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  Table of Contents 
Year : 2019  |  Volume : 20  |  Issue : 2  |  Page : 117-118

Inadequate ventilation with flexometallic tube: Hidden cotton ball a culprit

1 Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
2 Department of Physical Medicine and Rehabilitation, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Date of Web Publication28-Aug-2019

Correspondence Address:
Dr. Shipra Verma
Room No. 417, SR Hostel, AIIMS, Rishikesh - 249 203, Uttarakhand
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/TheIAForum.TheIAForum_44_19

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How to cite this article:
Verma S, Singh GK, Sogal S, Kanaujia V. Inadequate ventilation with flexometallic tube: Hidden cotton ball a culprit. Indian Anaesth Forum 2019;20:117-8

How to cite this URL:
Verma S, Singh GK, Sogal S, Kanaujia V. Inadequate ventilation with flexometallic tube: Hidden cotton ball a culprit. Indian Anaesth Forum [serial online] 2019 [cited 2020 Aug 12];20:117-8. Available from: http://www.theiaforum.org/text.asp?2019/20/2/117/265657


We would like to share our experience of an unexpected complication, while using a flexometallic tube.

A 40-year-old female was posted for right hemithyroidectomy for a malignancy in euthyroid state. There was left-sided tracheal shift without any compression on the lateral cervical spine X-ray film. General anesthesia was administered as per the standard protocol of institute. Stylet-guided endotracheal intubation was done using a 7.5-mm internal diameter-cuffed reinforced endotracheal tube (Ethylene oxide [ETO] sterilized). The tube was connected to anaesthetic circuit. Ventilation with self-inflating bag experienced high airway resistance and on auscultation bilaterally equal but decreased breath sounds were heard. Peak inspiratory pressure reached to 40 cmH2O.

Acute bronchospasm was suspected. N2O was turned off, ventilation with 100% oxygen resumed, plane of anesthesia deepened, and levosalbutamol spray and injection hydrocortisone 100 mg intravenous were given. Still, there was no improvement in ventilation. Tracheal compression due to thyroid mass, distal to the endotracheal tube (ET) tube was next suspected; hence, the tube further advanced by placing a stylet inside it. After repositioning of the tube stylet was removed, however, still, ventilation did not improve. EtCO2 progressively increased to 50 mmHg.

We suspected ET tube blockade; hence, a 16 F suction catheter was passed through the tube that did not pass beyond midway. The patient was immediately extubated, reintubated with a 7.5-mm cuffed polyvinyl chloride (PVC) endotracheal tube and was connected to the ventilator. All ventilatory parameters became normal and the surgery was started.

Inspection of the removed tube showed a cotton ball partially occluding the lumen near the middle of the tube [Figure 1]. We passed a stylet through the removed tube which easily passed through the cotton ball with its slight displacement toward the distal end [Figure 2].
Figure 1: Cotton ball occluding the lumen of flexometallic tube

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Figure 2: Flexometallic tube with stylet

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Flexometallic tube is useful in securing an airway against kinking and obstruction where significant manipulation of the central neck structures is anticipated. These conditions are surgery around head and neck,[1] around trachea and spine.[2] In spite of several advantages, the use of flexometallic tube can lead to complications. ETO-sterilized flexometallic tube is routinely reused in our hospital. Repeated sterilization makes the tube prone for kinking due to weakening of its framework.[3] Cause of endotracheal tube obstruction could be mucus, blood, and foreign body although later is a rare event.[4] The recommended maneuvers for suspected obstruction of the tube include performing a fiber-optic inspection of the tube and passing a suction catheter through the tube.[5] In our case, fiber-optic bronchoscope was not available.

Prompt change of the tube helped in avoiding further complications such as passage of cotton ball in the trachea, hypoxia, negative pressure pulmonary edema, and airway injury. We concluded that before reusing flexometallic tube, both internal and external surfaces must be inspected meticulously to avoid such complications.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Eipe N, Choudhrie A, Pillai AD, Choudhrie R. Neck contracture release and reinforced tracheal tube obstruction. Anesth Analg 2006;102:1911-2.  Back to cited text no. 1
Azim A, Matreja P, Pandey C. Desaturation with flexometallic endotracheal tube during lumbar spine surgery: A case report. Indian J Anaesth 2003;47:48-9.  Back to cited text no. 2
  [Full text]  
Thampi SM, Thomas S, Rai E. Intra-operative accidental extubation- an unexpected complication of the flexo-metallic tube. J Anaesthesiol Clin Pharmacol 2018;34:414-5.  Back to cited text no. 3
[PUBMED]  [Full text]  
Malhotra D, Rafiq M, Qazi S, Gupta SD. Ventilator obstruction with spiral embedded tube- are they as safe? Indian J Anaesth 2007;51:432-3.  Back to cited text no. 4
  [Full text]  
Stone DJ, Gal TJ. Airway management. In: Miller RD, editor. Anesthesia. New York: Churchill Livingstone; 2000. p. 1414-51.  Back to cited text no. 5


  [Figure 1], [Figure 2]


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