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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 4  |  Issue : 1  |  Page : 48-50

Unanticipated intraoperative airway emergency due to near-total transection of endotracheal tube during partial maxillectomy


1 Department of Anaesthesiology, Critical Care and Pain, Homi Bhabha Cancer Hospital, Varanasi, Uttar Pradesh, India
2 Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Mumbai, Maharashtra, India
3 Department of Head and Neck Services of Surgical Oncology, Mahamana Pandit Madanmohan Malviya Cancer Centre, Homi Bhabha Cancer Hospital, Varanasi, Uttar Pradesh, India

Date of Submission07-Feb-2021
Date of Acceptance24-Feb-2021
Date of Web Publication29-Apr-2021

Correspondence Address:
Dr. Sunil Kumar Valasareddy
Department of Anaesthesiology, Critical Care and Pain, Mahamana Pandit Madanmohan Malviya Cancer Centre, Homi Bhabha Cancer Hospital, Varanasi - 221 005, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/arwy.arwy_4_21

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  Abstract 


Endotracheal tube (ETT) damage during head and neck surgeries is an uncommon complication needing quick corrective action to avoid hypoxia and aspiration of blood into lungs. Our case illustrates an unanticipated complication created during partial maxillectomy by a reciprocating motor saw. Accidental near-total transection of ETT was successfully managed by a novel technique of reintubation guided by an airway exchange catheter placed alongside the damaged ETT.

Keywords: Airway emergency, airway exchange catheter, endotracheal tube transection, maxillary osteotomy, partial maxillectomy


How to cite this article:
Valasareddy SK, Singh NK, Chaudhari G, Mishra A. Unanticipated intraoperative airway emergency due to near-total transection of endotracheal tube during partial maxillectomy. Airway 2021;4:48-50

How to cite this URL:
Valasareddy SK, Singh NK, Chaudhari G, Mishra A. Unanticipated intraoperative airway emergency due to near-total transection of endotracheal tube during partial maxillectomy. Airway [serial online] 2021 [cited 2021 Jun 20];4:48-50. Available from: https://www.arwy.org/text.asp?2021/4/1/48/315164




  Introduction Top


Head and neck surgeries are a real challenge to anaesthesiologists as patients present with a difficult airway not only before surgery but rarely during surgery as well. If not recognised and managed in time, airway compromise in these patients can be fatal under general anaesthesia. Damage to the endotracheal tube (ETT) including transection by surgical instruments is an extremely rare cause and management is not easy as it poses various challenges such as difficulty in ventilation, aspiration of blood and difficulty in laryngeal view despite advanced gadgets due to blood in the field and shared work space.[1]


  Case Report Top


A 38-year-old male weighing 68 kg was scheduled for partial right maxillectomy, neck dissection and primary closure for carcinoma of hard palate. His prior medical history was unremarkable. Vital signs and systemic examination were within normal limits, and physical examination revealed a modified Mallampati Class II with normal mentohyoid distance, mouth opening and mandibular subluxation.

In the operating room, an 18 SWG intravenous (IV) cannula was secured and oxymetazoline nasal drops instilled. Following adequate preoxygenation, fentanyl 2 µg/kg and lignocaine 1.5 mg/kg were given IV, followed by propofol 2 mg/kg and vecuronium 0.1 mg/kg. Nasotracheal intubation was performed through the left nostril (7.5 mm ID cuffed ETT) under videolaryngoscopy. Anaesthesia was maintained with 50% oxygen in nitrous oxide and sevoflurane (1 MAC), and intermittent doses of vecuronium bromide administered as needed.

While resecting the medial aspect of the tumour, the surgeon informed of a probable damage to the ETT with the reciprocating motor saw. Simultaneously, collapse of the bellows was noticed and surgery was immediately stopped. While manual ventilation was initiated with high gas flows, the evaluation of the surgical field revealed damage to the ETT. It was decided to change the ETT while anaesthesia was maintained using intermittent boluses of propofol and fentanyl. Oxygenation was ensured by administering 100% oxygen. A suction catheter passed through the ETT encountered resistance around the halfway mark. A thorough suctioning was done to suck out blood that could be causing partial/complete tube obstruction. Continuous oral suctioning was performed to clear the pharynx of blood.

