Endotracheal Tube Displacement Research Articles

The PhLIP team: Feasibility of a physiotherapy-led intensive prone positioning team initiative during the COVID-19 pandemic

BackgroundThe coronavirus disease 2019 (COVID-19) pandemic resulted in a surge of patients with refractory hypoxaemic respiratory failure being admitted to the intensive care unit (ICU). Prone positioning can improve oxygenation but requires a team of skilled personnel to complete safely. Critical care physiotherapists (PTs) are ideally suited to lead proning teams, due to their expertise in moving critically unwell, invasively ventilated patients. ObjectivesThe aim of this study was to describe the feasibility of implementing a physiotherapy-led intensive proning (PhLIP) team to support the critical care team during surges. MethodsThis study involves descriptive evaluation of feasibility and implementation of the PhLIP team, a novel model of care, during the Delta wave of the COVID-19 pandemic, through a retrospective, observational audit of PhLIP team activity, ICU clinical activity, and a description of clinical outcomes. ResultsBetween 17 September and 19 November 2021, 93 patients with COVID-19 were admitted to the ICU. Fifty-one patients (55%) were positioned prone, a median [interquartile range] 2 [2, 5] times, for a mean (±standard deviation) duration of 16 (±2) h, across 161 episodes. Twenty-three PTs were upskilled and deployed to the PhLIP team, adding 2.0 equivalent full time to the daily service. Ninety-four percent of prone episodes (154) were led by the PhLIP PTs with a median 4 [interquartile range: 2, 8] turns per day. Potential airway adverse events occurred on three occasions (1.8%) and included an endotracheal tube leak, displacement, and obstruction. Each incident was promptly managed without prolonged impact on the patient. No manual handling injuries were reported. ConclusionThe implementation of a physiotherapy-led proning team was safe and feasible and can release critical care-trained medical and nursing staff to other duties in the ICU.

Effect of head position changes on the depth of tracheal intubation in pediatric patients: A prospective, observational study.

PurposeThe purpose of this study was to investigate the effect of changing head position on the endotracheal tube (ETT) depth and to assess the risk of inadvertent extubation and bronchial intubation in pediatric patients.MethodsSubjects aged 4–12 years old with orotracheal intubation undergoing elective surgeries were enrolled. After induction, the distances between “the ETT tip and the trachea carina” (T-C) were measured using a Disposcope flexible endoscope in head neutral position, 45° extension and flexion, 60° right and left rotation. The distance of the ETT tip movement relative to the neutral position (ΔT-C) was calculated after changing the head positions. The direction of the ETT tip displacement and the adverse events including endobronchial intubation, accidental tracheal extubation, hoarseness and sore throat were recorded.ResultsThe ETT tip moved toward the carina by 0.5 ± 0.4 cm (P < 0.001) when the head was flexed. After extending the head, the ETT tip moved toward the vocal cord by 0.9 ± 0.4 cm (P < 0.001). Right rotation resulted that the ETT tip moved toward the vocal cord direction by 0.6 ± 0.4 cm (P < 0.001). Moreover, there was no displacement with the head on left rotation (P = 0.126). Subjects with the reinforced ETT had less ETT displacement after changing head position than the taper guard ETT.ConclusionThe changes of head position can influence the depth of the ETT especially in head extension. We recommend using the reinforced ETT to reduce the ETT displacement in pediatrics to avoid intubation complications.Clinical trial registration[www.ClinicalTrials.gov], identifier, [ChiCTR2100042648].

Is endotracheal tube displacement during head and neck extension due to ascending movement or tracheal lengthening? An observational ultrasonographic study.

