A 36-year-old woman with a falco-tentorial meningioma was scheduled for a craniotomy
and excision in the left park bench position under general anesthesia. After induction,
the patient was intubated with a 7-mm inner diameter (ID) cuffed polyvinyl endotracheal
tube (ETT) fixed at 20 cm. A soft bite block was placed to prevent inadvertent tube
compression and tongue bite during monitoring. Mechanical ventilation was initiated
and adjusted to maintain an end-tidal carbon dioxide of 35 mm Hg. The initial peak
airway pressure (Ppeak) was 17 cmH2O, which increased to 21 cm H2O after the final position, ensuring optimum head and neck positioning. After 1 hour,
Ppeak gradually increased to 33 cm H2O without any modifications in the ventilation. The checklist for increased airway
pressure was followed, and extraoral ETT and breathing circuit were patent; cuff pressure
was 25 cm H2O, and the depth of anesthesia was adequate with a bispectral index (BIS) of 40. Chest
auscultation revealed diminished breath sounds bilaterally with no added sounds, and
significant low bag compliance was noted. There was no improvement after bronchodilator
therapy. Hence, an intraoral ETT kink was suspected, and a 10-Fr suction catheter
could not be negotiated beyond 15 cm. In view of ongoing surgery at the stage of tumor
resection, a gum elastic bougie (15 Fr, 5-mm outer diameter [OD], 70 cm, coude tip,
Portex) via the ETT was inserted, which could not be passed. An 11-Fr airway exchange
catheter (3.7-mm OD, Cook Medical) through the ETT passed beyond the obstruction and
stented the ETT. The catheter was then removed, and the circuit was connected. The
ventilation parameters then returned to normal after reshaping the tube. The surgery
was uneventful, and the patient was extubated postoperatively. Postextubation, the
ETT showed a minimal kink at 16 cm.
Intraoperative kinking of nonreinforced ETT can occur in neurosurgical procedures,
which frequently include neck flexion and rotation. This can be complicated by minimal
access to the airway, making its management tricky. Intraoperative kinks commonly
appear above the glottis at the cuff line exit site.[1] It can be insidious due to the thermal softening of ETT.[2] In this case, we did not use a flexometallic tube due to the possibility of postoperative
ventilation and difficulty in replacing it in an edematous airway. A change in the
neck position and tube exchange[3] have been reported maneuvers to overcome this problem, which were not feasible since
we encountered the stenosis at a crucial surgical stage. Bronchoscopy-aided stenting
of ETT stenosis has been proven to visualize and reestablish the airway,[4] but it is cumbersome and may require re-draping. Our technique is time sensitive
and feasible with minimal resources. Although this technique is not foolproof and
does not allow direct visualization of the stenosis, it gives us time until a definite
plan is possible and offers the option of repeatability if required with minimal complications.