Since there was difficulty in passing a suction catheter through the ETT, our plan of inserting an airway exchange catheter (AEC) through the ETT was changed to passing it alongside the ETT through the same nostril and advancing it beyond the vocal cords under videolaryngoscopic guidance [Figure 1]. Surgeons were asked to standby for tracheostomy. After adequate preparation, a sterile AEC was passed beyond the vocal cords after deflating the cuff of the transected ETT. The damaged ETT was cautiously removed while ensuring that the AEC was not dislodged. A fresh ETT was railroaded over the AEC under vision and its position confirmed by capnography before surgery was resumed. During the entire procedure of ‘tube-exchange', the patient was stable and the remaining surgery was completed uneventfully. The original ETT revealed near-total transection at the middle portion [Figure 2]. The patient was not extubated the same day in view of anticipated oedema and possible difficult airway. As planned, an uneventful extubation was performed the next day and the subsequent hospital course was smooth.
Figure 1: Airway exchange catheter placed alongside initial nasotracheal tube

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Figure 2: Initial endotracheal tube showing damage caused by reciprocating motor saw

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  Discussion Top


The role of the anaesthesiologist in identifying and tactfully managing intraoperative airway mishaps cannot be overemphasised. The first response such as the one described in this report must be to confirm the unanticipated mishap by switching to manual ventilation, a step that also ensures continued oxygenation. The choice and modality of airway management depend on the nature of damage to the ETT and the stage/type of surgery. Attention must be paid to maintaining safe vital parameters, and identifying the impact on respiration. Identifying the exact nature of airway compromise and the strategy to re-establish a secure airway should receive priority.[2]

Conservative management such as repositioning the head may improve the ventilation in the case of a partially severed ETT. Laryngeal packing or packing around the location of ETT damage may sometimes restore adequate ventilation to complete surgery.[3],[4] However, the only definitive solution is to replace the damaged tube even though changing the tube could be cumbersome midway through head and neck surgery.

Another option such as exchanging the ETT by railroading over an AEC was possible.[5],[6] However, since we could not pass a suction catheter through the possibly damaged segment of the ETT, we concluded that the ETT was either blocked or grossly damaged. Proceeding with an AEC under these uncertain circumstances could have resulted in dislodgement of a blood clot/debris or even push a completely transected distal portion of the ETT into the trachea. This could lead to a more disastrous situation such as a ‘foreign body’ obstructing a major airway below the level of vocal cords requiring ‘foreign body removal'. If the field of vision had been clear, a fibreoptic evaluation could have identified the extent of damage and an appropriate plan made to deal with this situation.

Oral intubation as an alternative in such an emergency will not serve the purpose as ETT will lie in the surgical field. We therefore inserted an AEC alongside the existing ETT through the same nostril and using Magill's forceps under videolaryngoscopic guidance, advanced the tip of the AEC beyond the vocal cords after deflating the cuff of the previous ETT. The severed ETT was carefully removed and a new ETT of the same size was railroaded over an AEC under vision and the surgery completed.

An emergency airway cart should be readily available at all times during complex head and neck surgery. This should include a tube exchanger, videolaryngoscope and a surgical airway kit as any of these could be needed immediately. The team should be prepared for difficult airway management perioperatively.


  Conclusion Top


A difficult airway can present in the perioperative period even after a seemingly successful intubation, creating an unanticipated difficult intubation setting. Near-total transection of the ETT is a rare, unanticipated, potentially fatal complication. Immediate replacement of the ETT is crucial in management and such situations should be handled with utmost caution in the presence of experienced airway managers, advanced equipment, meticulous planning and execution.

Declaration of patient consent

The authors certify that they have obtained appropriate patient consent form. In the form, the patient has given his consent for images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Nair VA, Balagopal P. Intra-operative endotracheal tube damage: Anaesthetic challenges. Indian J Anaesth 2012;56:311-2.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
El-Orbany M, Salem MR. Endotracheal tube cuff leaks: Causes, consequences, and management. Anesth Analg 2013;117:428-34.  Back to cited text no. 2
    
3.
Mayoral Rojals V, Casals Caus P. 2 different solutions to a severed nasotracheal tube during maxillary osteotomy. Rev Esp Anestesiol Reanim 2002;49:201-4.  Back to cited text no. 3
    
4.
Davies JR, Dyer PV. Preventing damage to the tracheal tube during maxillary osteotomy. Anaesthesia 2003;58:914-5.  Back to cited text no. 4
    
5.
Cooper RM. The use of an endotracheal ventilation catheter in the management of difficult extubations. Can J Anaesth 1996;43:90-3.  Back to cited text no. 5
    
6.
Mort TC, Meisterling EM, Waberski WM. Exchanging a tracheal tube in the ICU patient: A comparison of two exchangers with direct laryngoscopy. Anesthesiology 1997;89:240A.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2]



 

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