Endotracheal Tube Connector: Holding Breaths!

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Recently, we encountered partial airway obstruction while ventilating a pediatric patient, due to a manufacturing defect in the endotracheal tube (ETT) connector (Figure; Endotracheal tube 4 mm; Sterimed Medical Devices Limited, Bahadurgarh, Haryana, India). A similar defect has been reported previously in the literature from our institute.1 We therefore performed a literature search for defective ETT connectors.
Using ETT connector defects, defective ETT connectors, ETT connectors, and difficult ventilation as key words in PubMed/Medline, Scopus, EMBASE, and Google identified 18 papers (letters to editor, case reports) describing 20 cases. We would like to summarize the key papers (to avoid duplication), each describing a different manufacturing defect. Seven cases were due to a narrow ETT connector,1 and 6 described a membrane/meniscus partially occluding either the machine or patient end of the connector.1 One article identified complete occlusion of the ETT connector in the entire batch (ETT 4mm, Portex; Smiths Medical, Minneapolis, MN) with failed ventilation in an infant.2 One article reported 2 cases of vertical split in the ETT connector, (Mallinckrodt ETTs; Coviden, Mansfield, MA) associated with the use of Glidescope and its stylet.3 There was 1 article reporting a deformed ETT connector, and 2 with foreign body in the ETT connector (ETT 7.5 mm; Well Lead Medical Instruments, Panyu Guangzhou, P.R. China) as a manufacturing defect with potential for aspiration.4
Routine preuse check of the ETT for integrity and functionality remains the standard of care. Although preuse check of ETT cuff assembly to detect leaks is usually performed, visualization of ETT connector defects may be missed due to lack of suspicion and obscure location. A narrowed/blocked ETT connector was the most common manufacturing defect encountered, as in the index case. In a difficult postintubation ventilation scenario, after ruling out bronchospasm, poor pulmonary compliance, kinking/obliteration of the ETT lumen by mucous plugs, blood clots or foreign body, anesthesia gas delivery malfunction, and breathing circuit obstruction, an ETT connector defect should also be suspected. Failure to pass an appropriate-sized suction catheter through the ETT connector will help in establishing the diagnosis of a narrowed lumen/meniscus causing airway obstruction. We would like to highlight manufacturing defects in ETT connector as a possible cause of difficult ventilation, airway leaks, and potential foreign body aspiration. A thorough visual external and internal preuse check of the ETT connector by a vigilant anesthesia provider, in addition to checking cuff assembly, may avoid potential complications. We also suggest transparent ETT connectors and strict quality control at the manufacturer level.
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