Patient Safety, Complications, and Mishaps in Anesthesia

Kinked Endotracheal Tube: Possible Complication of Softening in Warm Water

Busaidy KF, Seabold C, Khalil S (Univ of Texas Health Science Ctr at Houston) J Oral Maxillofac Surg 69:1329-1330, 2011^§

Abstract

Background

Endotracheal tube (ETT) kinking during intubation is reported infrequently. Significant kinking complicated the intubation of a patient in preparation for an elective temporomandibular joint (TMJ) arthroscopic procedure. The case and possible risk factors for kinking were discussed.

Case Report

Woman, 53, came for elective bilateral TMJ arthroscopic surgery with lysis of the intra-articular adhesions. She reported no previous problems with intubation or anesthesia. Her range of mouth opening was restricted to about 30 mm secondary to severe TMJ osteoarthritis, and she had a Class 2 Mallampati classification and a diminished range of neck motion because of pain secondary to the radiculopathy. Size 7.0 and 6.5 nasotracheal RAE tubes were softened preoperatively by placing them in a sterile saline solution prewarmed to about 147°F. Midazolam was used to achieve sedation, preoxygenation was accomplished, and the patient was induced with fentanyl, propofol, and rocuronium. Direct laryngoscopy was used, but the 7.0-mm nasal RAE ETT met resistance when intubation was attempted. The resistance appeared to be at the level of the vocal cords and was initially thought to result from too large an ETT. The anterior presentation of the larynx further complicated ETT passage. The 6.5-mm ETT was substituted but it also met resistance, although it was eventually passed with difficulty and without direct visualization of the tube passing through the vocal cords. Capnography and positive auscultation of breath sounds in both lung fields were used to confirm ETT placement in the trachea. The patient’s oxygen saturation remained at 100% and her end-tidal carbon dioxide was 34 to 38 mm Hg. When positive pressure ventilation was instituted, an audible cuff leak was noted that did not resolve when more air was instilled into the cuff. Partial airway obstruction was confirmed on capnography waveform. Neither a suction catheter nor a pediatric bougie could be passed through the ETT, both meeting resistance at about 35 cm. A fiberoptic scope found an acute bend of the ETT at 35 cm, about 7 cm from the tube tip. A 7.0-mm oral RAE ETT was used and airway pressures normalized, allowing successful completion of the case.

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