The Indian Anaesthetists’ Forum

: 2022  |  Volume : 23  |  Issue : 1  |  Page : 79--80

A film you should definitely see: A case of endotracheal tube obstruction by packaging film

Bhavya Krishna1, Nidhi Pathak2, Sengottaian Sivakumar3, Santvana Kohli1,  
1 Department of Anesthesia and Critical Care, VMMC and Safdarjung Hospital, Okhla, New Delhi, India
2 Department of Anesthesia, ESI, Okhla, New Delhi, India
3 Department of Anesthesia, Metropolitan Hospitals, New York, USA

Correspondence Address:
Dr. Bhavya Krishna
D-52, Ground Floor, Saket, Next to Red Roses Public School, New Delhi - 110 029

How to cite this article:
Krishna B, Pathak N, Sivakumar S, Kohli S. A film you should definitely see: A case of endotracheal tube obstruction by packaging film.Indian Anaesth Forum 2022;23:79-80

How to cite this URL:
Krishna B, Pathak N, Sivakumar S, Kohli S. A film you should definitely see: A case of endotracheal tube obstruction by packaging film. Indian Anaesth Forum [serial online] 2022 [cited 2023 Jan 31 ];23:79-80
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Full Text

Dear Sir,

Manufacturing defects of endotracheal tube (ETT) connector have been reported,[1] but here, we describe a case where part of the packaging film left inside the ETT connector due to human error resulted in difficult ventilation.

A 28-year-old male patient belonging to the American Society of Anesthesiology Class 1 having normal airway and respiratory parameters was planned for elective laparoscopic inguinal hernia repair under general anesthesia. After routine preinduction checks of Sterimed® ETT cuff and anesthesia machine, the patient was preoxygenated and anesthesia induced with fentanyl, propofol, and vecuronium, followed by sevoflurane. After easy bag mask ventilation, trachea was intubated uneventfully under direct vision. Postintubation, manual ventilation was difficult (“tight bag”), chest rise was restricted bilaterally along with reduced air entry on auscultation, so ETT position was reconfirmed by direct laryngoscopy. Capnography showed increased alpha angle with peak airway pressures of >40 cmH2O. Differential diagnosis of bronchospasm or kinking of ETT/circuit, valve dysfunction, or foreign body was made. We ensured adequate depth of anesthesia while simultaneously ruling out other causes. Oxygen saturation was 98%–100% and hemodynamic parameters remained stable. On disconnecting the circuit from ETT for nebulization, we detected a small plastic film at the circuit end of the ETT connector, partially obstructing it, as shown in [Figure 1]. Attempts to remove this film using suction catheter/forceps failed, so we extubated and reintubated with a new ETT, leading to normal bag compliance, airway pressures, and capnography. The episode lasted <2 min and surgery was uneventful. The patient was extubated and after 1-h postoperative observation sent to the ward.{Figure 1}

On inspecting the ETT, we recognized that the aberrant film was a piece of the plastic cover of ETT packaging. Normally, the ETT comes in a covering where one side is a printed paper and the other is made of transparent plastic with a corner peel-off. In our case, the plastic side was very thin, like a cling film, encasing the ETT tightly. It also lacked a peel-off portion; hence, while removing the ETT from the packaging, a part of it adhered to the connector and was pushed inside inadvertently on connecting the circuit. Not only was the packaging faulty but the ETT was also removed from its plastic covering hastily and erroneously.

Difficulty in ventilating an intubated patient, due to bronchospasm or obstruction by mucus, blood, kinking, tracheobronchial secretions or foreign bodies, occurs commonly in anesthesia practice. Uncommon causes such as ETT defects, broken stylets,[2] manufacturing defects in endotracheal tube,[3] and other equipment[4] have also been encountered. In our case, although all preuse checks were performed, the plastic film inside the ETT connector was missed. Despite the practice of visual inspection, testing of ETTs for physical defects, and cuff functioning before use, some reasons go unnoticed. Awareness of such possibilities is prudent to avoid adverse outcomes, and protocols for equipment check must be established. Hence, anesthesiologists must be aware of all causes of difficult ventilation including rare equipment defects and inevitable human errors including organizational and procedural failures that led to this malpractice.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guarantee

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Conflicts of interest

There are no conflicts of interest.


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