P001: ANESTHETIC MANAGEMENT OF A PATIENT WITH A KINKED ENDOTRACHEAL TUBE
George Zhou; Nirav Bhavsar, MD; Nathalie Abitbol, MD, MBA
University of Miami
Introduction: Endotracheal tube (ETT) kinking under anesthesia is a rare but critical and life-threatening airway obstruction. Kinking of the ETT may result from positioning (extreme head/neck flexion), weight of the circuit or from tube softening due to temperature. Immediate recognition of the situation is imperative to maintain proper oxygenation and ventilation of the patient.
Methods: We describe the case of a 58-year-old woman with a history of colorectal cancer metastatic to the lungs and brain who presented for right frontal craniotomy for resection of tumor. Intraoperatively, peak pressures increased to 40 and ventilation became increasingly difficult. Kinking of the ETT was recognized via fiberoptic examination and ETT was exchanged to a reinforced ETT.
Results: After standard induction and easy intubation with a standard PVC ETT, patient was positioned supine with the operating room table turned at 180°. Head was pinned by neurosurgery and procedure started. Three hours into the procedure, patient was noted to have increased peak pressures and upsloping of capnography suggesting airway obstruction. Patient was initially given albuterol and anesthetic was deepened, while anesthesia resident went around and under the drapes to auscultate. No wheezing was apparent, but coarse breath sounds were heard. Examination of the ETT and circuit revealed the tube to still be taped at 21 cm at the lips, with no apparent kinking of the circuit or ETT up until the mouth. Fiberoptic examination however revealed a severe kink proximal to the glottis and the ETT was successfully exchanged, over an Aintree intubation catheter to a reinforced ETT without complication or hemodynamic instability. Remainder of the procedure was uneventful and patient was successfully extubated at the end of the procedure.
Discussion: Standard ETTs are made of PVC. They are therefore malleable and tend to bend under warmer and moist conditions, such as that of the buccal cavity, especially in procedures where the surgical drapes cover the head, trapping in heat. Though ETT kinking is most reported in pediatric or prone cases, it is important to evaluate further with a fiberoptic scope as part of the differential diagnosis for increased pressures and poor ventilation, with the goal to immediately resecure the airway if needed. Though a reinforced ETT may not be used in all cases due to cost considerations, it may be worthwhile considering it in cases in which the airway is remote and temperature may be expected to rise due to heat trapping and the length of the procedure.