then re-intubated with an 8.0 mm ID cuffed Portex ETT. We secured the ETT carefully this time at depth of 21 cm with plasters.

DISCUSSION

Problems can be encountered during removal of plasters or tie from ETT. The cuff inflation tubing getting snapped off from the ETT is a dangerous complication. When an ETT tie has been used for tube fixation, we must be careful while cutting the tie, to prevent accidental cutting off of the cuff inflation tube as in our case.

In case cuff inflation tubing is detached, cuff leak may lead to inadequate ventilation. Further, it may cause desaturation during re-intubation attempt, trauma due to hurried re-intubation in an emergency scenario and even aspiration.

In a difficult airway scenario, where awake fiberoptic intubation would have been done, the cuff leak due to severing of inflation tubing from ETT may lead to a catastrophe.

A principle of traction and counter traction must be followed during fixation of the ETT.[1] Cuff inflation system should not be included in the plaster as it can cause both kinking and rise in intra cuff pressure. It can also lead to a tear in the cuff tubing while trying to remove the plasters. The adhesive plaster when overlapped over the ETT multiple times may also lead to cuff leak.[1]

At the same time, if the cuff tubing is not fixed to the ETT and it is separate, it can get severed from the ETT during head and neck movement.[2] Furthermore, if it is not fixed at all to the ETT and lies separately, it can get accidentally severed while cutting an ETT tie.

Armored tubes which are reused after autoclaving have a higher propensity to have inflation tubing detachment.[2] To avoid this problem, after proper fixing of the ETT with adhesive plasters, the cuff inflation system can be fixed at the proximal end of ETT with a small plaster.

Anesthesiologist must be extra vigilant during ETT re-adjustment in scenarios such as difficult airway, upper airway trauma or surgery, where vomiting and aspiration are possible. Extreme caution is required in patients in ICU who require high oxygen concentration and positive end expiratory pressure.[1]

However, in spite of utmost sagacity during ETT re-adjustment, there may still be damage to the cuff inflation system. We may be faced with a difficult airway scenario where substantial risk may be involved during re-intubation. There are ways to salvage the cuff tubing to prevent cuff deflation is such scenarios also.

A novel technique of preventing cuff deflation in such a situation is to insert the cut end of the inflation tubing into the locking type Portex^® EpiFuse^® epidural connector (Smiths Medical) which may also be connected to a three way stopcock [Figure 1]. On attaching a cuff pressure monitor to the stopcock, the cuff pressure can also be monitored accurately [Figure 2]. The connection with this technique is so snug and reliable, that we were able to lift the ETT holding the epidural connector and there was no slippage of the inflation tubing from the epidural connector. Even without attaching a three way stopcock to the epidural connector, the cuff inflation can be maintained once the connector is locked. To the best of our knowledge, such a technique has not been described previously.

Figure 1.

The cuff of a severed inflation lumen kept inflated using locking type Portex epidural connector. The cuff will remain inflated when connector is locked

Figure 2.

Cuff pressure can be monitored by connecting a three way stopcock and a cuff pressure monitor, but the epidural connector has to be unlocked at that moment. It has to be locked thereafter to maintain the cuff pressure

If the inflation tubing is disconnected or torn from the ETT, another technique adopted by Sprung et al. may be used.[1,3] He had used the inflation tube of an unused ETT and connected it to the remaining portion of inflation tube of patient ETT using a hypodermic needle to prevent ETT cuff deflation [Figure 3]. Fisher had also used a similar technique to join the cut ends of a cuff inflation system to prevent cuff leak.[1,4]

Figure 3.

Technique used by Sprung et al. to keep the cuff inflated using a hypodermic needle (indicator arrow)

Sill had used a needle connected to the cut end of inflation tube, a three way stop-cock and a syringe to prevent the cuff from deflating[1,5] [Figure 4]. Watson and Harris had used a 22 G intravenous catheter soaked with alcohol to tunnel into the cut end of cuff inflation tubing and then attached to a stopcock to prevent cuff deflation[1,6] [Figure 5].

Figure 4.

Technique of maintaining cuff inflation used by Jims Sill et al. The use of a needle, a three way stopcock with a 10 cc syringe was described

Figure 5.

Technique used by Watson et al. for cuff inflation using a 22G catheter and a three way stopcock

All these techniques use either needle or catheters with needle, which can cause injury in an emergency scenario. The needle itself can rupture the cuff tubing, or can get displaced with change of position of patient in the ICU. However, the use of epidural connector to attach the torn portion of cuff tubing is extremely safe and easy to use. A simplified diagram illustrating this is described [Figure 6]. It provides a very secure connection which can be used even while changing the patient's position or while shifting them. It is also inexpensive, as many hospitals gas sterilize the epidural connectors for re-use. We must only ensure that during inflating or deflating the cuff, the epidural connector is unlocked. Once adequate cuff pressure is achieved, epidural connector can be locked to maintain the cuff pressure.

Figure 6.

Schematic diagram showing the endotracheal tube cuff being inflated by attaching a locking type epidural connector and syringe attached

CONCLUSION

Even though, there is a breakage of the inflation cuff tubing, the anesthesiologist can adopt any of the above mentioned techniques to prevent cuff deflation. This will avoid risk of aspiration, desaturation and trauma during a hasty re-intubation.