An unusual complication of endotracheal intubation.

A 21-month-old girl was admitted to the pediatric intensive care unit (PICU) following a near drowning. Emergency medical services personnel intubated the child in the field, using a 3.0 mm inner-diameter endotracheal tube (ETT). There was an undocumented report of a second intubation attempt by emergency personnel in the field. After arrival in the outlying emergency room the child vomited, dislodging the ETT. She was then reintubated with a 4.0 mm ETT. No chest radiograph was done to confirm placement. The child was transported to our facility for further management. Because of a substantial air leak around the ETT the child was reintubated nasally with a 4.5 mm ETT, under direct vision, with no difficulty, by a resident physician under the direct supervision of an attending pediatric intensivist. After the ETT change the child had good breath sounds bilaterally and an appropriate colorimetric change on the carbon dioxide detector, consistent with tracheal intubation. A chest radiograph (Fig. 1) was obtained after this tube change. On repeated examinations during her early PICU stay, the patient’s breath sounds over the left chest were intermittently decreased. On further discussion with the resident physician the epiglottis, vocal cords, and a second tube, thought to be the nasogastric tube, were seen during laryngoscopy at the time the ETT was changed. A procedure was performed and ventilation improved.