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Air leak with intact cuff inflation system: A case report with brief review of literature.

Pasupuleti H, Samantaray A, Surapneni K, Natham H - Indian J Anaesth (2015)

View Article: PubMed Central - PubMed

Affiliation: Department of Anaesthesiology and Critical Care, Sri Venkateswara Institute of Medical Sciences, SVIMS University, Tirupati, Andhra Pradesh, India.

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Sir, Tracheal re-intubation because of air leak after a successful tracheal intubation is not very uncommon in anaesthesia practice... The most common illustrated causes for air leaks are related to a defect in the cuff, inflation tube/lumen, pilot balloon, or the spring loaded inflation valve... However auscultation over trachea was negative; but to give the benefit of doubt we re-intubated the patient with a new ETT tube and with this, there was no air leak... After uneventful completion of surgery and subsequent extubation, we re-examined and compared both the ETTs to localise the cause of air leak... On careful physical examination, we found a small defect near the insertion point of the inflation tube in the first ETT [Figure 1], suggesting air leak from the wall of the tube despite the pilot balloon appearing to be firmly inflated... Normally, cuff leak or leak around the cuff can be identified by looking at pilot balloon, palpation of the cuff over suprasternal space, auscultation over trachea and bubbles coming out from the oral and nasal cavity if secretions are present... Literature search illustrated few more case reports implicating improper fixation of the tube by adhesive plaster, repeated use and attempt to remove the adhesive plaster, bitten notch on re-sterilised tube and low product quality compliance as the cause of unexpected air leak from after tracheal intubation... In all these reports, the recommended in vitro test failed to detect such type of occult leak... Considering the fact that a small air leak at the beginning of the surgery may become larger leading to dangerous inadequate ventilation, an ideal solution for this type of problem would be use of a magnifying glass to verify structural integrity of cuff, insertion point and pilot balloon... However, as it is practically not possible to check each and every tube using a magnifying glass, such problems do occur irrespective of manufacturer... Hence, anaesthesiologist should be aware of such possibilities, and this should be kept in the mind as a diagnosis of exclusion, for which the best solution is change of the tube... There are no conflicts of interest.

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The red in colour arrow pointing toward the oval defect in the wall of the flexometallic tube. The flexometallic endotracheal tube is straightened to make the defect more appreciable
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Figure 1: The red in colour arrow pointing toward the oval defect in the wall of the flexometallic tube. The flexometallic endotracheal tube is straightened to make the defect more appreciable

Mentions: The trachea of a 38-year-old lady posted for elective transsphenoidal excision of pituitary adenoma was successfully intubated with a 7 mm internal diameter disposable flexometallic endotracheal tube (ETTfm) (Sterimedâ„¢) and was secured with elastic adhesive plaster at lip line corresponding to 21 cm on the ETTfm tube. A few minutes later while positioning the patient, we noticed audible air leak from the mouth. Hence, we followed a stepwise approach to ascertain and fix the cause. In the first step, we pushed 2 ml air (in addition to 5 ml air used to inflate the cuff initially) and found that the pilot balloon was holding the air that ensured an intact cuff and a competent inflation valve. However, the air leak was still audible from patient's oral cavity with each mechanised positive pressure breath. In the next step, we ascertained the correct position of tracheal tube with check laryngoscopy which confirmed that the entire cuff is below the vocal cord. In the final step, we presumed that the tube may be too small for the trachea of the patient. However auscultation over trachea was negative; but to give the benefit of doubt we re-intubated the patient with a new ETTfm tube and with this, there was no air leak. After uneventful completion of surgery and subsequent extubation, we re-examined and compared both the ETTsfm to localise the cause of air leak. On careful physical examination, we found a small defect near the insertion point of the inflation tube in the first ETTfm [Figure 1], suggesting air leak from the wall of the tube despite the pilot balloon appearing to be firmly inflated.


Air leak with intact cuff inflation system: A case report with brief review of literature.

