Cuff Herniation Research Articles

Tracheostomy Cuff Herniation following Cardiac and Pulmonary Arrest

Tracheostomy is a common procedure performed on patients who require long-term airway maintenance and ventilation support. It is preferred over endotracheal intubation due to its reduced airway resistance, lower risk of displacement compared with the endotracheal tube, increased patient comfort, improved weaning from mechanical ventilation, and enhanced suction capabilities. According to the literature, patients needing airway support for fewer than 12 days can undergo translaryngeal intubation, while tracheostomy is indicated for patients requiring ventilatory support for more than 20 days. Although tracheostomy is frequently performed in ICUs and operating rooms, several complications can arise following the procedure. These complications include leakage, obstruction of the tracheal tube, minor or major bleeding or oozing, barotrauma, infections, tracheoesophageal fistula, stenosis, and injury to surrounding peripheral tissues such as arteries, veins, and nerves.1 While herniation of the endotracheal cuff is a more common cause of airway obstruction and hypoxia, tracheostomy tube cuff herniation is a rare complication of this procedure.1-7 In this report, we present a rare case of cardiopulmonary arrest following the implantation of a tracheostomy tube cuff in a female patient and its management.

Peri-tracheostomy Cuff Herniation: Unlisted Cause of Air Leak during Mechanical Ventilation

Peri-tracheostomy Cuff Herniation: Unlisted Cause of Air Leak during Mechanical Ventilation

Endotracheal tube obstruction due to cuff overinflation or cuff herniation in small equids: A case series

SummaryAdequate inflation of the endotracheal tube (ETT) cuff is important to avoid leakage of anaesthetic gases or aspiration of gastric contents and to allow positive pressure ventilation. However, overinflation or herniation of the cuff can cause tracheal mucosal damage and in rare cases even obstruction of the ETT. ETT obstruction due to the cuff itself may be an underrecognised phenomenon in equine practice and we aim to create awareness with this retrospective case series (n = 3). Cases identified between 2014 and 2021 with (partial) ETT obstruction due to cuff overinflation or cuff herniation at the Utrecht University Equine Clinic were selected. Anaesthesia records were examined and presented. Two cases occurred in foals and one in a pony. In each case, high airway pressure was encountered and no or minimal thoracic excursions were visible. In all three cases, cuff deflation led to immediate normalisation of ventilation parameters. When presented with an intubated patient that is difficult to ventilate and high airway pressures exist, ETT cuff overinflation or herniation should be considered as a possible cause; rapid cuff deflation should be included in algorithms for management of ventilation failure due to suspected airway obstruction.

Adverse event using Medtronic NIM™ EMG endotracheal tube on a patient receiving anesthesia for hemithyroidectomy: a case report

BackgroundThe neural integrity monitor (NIM) electromyogram (EMG) endotracheal (ET) tube is a widely used device to monitor neural response through muscle activity. It is helpful in surgical procedures with high risk of damaging delicate structures in the head and neck. This case provides a thorough analysis of an adverse event that was encountered in the operating room, which others can hopefully learn from.Case presentationWe are reporting a case in which a patient undergoing hemithyroidectomy had experienced an adverse event using the Medtronic NIM™ EMG endotracheal tube. After successful induction and intubation, confirming the proper positioning of the electrode wires was necessary before the incision could be made. Upon reexamination, the patient suddenly became difficult to ventilate with increased peak airway pressure, decreased tidal volume, and end tidal CO2. This episode lasted approximately 15 min and the patient’s condition remained stable despite low tidal volumes. The problem was unexpectedly resolved upon deflation of the cuff of the ET tube.ConclusionsThere are several similar reports of these endotracheal tubes causing obstruction, especially those in which overinflation of the cuff caused cuff herniation and blockage of the Murphy eye and the bevel. It is currently believed that the design of this tube allowed for the obstruction to occur. The patient’s short body habitus may have also been a small contributing factor. The distance that the electrodes must sit within the vocal cords to the tip of the bevel is longer in this type of ET tube compared with a standard ET tube. The distance from the true vocal cords to where the cuff sits in the trachea is also greater in this model NIM EMG tube. There was no confirmation of the exact obstructive process that took place, however, confirming the tube and cuff positioning would have been optimal.

