Sir,
Difficulty in extubation due to mechanical issues in the endotracheal tube (ETT) is not uncommon in clinical practice. Difficulty in the removal of ETT was mostly related to the failure of cuff deflation.[1] Sometimes because of a distorted anatomy of the larynx, ETT might get stuck which needed a twisting and turning manipulation for removal.[2] A case of difficult extubation due to a manufacturing defect of ETT has been also reported.[3] In another case report, difficult extubation has been reported due to an entanglement of a feeding tube with ETT, and removal of the feeding tube under fiber-optic guidance facilitated the extubation.[4] A case of stuck ETT, where the pilot balloon was being obstructed by the bite block, has also been reported.[5] Most of the cases reported of stuck tubes are from the era of rubber ETT where repeated use of the same tube caused sleeve formation by the cuff.[6] A mechanical issue arising from completely deflated ETT cuff and causing difficult extubation is probably not reported yet.
With consent, we present a case of an 87-year-old female, height 153 cm, having right-sided basi-cervical fracture of neck of femur posted for bipolar hemiarthroplasty. Her airway anatomy was apparently normal. Because of fluctuations in her mood and uncooperative nature along with senile dementia, she was taken for surgery under general anesthesia (GA). GA was induced and the trachea was intubated with a 7-mm internal diameter cuffed ETT after a failure to negotiate a 7.5-mm ID cuffed tube. ETT was well fitting in the trachea; hence, the cuff was inflated with just 1 mL of air. There was a minimal leak with manual positive pressure ventilation leak test with adjustable pressure limiting valve at 30 cmH2O. At the end of the surgery which lasted for 1 h, we planned extubation but we were unable to take the ETT out. Flexible video-scope examination of the oral cavity, periglottic area, and trachea did not show any feature of edema and inflammation. Cuff was reinflated with 1 mL of air again and deflated completely, but still the tube was stuck. Under the video-scope guidance, we turned and twisted the tube, but it was of no use. Inspection pilot balloon-cuff assembly revealed no malfunction. Vocal cord area was again inspected to find out any abnormal cuff herniation at the vocal cord, but the result turned out to be normal. Again, turning the tube to 180° and pulling with little more force under the guidance and over the video-scope resulted in successful extubation. On inspection of the ETT, a rigid near-complete ring formation was noted in the distal end of the cuff due to complete cuff deflation, a rare incidence in this age of PVC ETTs. A slight blood tinge on one point of the ring indicates that the tube was facing resistant on that area [Figure 1].
Figure 1.
The stuck endotracheal tube in situ (a), near complete ring on the deflated cuff, post extubation (b), and laryngeal inlet, post extubation (c)
The present case teaches us that the deflation of cuff to a great extent may be troublesome if the ETT is fitting near snuggly into the trachea. In such situations, reinsufflations with 1 mL of air after complete deflation, rotation, and a twist of ETT may make the extubation easier and less disastrous. Fiber-optic inspection of oral cavity and trachea through ETT can also help us exclude other mechanical issues and decision-making.
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
- 1.Blanc VF, Tremblay NA. The complications of tracheal intubation: A new classification with a review of the literature. Anesth Analg. 1974;53:202–13. [PubMed] [Google Scholar]
- 2.Sprung J, Conley SF, Brown M. Unusual cause of difficult extubation. Anesthesiology. 1991;74:796–7. doi: 10.1097/00000542-199104000-00036. [DOI] [PubMed] [Google Scholar]
- 3.Paliwal B, Jain S, Bhalla N. Difficult extubation: A rare cause. Indian J Anaesth. 2014;58:505–6. doi: 10.4103/0019-5049.139035. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Nakagawa H, Komatsu R, Hayashi K, Isa K, Tanaka Y. Fiberoptic evaluation of difficult extubation. Anesthesiology. 1995;82:785–6. doi: 10.1097/00000542-199503000-00022. [DOI] [PubMed] [Google Scholar]
- 5.Gleich SJ, Mauermann WJ, Torres NE. An unusual cause of a difficult extubation. Respir Care. 2008;53:376. [PubMed] [Google Scholar]
- 6.Khan RM, Khan TZ, Ali M, Khan MS. Difficult extubation. Anaesthesia. 1988;43:515. doi: 10.1111/j.1365-2044.1988.tb06660.x. [DOI] [PubMed] [Google Scholar]