Difficult extubation due to failure of an endotracheal tube cuff deflation.

Sir/Madam,

Failure to remove the endotracheal tube (ET) at the end of surgery can be disconcerting for the anesthetist as well as the patient. We recently experienced this problem in a 36 year old female patient anesthetized for an elective lumbar laminectomy. She was intubated orally with a 7.0 mm ID, cuffed ET (CURITY Tracheal Tube, Kendall, Tyco healthcare, USA) that was fixed at 19 cm at her lips after confirming bilateral equal air entry. Following an uneventful surgery extubation was intended for which the pilot balloon was deflated. However, resistance to pull was felt and the ET could not be removed; extubation was not forced. Meanwhile, the intubated patient was becoming distraught and had to be re-anesthetized. On direct laryngoscopy, a fully inflated cuff was visualized below the vocal cords which did not deflate with deflation of the pilot balloon. Examination of the ET revealed that the adhesive tape used for securing it was tightly wound around the inflating tubing near its origin from the ET. It had completely kinked and flattened the tubing and occluded its lumen (figure 1). Prompt removal of the tape and straightening of the inflating tube enabled cuff deflation and extubation of the patient.

Figure 1

Figure illustrates how an adhesive tape could kink the inflating tube thus preventing deflation of the endotracheal cuff

Inability to remove the ET is a rare, but potentially dangerous complication of tracheal intubation. Forcibly pulling out the tube with a fully inflated cuff can result in laryngeal trauma, vocal cord edema and dislocation of the arytenoid cartilage.1 The usual reasons for this complication include failure to deflate the ET cuff, a very large cuff impinging on the vocal cords and adhesion of the ET to the tracheal wall due to insufficient lubrication or its trans-fixation by a suture or wire.2 Majority of difficult extubations are due to a cuff deflation failure which may be caused by compression of the pilot balloon tubing, malfunction of the inflating valve, inadvertent detachment of the inflating port from the ET and the inadvisable practice of deliberately pulling-off the pilot balloon tubing from the ET to facilitate rapid cuff deflation.3 Inadvertent kinking and occlusion of the inflating tubing secondary to a bite block, artery forceps or a retaining bandage have been reported earlier.234 Measures used to deflate the cuff of a stuck ET include removal of the occluding equipment or bandage from the pilot balloon assembly, pulling out the tube till the cuff rests against the vocal cords and deflating it under direct vision, puncturing the cuff via the cricothyroid membrane and deflation with a needle inserted into the broken stump of the inflating tube.23

In our patient compression of the inflating tube was caused by inadvertent fixation of the adhesive tape too close to the junction of the tubing with the main ET. Whether or not the tubing should be included in the tape and fixed alongside the ET is a matter of opinion14 though this case does suggest that by doing so the inflating tubing may get compressed. Despite tracheal intubation being a routine procedure for the anesthetist, careless mistakes like these continue to happen, reiterating the importance of exercising caution while securing the ET.