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| CASE REPORT |
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| Year : 2008 | Volume
: 52
| Issue : 1 | Page : 83 |
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A Case of Difficult Extubation
Sharmila Borkar1, Ranjit Ashok Desai1, Pankaj Naik2, Pooja Gautam3
1 Lecturer, Department of Anaesthesiology, Goa Medical College, Bambolim Goa 403202., India
2 Senior Resident, Department of Anaesthesiology, Goa Medical College, Bambolim Goa 403202., India
3 P.G Student, Department of Anaesthesiology, Goa Medical College, Bambolim Goa 403202., India
| Date of Acceptance | 25-Nov-2007 |
| Date of Web Publication | 19-Mar-2010 |
Correspondence Address:
Sharmila Borkar
C-7, Kavlekar Apt. Behind Kashinath Building, Khorlim, Mapusa, Goa 403507.
India
The management of a case of difficult extubation due to inability to deflate the endotracheal tube cuff as a result of failure of pilot balloon assembly is presented. The importance of checking the endotracheal tube cuff and pilot system before administration of anaesthesia even in the case of a new endotracheal tube is emphasized. Keywords: Difficult extubation, Endotracheal tube cuff, Pilot balloon.
How to cite this article:
Borkar S, Desai RA, Naik P, Gautam P. A Case of Difficult Extubation. Indian J Anaesth 2008;52:83 |
 Introduction | |  |
Difficult extubation is a rare but dangerous and occasionally fatal complication. [1] Here, we report the management of a case of difficult extubation due to inability to deflate the endotracheal tube cuff with emphasis on the need to check the cuff pilot system before intubating the patient even when a new endotracheal tube is being used.
| Case report | | |
A 60-year-old, female weighing 50 kg was scheduled for right breast lumpectomy. There were no significant findings on history, examination and investigations.
Patient was premedicated with ondansetron 4 mg and glycopyrrolate 0.2 mg IV. After pre-oxygenation, patient was induced with propofol 110 mg IV. Muscle relaxation was achieved with vecuronium 5mg IV. Fentanyl 100 mcg IV was given as analgesic. Tracheal intubation was accomplished smoothly using a 7.5 mm cuffed polyvinyl chloride tracheal tube. Anaesthesia was maintained with oxygen, nitrous oxide and vecuronium. Patients' vitals remained stable throughout the surgical procedure which lasted 60 minutes.
On completion of the surgery, the neuromuscular blockade was reversed with neostigmine 50 mcg.kg -1 and glycopylorrate 10 mcg.kg -1 IV. The patient was fully conscious and responding to verbal commands. The endotracheal tube cuff was deflated. Extubation was attempted, however there was resistance to pull out the tube [Figure 1]. Patient was restless and bucking continuously. The patient was reassured and sedated with intravenous propofol and fentanyl. Direct laryngoscopy was attempted but the cuff of the tube could not be visualized. Assistance from an ENT surgeon was sought; fibreoptic nasopharyngoscopy was done and the inflated cuff was visualized. Steroid prophylaxis was given to the patient and the patient was further sedated with IV propofol and fentanyl. Cricothyroidotomy puncture was attempted but failed. Direct laryngoscopy was repeated and with manipulation the inflated cuff was visualized and was punctured with a 23G spinal needle which was passed orally crossing the vocal cords [Figure 2]. The patient was extubated and nebulised with budesonide. Post extubation patient was comfortable.
She was observed in post-anaesthesia care unit thereafter dexamethasone IV was given in a dose of 8 mg eight hourly. She had no respiratory difficulty in the ICU and was shifted to the ward the next day. Her stay in the surgical ward was uneventful and she was discharged on the 3rd post operative day.
| Discussion | | |
Difficulty in removing an endotracheal tube at the end of surgery is a rare complication.
Causes of difficult extubation include;
- Failure to deflate the cuff (most common cause)
- Excessively large cuff catching onto the vocal cords
- Adhesion of tracheal tube to the tracheal wall due to absence of lubricant
- Tube may be sutured or wired to an adjacent structure.
- Entanglement with nasogastric tube (rare cause) [2] when nasal intubation is done.
- When the self-retaining spongy cuff gets trapped after the cuff tube breaks off at the junction with tracheal tube preventing deflation.
- Biting on the tube
The most common cause is failure to deflate the cuff. Most often this occurs due to obstruction of the inflation tube. If the obstruction is distal to the pilot balloon, the balloon will offer no clue that the cuff has not deflated.
Heat from a laser or a drill may melt the inflating tube causing it to occlude. Biting by the patient may cause the inflating tube to be occluded.
Some users pull the pilot balloon and inflation valve from the inflation tube to deflate the cuff. This can cause the inflation tube to seal. [3],[4]
The connector may occlude the inflation tube if it fits below the point where the tube leaves the wall of the tracheal tube. The pilot tube may be kinked by a retained bandage. [1]
In cases in which it is impossible to deflate the cuff; a V-shaped cut can be made in the inflation tube to relieve the pressure in the cuff. [4] It may be possible to insert a syringe and needle into the stump of the pilot and deflate the cuff. If the cuff still remains inflated, the tube should be pulled until the cuff is close to the surface of the vocal cords. A needle can then be inserted through the cricothyroid membrane to puncture the cuff. Alternatively, the tube can be withdrawn so that the cuff in seen below the cords and can be punctured with a sharp object. Removal may be aided by relaxing the vocal cords or tube rotation. Reinsertion, rotation and traction of the tube or manipulation of the larynx may cause the cuff is smoothen out. Skin hooks or forceps may be necessary to free the tube.
In conclusion, it is apt to emphasize that it is of prime importance to check the cuff pilot balloon assembly before proceeding with intubation even when using a new endotracheal tube as failure to do so may be the cause of a difficult extubation.
| References | | |
| 1. | Hartley M, Vaughan RS. Problems associated with tracheal extubation. Br J Anaesth 1993;71:561-568.  [PUBMED] [FULLTEXT] |
| 2. | Sklar GS, Alfonso AE, King BD. An unusual problem in nasotracheal extubation. Anesth Analg 1976;55:302-303. [PUBMED] [FULLTEXT] |
| 3. | Brock-Utne JG, Jaffe RA, Robins B,et al. Difficulty in extubation: A cause for concern. Anaesthesia 1992;47:224-230. |
| 4. | Singh B, Gupta B. Difficult extubation: A new management. Anesth Analg 1995;81: 433. |
[Figure 1], [Figure 2]
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