Sir,
Failure to ventilate lungs postintubation in an infant can be life-threatening. The patient or equipment factors are commonly implicated for airway obstruction. Etiology commonly includes tension pneumothorax; bronchospasm; obstruction due to mucus plug, clot, and kink in the endotracheal tube (ETT); and breathing circuits.[1]
We report a case of left pelvic ureterojunction obstruction in a 3-month-old male infant weighing 10 kg planned for pyeloplasty. Preanesthesia checkup was normal. On arrival to the operation theater, fasting status and consent for surgery were confirmed. Patency for intravenous (IV) access which was secured in the ward after the application of the eutectic mixture of local anesthetic was established. General anesthesia with continuous transversus abdominis plane block was planned. Standard noninvasive monitoring was instituted. The infant was premedicated with injection glycopyrrolate 4 μ/kg, injection midazolam 0.05 mg/kg and injection fentanyl 2 μg/kg IV. Induction was done with injection propofol 2 mg/kg IV. The adequacy of ventilation was ascertained, and the airway was secured under vision with size 4-mm internal diameter uncuffed polyvinyl chloride ETT following administration of injection atracurium 0.5 mg/kg.
Postintubation, chest auscultation revealed minimal air entry on both sides with bilateral wheeze, and there was an imperceptible chest lift. The compliance of the breathing bag was reduced, and there was an increased resistance to ventilation. The airway pressure was high (34 cmH2O), and end-tidal carbon dioxide (ETCO2) steadily increased up to 55 mmHg with “shark fin” capnogram. Immediate corrective measures were taken. Manual ventilation with 100% oxygen ensued; meanwhile, gentle laryngoscopy was done to rule out any displacement or intraoral kinking of the ETT. Simultaneously, breathing circuits were inspected externally, and nothing conclusive was found. Suspecting the block in the ETT lumen, a 6-Fr suction catheter when introduced, failed to negotiate beyond the connector of the ETT. Trachea was extubated and new ETT of similar size was exchanged. On auscultation, there was a considerable improvement in the air entry with evident rise in the chest. The airway pressures normalized to 15 cmH2O, and ETCO2 gradually decreased to 40 mmHg. The saturation of oxygen never went below 94%. Inspection of the removed ETT connector revealed nearly obliterated end [Figure 1]. The rest of the intraoperative period was uneventful.
Figure 1.
Pinhole opening in an endotracheal connector and its comparison with the normal endotracheal connector
Ventilation through the pinhole opening of the connector of ETT due to the manufacturing defect could be hazardous. The airway resistance in infants increases to airflow in view of smaller diameter of the airways as resistance is inversely proportional to the radius raised to the power of four (r4).[2] Literature shows an increased incidence of airway obstruction with the use of resterilized ETT, deformed T connector, and the presence of plastic meniscus at the patient end of the connector.[3,4] Adoption of a systematic approach while remembering the simple mnemonic DOPE (displacement of the tube, obstruction, pneumothorax, and equipment failure) can help in preventing morbidity by early detection.[5] In our case, the hospital purchasing committee was notified, and strict quality control from the manufacturers was ensured. Such life-threatening event could be averted by being vigilant and formulating a protocol for the equipment check, which includes detailed external inspection of all anesthetic equipment and their accessories.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal patient identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
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Conflicts of interest
There are no conflicts of interest.
REFERENCES
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