Complications of the endotracheal tube (ETT) displacement during head and neck positional changes are related to not only the tip position but also the cuff pressure against the larynx. Here, we evaluated movement of the ETT cuff relative to laryngeal structures as well as tip displacement from the carina.Sixty-two patients scheduled for thyroidectomy were recruited. The distance from the cricoid cartilage to the upper margin of the cuff (CC) and that from the ETT tip to the carina (TC) were measured using ultrasonography and fiberoptic bronchoscopy, respectively, during flexion and extension. The total tracheal length (TTL) was defined as the combination of CC, TC, and the distance from the upper margin of the cuff to the tip.During flexion, the CC and TC were 1.5 ± 0.6 and 2.9 ± 1.0cm respectively. Seven patients (11.7%) exhibited excessively deep intubation. After adjusting the cuff position under ultrasonography (CC = 0), the tip position was corrected in 96.7%. While the TC increased by 2.1 ± 1.0cm after the positional change in extension, the CC decreased by 0.6 ± 0.7cm because the TTL lengthened (1.4 ± 1.1cm). Four patients (6.7%) exhibited excessive cuff displacement beyond the cricoid cartilage, which could have been corrected under ultrasonography.In conclusion, the ETT cuff displaced toward the larynx in a less degree than the tip did from the carina due to the tracheal lengthening during head and neck extension. Nevertheless, we suggest that ultrasonographic assessment of cuff position may avoid ETT misplacement. Trial registration https://cris.nih.go.kr/ (approval no. KCT0005319); registered on May 14, 2019.

Endotracheal Tube Displacement during Cardiac Surgery in Infants: A Retrospective Cohort Study of Its Incidence and Predictors

Introduction: With the traction on the trachea and intrathoracic manipulation during cardiac surgery, the position of the endotracheal tube (ETT) might be changed as compared to before surgery. Migration of the ETT during pediatric cardiac surgery is particularly problematic in infants. Methods: In this retrospective cohort study, chest X-rays were taken in the operating room just before and after surgery. The position of the ETT among all infants under 1 year of age who underwent cardiac surgery between December 2017 to December 2019 was evaluated. The displacement of the ETT position was examined by measuring the position of the tube tip from the tracheal bifurcation on a chest X-ray, and the relationship between surgery-related factors (age, height, weight, sex, surgery time, cardiopulmonary bypass, tube size, use of tube cuff) was analyzed. Results: Eighty-eight of the 141 patients were enrolled. There was a significant proximal displacement of the ETT tip during cardiac surgery. The distance from the carina to the tube tip after surgery was long, on average 2.5 mm, compared to that before surgery (P = 0.013). Cephalad displacement of the ETT either ≥5 mm or ≥2.5 mm was found in 28 and in 38 out of 88 infants after surgery, respectively. After performing multivariate analysis, the use of un-cuffed ETT was the sole exploratory variable predictive of tube tip displacement (OR 0.34, 95% CI 0.10 - 0.93 if ≥5 mm; and OR 0.24, 95% CI 0.08 - 0.75 if ≥2.5 mm displacement; P = 0.04 and 0.01, respectively). Conclusion: Proximal displacement of the ETT during cardiac surgery occurs more frequently in infants with un-cuffed ETT.

Hypothermia for moderate or severe neonatal encephalopathy in low-income and middle-income countries (HELIX): a randomised controlled trial in India, Sri Lanka, and Bangladesh