Unusual Airway Obstruction during General Anesthesia following Endotracheal Tube Cuff Herniation; A Case Report

Abstract Background: Airway management is always of great concern for anesthesiologists especially in the prone position. Utilizing an Armored endotracheal tube is considered to be safe in such patients. Cases Report: In this current case, we introduce a patient undergoing a wake-up test during spinal surgery who suffered from hypoventilation at the end of surgery. His condition improved only after extubation. After extubation, we confronted a herniated cuff that was not deflated, although we tried twice. We concluded that the patient's respiratory effort against obstructed airway produced a negative pressure, which made the cuff herniated, resulting in airway obstruction. Moreover, the patient biting the tube during the wake-up test damaged the tube and cuff deflation pathway. Conclusion: It is important to consider cuff herniation as a cause of obstruction when other possible etiologies are ruled out.

Unusual cause of airway obstruction after nasal intubation with a preformed endotracheal tube.

Unusual cause of airway obstruction after nasal intubation with a preformed endotracheal tube.

A Case of Difficult Ventilation

Difficult ventilation is a problem related to airway management which is a frequent and significant problem encountered during anesthesia. The main causes of difficult ventilation include disturbances in anesthetic gas flow, obstructions in the breathing-circulation system, decreased pulmonary compliance, severe acute bronchospasm, tension pneumothorax and endobronchial mass lesions. Secretions, cuff herniation, faults in manufactured airway equipment and kinking of the tube might also cause obstructions in the breathing-circulation systems. This report presents a case of difficult ventilation following intubation due to an endotracheal tube defect.

The distance between the carina and the distal margin of the right upper lobe orifice measured by computerised tomography as a guide to right‐sided double‐lumen endobronchial tube use

Our hypothesis was that the incidence of malposition of a right-sided double-lumen endobronchial tube and right upper lobe collapse may increase when the distance between the carina and the distal margin of the right upper lobe orifice is less than 23 mm, measured from a computerised tomography scan. A total of 76 patients undergoing left-sided thoracic surgery were enrolled. Patients with a measured distance of <23 mm (n=38) were compared with age-, sex- and body mass index-matched patients with a distance≥23 mm (n=38). Right-sided double-lumen endobronchial tubes were used universally. We monitored endobronchial tube malposition and incidence of right upper lobe collapse throughout surgery. There was a significantly higher incidence of bronchial cuff herniation in patients with a distance<23 mm in both the supine position and the lateral decubitus position (p<0.001). The incidence of intra-operative malposition in the <23 mm group was also significantly higher than in the ≥23 mm group (31 (82%) vs 8 (21%), respectively, p<0.001). Right upper lobe collapse was detected postoperatively in five patients (13%) in the distance<23 mm group, compared to none in the ≥23 mm group. We recommend that the distance between the carina and the distal margin of the right upper lobe bronchus should be routinely measured on the pre-operative computerised tomography scan, and if it is <23 mm, consideration should be given to using a left-sided endobronchial double-lumen tube in preference to a right-sided one.

Failure of both suction catheter passage and bronchoscopy to diagnose an obstructing tracheal mucus plug

To the Editor, The patient’s spouse gave informed consent for publication of this report. A 55-yr-old male sustained burns in a welding accident extending caudad from shoulder level over 65% of his body surface area. In the intervening two months, he required multiple surgeries, including debridement and skin grafting, a laparotomy for abdominal compartment syndrome, and a tracheostomy. Presenting on this occasion for further skin grafting, he was breathing easily and spontaneously through a size 8 fenestrated Shiley tracheostomy cannula (Covidien, Mansfield, MA, USA) capped with a decannulation plug. In the operating room, the fenestrated inner cannula was exchanged for a non-fenestrated tube. Shortly after this change, the patient indicated some dyspnea. A suction catheter was introduced and moderate amounts of sputum were obtained, after which the patient signalled at least partial relief. Following application of routine monitors, anesthesia was induced using sevoflurane in oxygen through a circle system connected to the tracheostomy tube, supplemented with midazolam 2 mg and propofol 30 mg iv. After induction, it was almost impossible to ventilate the patient’s lungs. We detected a markedly prolonged expiratory phase and made a working diagnosis of severe bronchospasm although minimal rhonchi were present. We administered rocuronium 50 mg iv, increased the inspired sevoflurane concentration to 4%, and administered salbutamol, magnesium sulphate, and small doses (50–100 lg) of intravenous epinephrine. Although the oxygen saturation remained [ 90%, little improvement was achieved in response to these measures. An 18-Fr suction catheter was introduced on at least three further occasions. Each time, a scant amount of sputum was obtained, but no improvement in ventilation resulted. We twice passed a fibreoptic bronchoscope, but saw no obvious impediment to ventilation, and the tracheobronchial tree looked normal. Interestingly, when the tracheostomy tube was disconnected from the circuit for suctioning or bronchoscopy, we observed the patient’s chest gradually fall with loud yet slow gas egress from the tracheostomy cannula, suggesting gas escaping under conditions of high intrathoracic pressure. Following each such thoracic decompression, ventilation was easier for the next two or three positive pressure inspirations. Eventually, an inspiratory:expiratory (i:e) ratio of about 1:10 was observed to allow sufficient time for expiration, such that ventilation was now possible, albeit with ongoing high airway pressures. To rule out a circuit or machine problem, ventilation was assessed with a manual resuscitator, which confirmed that the high airway pressures originated from either the tracheostomy cannula or the patient. A portable chest radiograph showed only bilateral lung hyperinflation. Although substantially hypercarbic (PetCO2 up to 93 mmHg), fortunately, the patient suffered no cardiovascular instability. Ultimately, a change of tracheostomy was planned given the poor response to treatment for bronchospasm, ongoing problems with positive pressure ventilation, evidence of air trapping, and the initial history of dyspnea with tracheostomy manipulation. Repeat bronchoscopy was performed by a different clinician using a videobronchoscope. The visual field was briefly obscured as the videobronchoscope was advanced beyond the distal end of the tracheostomy cannula, after which a clear view of the trachea was observed. At this point, the possibility of cuff herniation was considered. Direct laryngoscopy prior to tracheostomy J. A. Law, MD (&) C. Mariotti, MD T. Mullen, MD Dalhousie University/QEII Health Sciences Centre, Halifax, NS, Canada e-mail: jlaw@dal.ca

