Big cuff: Big problem.

Sir,

Flexometallic/reinforced tubes are often used to replace the tracheostomy tubes during laryngectomy procedures. This report identifies the problem that can happen with the insertion of flexometallic tube (Rusch®, Teleflex Medical, Germany) through a low tracheostoma that was solved with the use of flexometallic tube from another manufacturer (UnoFlex™, Unomedical Sdn Bhd, Kedah, Malaysia).

A 38-year-old male with carcinoma larynx was scheduled for total laryngectomy. He had already been tracheostomised with 8.0 mm ID Portex® tube. Following induction of anaesthesia, the Portex® tracheostomy tube was replaced with 8.0 mm ID flexometallic tube (Rusch®, Teleflex Medical, Germany) till its black mark was at the tracheostoma and the cuff was inflated. However, soon after this, auscultation of the chest revealed absence of air entry on left side and a drop in saturation to 92% with 100% O2, associated with sudden increase in peak airway pressures to 30 cm H2O leading to suspicion of endobronchial intubation. Therefore, the tracheal tube was gradually withdrawn with simultaneous auscultation for air entry on the left side. However, the tube appeared to remain endobronchial despite pulling the tracheal tube till proximal portion of its cuff was visible at the stomal site. At this juncture, we replaced the existing flexometallic tube (Rusch®, Teleflex Medical, Germany) with another 8.0 mm ID flexometallic tube from another manufacturer (UnoFlex™, Unomedical Sdn Bhd, Kedah, Malaysia) which was inserted until its cuff was well below the stomal site. This resulted in bilateral equal air entry, improvement in SpO2 to 100% and return of airway pressures to 16 cm H2O. Rest of the intraoperative period was uneventful and at the end of the surgery, the flexometallic tube was replaced by 8.0 mm ID Portex® tube.

Most patients with carcinoma larynx scheduled for total laryngectomy would have been already tracheostomised or will require a preoperative tracheostomy. Proceeding to total laryngectomy with standard tracheostomy tube has got various problems like flange interfering with surgical site, difficulty in fixation and accidental dislodgement due to excessive drag by ventilator circuits. Whereas flexometallic tubes can be easily angled away from the surgical site without getting kinked and safely secured by suturing or taping it to the chest wall of the patient.[1] Though these tubes are certainly useful, there are various complications associated with these tubes like narrowing of the lumen and complete obstruction.[234]

Flexometallic (Rusch®, Teleflex Medical, Germany) tubes usually contain a barrel shaped large cuff meant for a better seal and their use in patients with low tracheostomy may lead to endobronchial intubation as the distance between the proximal end of the cuff and the tip of the tube is relatively long (8 cm) compared to the other brand (UnoFlex™, Unomedical Sdn Bhd, Kedah, Malaysia) tube, where it is 6 cm [Figure 1]. Thus, changeover to UnoFlex™ tube, (which has smaller cuff) solved the problem of endobronchial intubation in our case. Though different manufacturers produce tubes with different cuff size for added advantage, this may become detrimental at specific situations.

Figure 1

(a) Flexometallic (Rusch®) tube 8.0 mm ID. (b) Flexometallic (UnoFlex™) tube 8.0 mm ID. (c) Tracheostomy (Portex®) tube 8.0 mm ID

In cases where low tracheostomy is anticipated, this problem can be avoided by the use of laryngectomy tubes. Laryngectomy (Montando®) tubes are reinforced cuffed tubes with J-configuration that have a short distance between cuff and tip and also short bevel to avoid endobronchial intubation.[5]