A rare cause of complete airway obstruction caused by a defective pilot tube of a reinforced endotracheal tube

Abstract

BackgroundThe common causes of failure to inflate the lungs after placement of an endotracheal tube include mechanical obstruction of the tube by tight gauzes, tongue blade, tube kinking, patient biting on the tube, obstruction of the lumen by blood or foreign body, bronchospasm, haemothorax, tension pneumothorax or equipment malfunction.Case presentationWe report a case of complete airway obstruction due to herniation of the pilot inflation line into the lumen at the proximal end of a reinforced tube when the tracheal cuff was inflated. Prior to use, the endotracheal tube was tested and functioned normally. The patient was uneventfully reintubated with a new endotracheal tube. With the endotracheal tube, device problems often involve the pilot balloon and cuff assembly and leaks are more common.ConclusionThis case report highlights an unusual cause of complete proximal lumen obstruction due to a manufacturing defect which could have caused a critical incident in the theatre.