Iatrogenic Endotracheal Tube Obstruction by Tegaderm

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While iatrogenic airway obstruction by foreign body has been well documented,1–3 I am compelled to report a case of complete airway obstruction by Tegaderm, which necessitated immediate removal of the endotracheal tube (ETT). A healthy 7-year-old, 26-kg boy presented for a mastoidectomy and endoscopic sinus surgery for chronic sinusitis. After induction of anesthesia a 5.5 oral RAE ETT was secured to the patient’s chin using benzoin tincture and plastic tape, followed by a Tegaderm dressing. The bed was turned 180°, and the ETT connections were pressed together to ensure tightness before the patient was prepped and draped. Approximately 40 minutes later, the flow sensor alarmed “low flow” with a pressure control setting 12 cm H2O. There was no obvious change in tidal volume (180–200 mL). Fractional inspired oxygen was maintained at 0.45 with total air and oxygen flows at 3 L/min. The cause for the low flow alarm could not be determined.
While anesthesia technicians were inspecting the anesthesia ventilator, as well as air and oxygen intake connections, a massive leak in the system was noted with a loss of the end-tidal carbon dioxide waveform. Inspection of the anesthesia circuit revealed that the ETT had become disconnected from the circuit. Upon reconnection, there was immediate restoration of ventilation with the expected tidal volumes and a return of the end-tidal carbon dioxide waveform. But approximately 1 minute later, the end-tidal carbon dioxide waveform decreased in height by 50% and then quickly went flat, tidal volumes dropped to 0 mL, and peak inspiratory pressures increased to 30 cm H2O, all of which triggered multiple ventilator alarms. Given the lack of clarity as to the etiology of the previous low flow alarm, help was called immediately, oxygen flow was turned up to 10 L/min, and the surgical drapes were promptly removed in order to properly examine the patient and airway connections. With the patient’s oxygen saturation now at 46% and no chest or air movement, no apparent kinking in the ETT, and an inability to ventilate, the ETT was promptly removed without attempting to suction. Mask ventilation was performed followed by generous chest rise and a rapid return of oxygen saturation to 100%. On further examination of the ETT, it appeared that the Tegaderm had migrated internally and caused a complete obstruction in the distal end of the ETT (Figures 1 and 2). It is likely that the obstruction developed as the ETT was reconnected to the circuit.
In the case of complete airway obstruction, the best first action is to attempt manual ventilation. If manual ventilation is not possible and bronchospasm is not suspected, dislodgment or obstruction of the ETT can be immediately diagnosed and treated by removal of the ETT and performing mask ventilation.4 The inability to suction the ETT may confirm that removing the ETT is the next best action, but this will also further delay the resolution. In situations with a favorable airway and ease of access to perform mask ventilation and reintubation, the multistep process of obtaining a suction catheter, ensuring it is the correct size, ensuring the catheter and suction tubing connection is tight, and the suction is turned on may prove to be a futile effort, especially in cases with complete obstruction.
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