Epidural analgesia for a laparotomy in a morbidly obese patient with a history of difficult intubation.

of 50 cm H2O and no CO2 waveform was observed. Auscultation revealed no breath sounds over both lung fields and no gurgling sounds over the epigastrium. The ventilation equipment was checked and found to be normal, so we withdrew the ETT into the oropharynx and reinserted the tube again. The tube was reinserted smoothly but manual ventilation was still difficult. After treatment for a suspected bronchospasm, breath sounds were still not heard and SpO2 dropped from 99% to about 70%. We checked the tube a second time with a flexible fibreoptic bronchoscope, which, however, could not pass through the tube. Occlusion of the ETT was diagnosed and the tube was removed. We found a kink in the intracuff portion of the ETT (Figure). We then used an ID 6.0 mm ETT for nasotracheal intubation, which was inserted successfully without difficulty. The subsequent anesthetic course was uneventful. Inspection of the ETT after it was removed from the patient demonstrated kinking occurred at the site where the inflating lumen opens into the cuff. Although the exact cause of this problem remains unclear, we assume that crushing of the ETT while it was forced through the narrow nasal passage may have weakened the tube and made it prone to kink. It is important for us to consider both mechanical and pathologic factors when airway obstruction is encountered in an intubated patient. Kinking of the ETT inside the trachea is an uncommon problem but must be kept in mind as one of the differential diagnoses.