SummaryBackgroundAlthough therapeutic hypothermia reduces death or disability after neonatal encephalopathy in high-income countries, its safety and efficacy in low-income and middle-income countries is unclear. We aimed to examine whether therapeutic hypothermia alongside optimal supportive intensive care reduces death or moderate or severe disability after neonatal encephalopathy in south Asia.MethodsWe did a multicountry open-label, randomised controlled trial in seven tertiary neonatal intensive care units in India, Sri Lanka, and Bangladesh. We enrolled infants born at or after 36 weeks of gestation with moderate or severe neonatal encephalopathy and a need for continued resuscitation at 5 min of age or an Apgar score of less than 6 at 5 min of age (for babies born in a hospital), or both, or an absence of crying by 5 min of age (for babies born at home). Using a web-based randomisation system, we allocated infants into a group receiving whole body hypothermia (33·5°C) for 72 h using a servo-controlled cooling device, or to usual care (control group), within 6 h of birth. All recruiting sites had facilities for invasive ventilation, cardiovascular support, and access to 3 Tesla MRI scanners and spectroscopy. Masking of the intervention was not possible, but those involved in the magnetic resonance biomarker analysis and neurodevelopmental outcome assessments were masked to the allocation. The primary outcome was a combined endpoint of death or moderate or severe disability at 18–22 months, assessed by the Bayley Scales of Infant and Toddler Development (third edition) and a detailed neurological examination. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, NCT02387385.FindingsWe screened 2296 infants between Aug 15, 2015, and Feb 15, 2019, of whom 576 infants were eligible for inclusion. After exclusions, we recruited 408 eligible infants and we assigned 202 to the hypothermia group and 206 to the control group. Primary outcome data were available for 195 (97%) of the 202 infants in the hypothermia group and 199 (97%) of the 206 control group infants. 98 (50%) infants in the hypothermia group and 94 (47%) infants in the control group died or had a moderate or severe disability (risk ratio 1·06; 95% CI 0·87–1·30; p=0·55). 84 infants (42%) in the hypothermia group and 63 (31%; p=0·022) infants in the control group died, of whom 72 (36%) and 49 (24%; p=0·0087) died during neonatal hospitalisation. Five serious adverse events were reported: three in the hypothermia group (one hospital readmission relating to pneumonia, one septic arthritis, and one suspected venous thrombosis), and two in the control group (one related to desaturations during MRI and other because of endotracheal tube displacement during transport for MRI). No adverse events were considered causally related to the study intervention.InterpretationTherapeutic hypothermia did not reduce the combined outcome of death or disability at 18 months after neonatal encephalopathy in low-income and middle-income countries, but significantly increased death alone. Therapeutic hypothermia should not be offered as treatment for neonatal encephalopathy in low-income and middle-income countries, even when tertiary neonatal intensive care facilities are available.FundingNational Institute for Health Research, Garfield Weston Foundation, and Bill & Melinda Gates Foundation.TranslationsFor the Hindi, Malayalam, Telugu, Kannada, Singhalese, Tamil, Marathi and Bangla translations of the abstract see Supplementary Materials section.

Should We Pay More Attention to Endotracheal Tube Fixation during Anesthesia—Surveys from Chinese Anesthesiologists for Endotracheal Tube Fixation and Endotracheal Tube Displacement in 2014 and 2020

Background: Displacement of endotracheal tube (ETT) can result in endobronchial intubation and accidental extubation that severely threatens safety of surgical patients. However, few surveys have investigated intraoperative ETT displacement experienced by anesthesiologists. The objective of these surveys was to investigate ETT fixation method and ETT displacement during general anesthesia experienced by anesthesiologists in China in 2014 and 2020. Methods: A questionnaire was designed with twenty questions and randomly distributed to anesthesiologists in two survey methods. In 2014, we collected responses from anesthesiologists who participated in the 22nd annual meeting of the Chinese Society of Anesthesiology in a face-to-face setting; in 2020, anesthesiologists from twenty-eight provinces completed the questionnaire through an online questionnaire survey platform. Differences in the responses from the anesthesiologists in 2014 and 2020 were assessed with a chi-square test. Results: In total, 568 questionnaires were collected, of which 541 questionnaires were valid (valid response rate 95.2%). A majority of the respondents (65.6%) had experienced ETT displacement, and 4.3% of respondents had experienced serious complications due to ETT displacement. Three hundred and twenty-nine respondents (60.8%) fixed the ETT with adhesive tape in the shape of the letter X. A majority of respondents considered the influence of surgical site, body position (97.8% of all respondents), and age (77.1% of all respondents) on fixing the ETT. Adhesive tape was the most commonly used material to fix the ETT (90.4% of the respondents). Conclusion: During clinical anesthesia, a majority of anesthesiologists experienced ETT displacement that can result in serious consequences. Therefore, the management of ETT should be a priority during the operation.

A Quick Review on the Multisystem Effects of Prone Position in Acute Respiratory Distress Syndrome (ARDS) Including COVID-19.

