Ventilation difficulty due to herniation of inflating tube of the cuff inside the endotracheal tube.

The complications due to airway equipments remain to be one of the most challenging situations for the anesthesiologists. Any part of an endotracheal tube may cause a risk when it leads to an obstruction in the airway. Here, we present an increased airway pressure due to herniation of inflating tube of the cuff inside an armored (wire reinforced) endotracheal tube during neurosurgery in prone position. A 34 years old, female patient was scheduled for 6th thoracic vertebraectomy and bilateral transpedinculer fixation after vertebrae fracture and dislocation. The patient was intubated uneventfully with an armoured tube (I.D. 7.5 mm, O.D. 17 mm, Mallinckrodt, St. Louis, USA). The tube level was checked by auscultation and taped at 19 cm. The initial airway pressure was between 14 16 cm H2O with a tidal volume of 450 ml and 11 breaths/min. The anesthesia was maintained by isoflurane and nitrous oxide/O2 (50%/50%). The endotracheal tube checked again for an unintentional malpositioning of the tube after prone positioning and confirmed by auscultation and airway pressure which remained between 18 and 20 cm H2O. After two hours, air leakage was suspected from the tube and the cuff was inflated with 1 ml of air and the leakage was ended. Airway pressure started to rise during rod placement after transpedinculer screws insertion at the 3rd hour, and the neurosurgeons were informed about the problem assuming that the rise in airway pressure might be related to the surgical procedure as the manipulations due to the reduction for obtaining thoracic lordosis could be the cause of increased airway pressure. We tried to aspirate through the endotracheal tube with a 14 Ch aspiration catheter. However, we couldn’t insert the catheter more than 5 cm inside the tube. The manual ventilation was started until suturation since the airway pressure and PaCO2 peaked at 60 cm H2O and 70 mmHg, respectively. After a rapid closure of the surgical site, the patient positioned supine, however airway pressure still remained high and the suctioning was impossible. When we inspected inside the tube, we noticed a transparent projection obstructing 1⁄2 of the inner diameter of the endotracheal tube (Fig. 1). Immediately, we removed the obstructed tube and replaced it with a standard 7.5 mm tube. The airway pressure returned into normal and increase in PaCO2 resolved quickly. The patient was extubated uneventfully.