Dear Editor,
Difficulty in ventilating a patient once intubated is not that common in anesthesia practice but in case such a situation arises it creates utter panic. There are only few cases of manufacturing defect of endotrachealtube (ETT) connectors reported, primarily pertaining to pediatric population because of their narrowed lumen. To the best of our knowledge no case has been reported in adult sized ETT connector.
We came across a 23-year-old, patient of road side accident for extradural hemorrhage evacuation having partial obstruction to airway. Following intubation, there was sudden rise of peak pressure, inadequate tidal volume delivery, and change in ventilator graphics[Figure 1]. All the common possible causes of obstruction including bronchospasm, poor pulmonary compliance, anesthesia gas delivery malfunction, and breathing circuit obstruction were ruled out. The 14Fr suction catheter was passed through the ETT but to our astonishment, ETT connector was found to be occluded and the cause of airway obstruction was established Figure 1: Endotracheal tube 8mm; Sterimed Medical Devices Limited, Bahadurgarh, Haryana, India]. The defected connector was immediately replaced and the ventilation was ensured. Varied defects of ETT connector have been reported previously of the same manufacturer from other institutes as well.[1] The information regarding the defect has been sent to the manufacturer and purchase committee of our institution.
Figure 1.
Manufacturing defect of ETT connector along with monitor showing raised peak pressure, inadequate tidal volume delivery, and variation in ventilation graphics
The varied manufacturing defects are described like complete occlusion, narrowed ETT connector, membrane/meniscus partially occlusion, and vertical split.[2,3] Routine pre-use check of the ETT for integrity and functionality remains the standard of care. Despite the common practice of visual inspection and testing of ETTs for physical defects prior to use, some manufacturing defects still go unnoticed.[4] Although pre-use check of ETT cuff assembly to detect leaks is usually performed. The visualization of ETT connector deficiencies may be missed due to ignorance, lack of suspicion, and esoteric location. A tapered/occluded ETT connector is the most common manufacturing defect encountered, as in the index case. Athorough visual external and internal pre-use check of the ETT connector by a vigilant anesthesia provider, in addition to checking cuff assembly is in routine practice. The transparent ETT connectors have also been used by few manufacturers despite that these defects are still difficult to rule out.
The aim of highlighting this incident is to incorporate checklist for ETT malfunction. Addition of the stylet insertion to the ETT may help in detecting intraluminal defects or any foreign body effectively by checking the patency of ETT. To conclude, thorough inspection along with the use of stylet maybe recommended for early detection of these miniscule yet life-threatening defects of ETT connectors to prevent intraoperative catastrophic events.
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References
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