Intraoperative bronchoscopy prevents hypoxaemia during one-lung ventilation for second-stage oesophagectomy: a prospective cohort study

Intraoperative bronchoscopy prevents hypoxaemia during one-lung ventilation for second-stage oesophagectomy: a prospective cohort study

The effectiveness of ARNDT endobronchial blockers in paediatric scoliosis surgery

Introduction: Although described for paediatric thoracic surgery (1), there is little data on the use of the Arndt endobronchial blocker in paediatric spinal deformity surgery. We present its successful application in these patients.Methods: Thirteen patients undergoing surgical correction of scoliosis involving a lateral thoracotomy anterior approach were suitable for lung isolation using an Arndt endobronchial blocker. Placement was via an armoured tracheal tube; the endobronchial blockers were 5 or 9 FG with low‐volume low‐pressure cuffs (spherical or elliptical balloons). Placement was by a paediatric anaesthetist trained in paediatric bronchoscopy and required a 2.2 or a 2.8 mm paediatric fibreoptic bronchoscope.Results: Patient ages ranged from 18 months to 18 years and weights from 9 kg to 71 kg. All had idiopathic or congenital scoliosis; one patient underwent a VEPTR procedure. In all 13 patients, placement was easily and promptly achieved with no incorrect placements, displacements (including after patient repositioning), or failures to isolate one lung. Median time of insertion was 5 min (with checks), speed of insertion increasing as experience improved. Inflation times for the blocker balloon ranged from 1.5 h to 5 h. There was no airway trauma; direct bronchial inspection revealed local erythema only. Saturations were supported with 5 cm CPAP to the isolated lung and one‐lung ventilation was well tolerated in all but one patient with acceptable airway pressures (&lt;35 cm water); this one patient required partial lung inflation (blocker in place, balloon not inflated) to maintain adequate saturations and airway pressures. The surgical field was excellent in all cases.Discussion: Complex paediatric spinal surgery may require lung collapse to improve spinal access, and is traditionally achieved using a double‐lumen tracheal tube. Difficulties can arise as the children are often small for age with potentially distorted airway anatomy and there are a limited number of double lumen tube sizes. This can lead to inadequate isolation, a poor surgical field, endobronchial cuff herniation or obstruction of left upper lobe (tube too small or too long). The careful use of the Arndt endobronchial blocker avoids all these problems and enables easy reliable and safe isolation. Potential complications include malposition, migration, and direct airway trauma, allied to the usual complications of one lung anaesthesia. In our series, there were no complications relating to its use and insertion was quick and straightforward.Conclusions: Lung isolation with the Arndt endobronchial blocker is both safe and very effective in paediatric spinal deformity surgery.Reference 1 Wald SH, Mahajan A, Kaplan MB et al. Experience with the Arndt paediatric bronchial blocker. Br J Anaesth 2005; 94: 92–94.