Pasupuleti H, Samantaray A, Surapneni K, Natham H - Indian J Anaesth (2015)

The red in colour arrow pointing toward the oval defect in the wall of the flexometallic tube. The flexometallic endotracheal tube is straightened to make the defect more appreciable
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4697255&req=5

Figure 1: The red in colour arrow pointing toward the oval defect in the wall of the flexometallic tube. The flexometallic endotracheal tube is straightened to make the defect more appreciable
Mentions: The trachea of a 38-year-old lady posted for elective transsphenoidal excision of pituitary adenoma was successfully intubated with a 7 mm internal diameter disposable flexometallic endotracheal tube (ETTfm) (Sterimedâ„¢) and was secured with elastic adhesive plaster at lip line corresponding to 21 cm on the ETTfm tube. A few minutes later while positioning the patient, we noticed audible air leak from the mouth. Hence, we followed a stepwise approach to ascertain and fix the cause. In the first step, we pushed 2 ml air (in addition to 5 ml air used to inflate the cuff initially) and found that the pilot balloon was holding the air that ensured an intact cuff and a competent inflation valve. However, the air leak was still audible from patient's oral cavity with each mechanised positive pressure breath. In the next step, we ascertained the correct position of tracheal tube with check laryngoscopy which confirmed that the entire cuff is below the vocal cord. In the final step, we presumed that the tube may be too small for the trachea of the patient. However auscultation over trachea was negative; but to give the benefit of doubt we re-intubated the patient with a new ETTfm tube and with this, there was no air leak. After uneventful completion of surgery and subsequent extubation, we re-examined and compared both the ETTsfm to localise the cause of air leak. On careful physical examination, we found a small defect near the insertion point of the inflation tube in the first ETTfm [Figure 1], suggesting air leak from the wall of the tube despite the pilot balloon appearing to be firmly inflated.

View Article: PubMed Central - PubMed

Affiliation: Department of Anaesthesiology and Critical Care, Sri Venkateswara Institute of Medical Sciences, SVIMS University, Tirupati, Andhra Pradesh, India.

AUTOMATICALLY GENERATED EXCERPT
Please rate it.

Sir, Tracheal re-intubation because of air leak after a successful tracheal intubation is not very uncommon in anaesthesia practice... The most common illustrated causes for air leaks are related to a defect in the cuff, inflation tube/lumen, pilot balloon, or the spring loaded inflation valve... However auscultation over trachea was negative; but to give the benefit of doubt we re-intubated the patient with a new ETT tube and with this, there was no air leak... After uneventful completion of surgery and subsequent extubation, we re-examined and compared both the ETTs to localise the cause of air leak... On careful physical examination, we found a small defect near the insertion point of the inflation tube in the first ETT [Figure 1], suggesting air leak from the wall of the tube despite the pilot balloon appearing to be firmly inflated... Normally, cuff leak or leak around the cuff can be identified by looking at pilot balloon, palpation of the cuff over suprasternal space, auscultation over trachea and bubbles coming out from the oral and nasal cavity if secretions are present... Literature search illustrated few more case reports implicating improper fixation of the tube by adhesive plaster, repeated use and attempt to remove the adhesive plaster, bitten notch on re-sterilised tube and low product quality compliance as the cause of unexpected air leak from after tracheal intubation... In all these reports, the recommended in vitro test failed to detect such type of occult leak... Considering the fact that a small air leak at the beginning of the surgery may become larger leading to dangerous inadequate ventilation, an ideal solution for this type of problem would be use of a magnifying glass to verify structural integrity of cuff, insertion point and pilot balloon... However, as it is practically not possible to check each and every tube using a magnifying glass, such problems do occur irrespective of manufacturer... Hence, anaesthesiologist should be aware of such possibilities, and this should be kept in the mind as a diagnosis of exclusion, for which the best solution is change of the tube... There are no conflicts of interest.

No MeSH data available.