Indian Journal of Anaesthesia

: 2014  |  Volume : 58  |  Issue : 2  |  Page : 230--231

All endotracheal tubes that appear endotracheal are not so!

Harihar V Hegde 
 Department of Anaesthesiology, SDM College of Medical Sciences and Hospital, Sattur, Dharwad, Karnataka, India

Correspondence Address:
Harihar V Hegde
Department of Anaesthesiology, SDM College of Medical Sciences and Hospital, Sattur, Dharwad - 580 009, Karnataka

How to cite this article:
Hegde HV. All endotracheal tubes that appear endotracheal are not so!.Indian J Anaesth 2014;58:230-231

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Hegde HV. All endotracheal tubes that appear endotracheal are not so!. Indian J Anaesth [serial online] 2014 [cited 2021 Mar 6 ];58:230-231
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We received a 30-year-old man into our intensive care unit who had met with a road traffic accident and suffered head injury. He was referred from another hospital after a resident there intubated him and transported on oxygen supplementation. On examination, the patient was in altered sensorium and agitated (Glasgow Coma Scale E 4 V T M 5 ). The endotracheal tube (ETT) was fixed at 24 cm mark at the angle of the mouth. He was breathing spontaneously. There was equal movement and air entry on both sides of the chest with respiration. Oxygen saturation of haemoglobin could not be recorded before the administration of sedation as he was agitated. However, gurgling sounds were heard at the mouth. The ETT was connected to a T-piece to administer oxygen and intravenous sedation was administered. Soon, there was oxygen desaturation even though breathing seemed adequate. An Ambu bag was used to ventilate the patient. It was evident immediately that the ETT was not endotracheal as detected by observation and auscultation. A direct laryngoscopic examination confirmed the ETT in the oesophagus which was promptly removed and airway secured with another ETT.

Retrospectively, the chest radiograph taken in the emergency department [Figure 1] was examined. Initially, it appeared that the tip of the ETT was in the right main bronchus. A closer examination however revealed that the ETT was only partially overlapping the tracheal shadow and the ETT was actually lying parallel to the trachea and not inside it. Since trachea is a tubular structure, the margins of an ETT should always be within that of the trachea on a chest radiograph. An unsuspecting radiologist had reported the ETT to be right endobronchial! The lesson learnt here is that a chest radiograph can at times be confusing and the clinical methods to confirm the proper position of an ETT should never be neglected. A potential catastrophe was averted by the bedside standard five-point auscultation and clinical judgement. The importance of clinical examination need not be overemphasised. If available, end-tidal CO 2 monitoring will be most useful to quickly confirm the endotracheal placement of the tube in doubtful cases. End-tidal CO 2 monitoring was not available in our intensive care unit.{Figure 1}