Acute tracheobronchial injuries: Impact of imaging on diagnosis and management implications

Purpose To evaluate the role of chest radiography, single-slice CT and 16-row MDCT in the direct evidence of tracheobronchial injuries. Methods Patients with acute tracheobronchial injury were identified from the registry of our level 1 trauma center during a 5-year period ending July 2005. Findings at chest radiograph and CT were compared to those shown at bronchoscopy. Results Eighteen patients with tracheobronchial injury – three patients with cervical trachea injury, eight with thoracic trachea injury and seven with bronchial injury – were identified. Twelve patients had a blunt trauma (67%), six patients had a penetrating (iatrogenic) injury (33%). Chest radiograph directly identified the site of tracheal injury in four cases, showing overdistension of the endotracheal cuff in three cases and displacement of the endotracheal tube in one case. At the level of the bronchi, chest radiograph demonstrated only one injury. CT directly identified the site of tracheal injury in all the cases showing the overdistension of the endotracheal cuff at the level of the thoracic trachea (three cases), posterior herniation of the endotracheal cuff at the thoracic trachea (three cases), lateral endotracheal cuff herniation at the thoracic trachea (one case), tracheal wall discontinuity at the cervical (one case) and at the thoracic trachea (one case) and displacement of endotracheal tube at the cervical trachea (two cases). At the level of the bronchi, CT correctly showed the site of injury in six case including: discontinuity of the left main bronchial wall (two cases), the “fallen lung” sign (one case), right main bronchial wall enlargement (one case), discontinuity of the right middle bronchial wall (two cases). In one case, CT showed just direct “air leak” at the level of the carina suggesting main bronchus injury. This finding was confirmed by bronchoscopy. Conclusion Chest radiograph was helpful for the assessment of iatrogenic tracheal injuries. CT detected the site of blunt tracheobronchial injuries in 94% of the cases. Multiplanar 16-row MDCT reconstructions, were essential for the optimal surgical approach.

Two cases of intraoperative herniation of the endotracheal tube cuff

During anaesthesia for elective procedures, 2 dogs developed acute airway obstruction caused by herniation of the endotracheal cuff. This is an uncommon but potentially fatal complication especially when minimal monitoring of the patient leads to late recognition of the condition. The most typical symptoms are decreased thoracic excursions and tidal volume, absence of gas flow through the endotracheal tube, change in the capnographic waves morphology and increased airway pressures. In both cases desaturation of haemoglobin (measured by pulse oximetry) occurred in-between 6 and 8 minutes after cuff herniation. All signs normalised following partial deflation of the cuff. Careful management of cuff pressures especially when nitrous oxide is used, awareness of the condition and monitoring of the patient can prevent fatal consequences.

An in vitro study of tracheostomy tube cuff herniation and inflation characteristics.

Seven of the most commonly used tracheostomy tubes used in the UK were tested for cuff herniation and creasing in synthetic tracheas corresponding to the shapes and sizes found in vivo. Results demonstrated that only two tubes of one particular brand herniated and that creasing occurred in tubes disproportionately large for the trachea used. A discussion of modern tracheostomy tube manufacture is included.

Intraoperative herniation of a tracheostomy tube cuff

A case of intraoperative tracheostomy tube obstruction is reported. The clinical features and the chain of events leading to the diagnosis of cuff herniation are presented. The different mechanisms of herniation are discussed. In the present case we speculate that a manufacturing defect together with nitrous oxide diffusion into the cuff caused dilatation and herniation of the latter which led to obstruction of the distal tube lumen. We draw attention to this rare but life-threatening complication.

The Australian Incident Monitoring Study. Problems related to the endotracheal tube: an analysis of 2000 incident reports.

The first 2000 incidents reported to the Australian Incident Monitoring Study were analysed with respect to problems with the endotracheal tube; 189 (9%) were reported. The most common problem was endobronchial intubation which accounted for 42% of these 189 reports; endobronchial intubation was the most common cause of arterial desaturation in the 2000 incidents. Obstructions and oesophageal intubation each accounted for 18% of the 189 problems with tubes. The remainder was made up of disconnections and leaks (7% each), misplacements other than endobronchial or oesophageal (4%), inappropriate choice of tube (3%), cuff herniation (1%), failure to deflate the cuff and foreign body in the tube (0.5% each). The pulse oximeter and capnograph first detected 58% of these incidents; a further 25% were detected clinically. The pulse oximeter is the "front-line" monitor for endobronchial intubation, and the capnograph the "front-line" monitor for oesophageal intubation, disconnection and obstruction. Recommendations are made for how to prevent problems and how to determine the nature of those that do occur.

An obstructed airway: cuff herniation during nasotracheal anaesthesia for a bimaxillary osteotomy

A case of airway obstruction resulting from lumen occlusion by an inflated endotracheal tube cuff is reported. The possible causes and remedies for this unusual complication are discussed.

Missed Diagnosis of Cuff Herniation in a Modern Nasal Endotracheal Tube

Department of Anesthesia and Intensive Care, University College Hospital, Newcastle Road, Galway, Republic of Ireland