COVID-19 patients may suffer from proximally displaced endotracheal tubes misdiagnosed as cuff leaks.

COVID-19 causes a physiologic condition similar to acute respiratory distress syndrome, necessitating invasive and prolonged ventilatory support [1], leaving patients at risk for complications related to airway management. Due to the emergence of prone positioning as a commonly used treatment modality, there is a potential for airway compromise, as well as an increased risk for changes in tube positioning and conformation [2,3]. These complications can result in an airway leak, inability to generate sufficient tidal volumes, insufflation of the stomach, and endobronchial intubation, as well as a need for emergent re-intubation or possible emergent tracheostomy affecting the patient's morbidity and mortality.

During the COVID-19 outbreak of 2019–2020, at University Hospital in Newark, NJ, the Anesthesia Department was called to respond to two patients with displaced endotracheal tubes during prolonged intubation and ventilation that were instead found to have proximally displaced endotracheal tubes (ETTs) with over-inflated cuffs.

Patient 1 is a 74-year-old male admitted for a massive pulmonary embolus, given tissue plasminogen activator (tPA) and Lovenox, then diagnosed with COVID-19 and intubated. The anesthesia team was called to reintubate the patient for presumed cuff leaks on hospital days 16, 22 and 26. Exchange was done with airway exchange catheter on day 16 and video laryngoscopy on days 22 and 26. In each instance the ETT was found to have an over-inflated cuff with 60-80 mL of air and severely bent between the 13 and 19 cm markings (Fig. 1a).

Fig. 1

a Endotracheal tube for Patient 1, misdiagnosed for a cuff leak, and found to have a severe bend in the middle portion, causing herniation above the vocal cords (picture taken after third re-intubation).

b Endotracheal tube for Patient 2, misdiagnosed for a cuff leak, and found to have a severe bend in the middle portion, causing herniation above the vocal cords.

Patient 2 is a 61-year-old admitted with atrial fibrillation who tested positive for COVID-19. On day 8, she was in PEA arrest and was intubated. On hospital day 22, anesthesiology was called for a persistent cuff leak, and the ETT was replaced using video laryngoscopy. The patient's endotracheal tube was found to be severely bent at the 15 cm mark with an overinflated cuff from which 60 mL air was removed (Fig. 1b).

Given the propensity of COVID-19 patients to be intubated, anesthesiologists must be prepared to deal with the long-term care of endotracheal tubes and their possible complications. In each of these cases, respiratory therapists and critical care physicians misdiagnosed an airway leak as a rupture of the endotracheal tube cuff requiring increasing amounts of air to be injected into the cuff. And in each case, this was disproven when the ETT was found to be herniated out of the trachea, above the vocal cords with overly-inflated cuffs.

The endotracheal tubes were all severely bent in the region of the rear oropharynx, which allowed for the proximal displacement without a change in the measured distance at the lips. These severely bent and displaced tubes may be caused by changes in head position, patient position, patient condition, external pressures, as well as patient proning. However, it is also possible that a prolonged hospital stay and extended intubation time is an independent factor. Given that the endotracheal tube is not changing the position at which it is secured at the lips, it is understandable for the ICU team to misdiagnose the patient as suffering from a cuff leak. Anesthesiologists, critical care physicians and respiratory therapists must be prepared to deal with these unusual conditions to ensure continued and uninterrupted ventilation.

Ethics approval and consent to participate

Consent for publication given by primary decision makers for both patients, the first of which is deceased and second is intubated/sedated.

Availability of data and materials

All data available upon request.

Funding

No external funding for this research.

Authors' contributions

GT, RM, EG and YB contributed to the concept, writing and editing of the Letter to the Editor.

Declaration of competing interest

Not applicable.