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| LETTER TO THE EDITOR |
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| Year : 2016 | Volume
: 9
| Issue : 3 | Page : 419-420 |
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Cuffed tracheal tube impaction in a 9-year-old child
Smita Prakash, Pavan Nayar, Neha Mehra, Mridula Pawar
Department of Anaesthesia and Intensive Care, Vardhman Mahavir Medical College and Safdarjang Hospital, New Delhi, India
| Date of Web Publication | 17-May-2016 |
Correspondence Address:
Smita Prakash
C 17, Hudco Place, New Delhi - 110 049
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0975-2870.167992
How to cite this article:
Prakash S, Nayar P, Mehra N, Pawar M. Cuffed tracheal tube impaction in a 9-year-old child. Med J DY Patil Univ 2016;9:419-20 |
Sir,
Inability to remove the tracheal tube (TT) can be disconcerting for the anesthetist. We recently experienced this problem in a 9-year-old boy with cerebral palsy (CP) scheduled for Achilles tendon lengthening in prone position. Anesthesia was induced with propofol 50 mg, morphine 2 mg, and tracheal intubation (flexometallic cuffed TT [CTT] size 5.5) was facilitated with vecuronium 2.5 mg. After the cuff had passed the vocal cords, resistance to insertion was felt, and it was decided to insert a smaller size tube. To our dismay, the CTT could neither be withdrawn nor advanced further. Gentle to moderate traction on the CTT did not relieve the impaction. The tube was connected to closed-anesthesia circuit, and the lungs were ventilated with isoflurane 0.6% and nitrous oxide in oxygen. The following steps were undertaken to facilitate tracheal extubation. Under direct laryngoscopy, gentle rotational movement of the CTT was attempted but failed. Next, the cuff was momentarily inflated and then immediately deflated completely with the intention that the cuff folds might be impinging on the vocal cords and hindering tube removal. We tried to manipulate the distal end of the tube (above the vocal cords) in the oropharynx by Magill forceps but to no avail. Finally, the child's head was flexed on the neck, and the tube was removed easily. Slight blood-tinged secretions on the cuff were observed. The fiberoptic examination did not reveal any obvious trauma or bleeding, subglottic stenosis or tracheal narrowing. The trachea was reintubated with plain 5.5 Portex tube, and the oropharynx was packed to prevent gas leak. Hydrocortisone 50 mg intravenous was administered. The intraoperative period was stable. Following extubation, the child was comfortable with no signs of respiratory difficulty.
The airway was secured using a cuffed flexometallic TT because patients with CP are at increased risk of aspiration due to inadequate upper airway muscle tone, and the surgery was in prone position. Although succinylcholine is not contraindicated in patients with CP, some studies have demonstrated the presence of extrajunctional acetylcholine (ACh) receptors in up to 30% of CP patients that may prolong its duration of action. [1] Due to the up-regulation of ACh receptors, CP patients have nondepolarizing muscle relaxant resistance which is offset clinically by redistribution of these water soluble drugs in a smaller volume of total body water as these patients are often relatively dehydrated. Therefore, vecuronium was used to facilitate tracheal intubation. [1]
Inability to remove the TT is a rare, but potentially dangerous complication of tracheal intubation. A forced extubation can result in laryngeal trauma, edema, and arytenoid dislocation. [2] Possible mechanical causes of difficult extubation include failure to deflate the cuff, trauma to the larynx, cuff herniation, adhesion to the tracheal wall, and surgical fixation of the tube to adjacent structures. [2] Treatment options include puncturing the cuff transtracheally or using a needle inserted into the stump of the pilot tube; rotation and traction of the tube; using a fiberoptic scope for diagnosis; and surgical removal of tethering sutures. [2] In the present case, rotation and traction of the TT failed to solve the problem.
The high volume low-pressure cuff is 1.5-2 times the diameter of the adult trachea when fully inflated. [3] The cuff adds to the outer diameter of the tube. When deflated, the excess material folds over itself. These folds could be impinging on the vocal cords preventing extubation. Adherence of the outer TT wall to the tracheal mucosa is another possibility. Lubrication of the TT with water soluble jelly may prevent sticking of the TT to the tracheal wall. [4] Neck flexion has been found to significantly displace the tube toward the carina by 1.0 ± 0.5 cm. [5] Therefore, head flexion on the neck could have resulted in relative movement of the CTT against the tracheal wall, resulting in disimpaction. The literature search did not reveal any previous instance of an impacted TT. There are reports of the suction catheter or fiberoptic bronchoscope getting stuck within the TT. [6],[7]
Prior lubrication, insertion of appropriate size TT, avoidance of laryngeal trauma/edema, and careful management of the airway in patients at risk of gastroesophageal reflux are important. This report enumerates the various techniques that may assist the clinician in tracheal extubation in case of TT impaction.
| References | |  |
| 1. | Prosser DP, Sharma N. Cerebral palsy and anaesthesia. Contin Educ Anaesth Crit Care Pain 2010;10:72-6.  |
| 2. | Karmarkar S, Varshney S. Tracheal extubation. Contin Educ Anaesth Crit Care Pain 2008;8:214-20. |
| 3. | Seegobin RD, van Hasselt GL. Aspiration beyond endotracheal cuffs. Can Anaesth Soc J 1986;33:273-9. [ PUBMED] |
| 4. | Borkar S, Desai RA, Naik P, Gautam P. A case of difficult extubation. Indian J Anaesth 2008;52:83-4.  |
| 5. | Kim JT, Kim HJ, Ahn W, Kim HS, Bahk JH, Lee SC, et al. Head rotation, flexion, and extension alter endotracheal tube position in adults and children. Can J Anaesth 2009;56:751-6. |
| 6. | Gupta A, Mohta A, Kamal G, Bathla S. Impaction of suction catheter - Complication of endotracheal suctioning. Indian J Crit Care Med 2010;14:222. [ PUBMED] |
| 7. | Krensavage TJ. Saline solution as lubrication to manipulate a stuck fiberoptic bronchoscope. Anesth Analg 1999;88:965. [ PUBMED] |
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