Objective:The purpose of this review is to highlight the multisystem effects of prone position in ARDS patients with a focus on current findings regarding its use in COVID-19 patients.Methods:Two reviewers comprehensively searched PubMed database for literature regarding pathophysiology and efficacy of prone position in ARDS patients as well as specific data regarding this approach in COVID-19 patients.Conclusion:Prone positioning is well-documented to improve oxygenation and cardiac function in ARDS patients and might confer increased survival, with benefits that outweigh risks such as facial edema, endotracheal tube displacement, and intraabdominal organ dysfunction in obese patients. Severe COVID-19 pneumonia, while meeting ARDS criteria, differs from typical ARDS in several ways. Data would suggest that advantages of prone position would become limited after significant disease progression and fibrosis. The use of this technique in COVID-19 requires prolonged sessions that are unprecedented in the treatment of ARDS patients. New data regarding COVID-19 pathophysiology and patients continues to evolve daily. More frequently, patients are proned while maintaining spontaneous breathing—the results of this intervention are an area for future studies. There is more to learn about the appropriate use of prone position in COVID-19 patients. The multisystem risks and benefits require clinicians to adopt a patient centered decision-making algorithm when employing this technique in COVID-19 patients.Level of evidence:NA

Assessment of interhospital transport care for pediatric patients.

BackgroundMany critically ill patients require transfer to a higher-level hospital for complex medical care. Despite the publication of the American Academy of Pediatrics guidelines for pediatric interhospital transportation services and the establishment of many pediatric transport programs, adverse events during pediatric transport still occur.PurposeTo determine the incidence of adverse events occurring during pediatric transport and explore their complications and risk factors.MethodsThis prospective observational study explored the adverse events that occurred during the interhospital transport of all pediatric patients referred to the pediatric intensive care unit of Ramathibodi Hospital between March 2016 and June 2017.ResultsThere were 122 pediatric transports to the unit. Adverse events occurred in 25 cases (22%). Physiologic deterioration occurred in 15 patients (60%). Most issues (11 events) involved circulatory problems causing patient hypotension and poor tissue perfusion requiring fluid resuscitation or inotropic administration on arrival at the unit. Respiratory complications were the second most common cause (4 events). Equipment-related adverse events occurred in 5 patients (20%). The common causes were accidental extubation and endotracheal tube displacement. Five patients had both physiologic deterioration and equipment-related adverse events. Regarding transport personnel, the group without complications more often had a physician escort than the group with complications (92% vs. 76%; relative risk, 2.4; P=0.028).ConclusionThe incidence of adverse events occurring during the transport of critically ill pediatric patients was 22%. Most events involved physiological deterioration. Escort personnel maybe the key to preventing and appropriately monitoring complications occurring during transport.

Comparison of the effectiveness of endotracheal tube holder with the conventional method in a manikin model.

OBJECTIVES:Endotracheal tube (ETT) displacement occurs by improper fixation. To fix an ETT, many types of fixation tools are employed. Thomas tube holder is one of the fixation tools widely used in many countries. This study aims to compare the ETT fixation using the Thomas tube holder with the conventional method (adhesive tape) in a mannequin model.METHODS:The fixation tools were random, using the box of six randomizes to Thomas tube holder and conventional method. After fixation, the mannequin model was being logged roll, chest compression by automated chest compression machine, and transported by the paramedic. The time to ETT fixation and displacements were recorded.RESULTS:The mean time (standard deviation) to fixate an ETT was shorter (33.0 s [7.3]) with a Thomas tube holder compared to adhesive tape (52.6 s [7.3], P < 0.001). The number and proportion of the ETT displacements were significantly less with Thomas tube holder compared to adhesive tape during log roll (16, 35.6% vs. 29, 64.4%, P = 0.011), chest compression with automated machine (23, 51.1% vs. 37, 82.2%, P = 0.003), and transport (26, 57.8% vs. 40, 88.9%, P = 0.002).CONCLUSION:The Thomas tube holder is more effective than adhesive tape in preventing ETT displacement in a mannequin subjected to log roll, chest compressions, and transportation.

Anterior laryngeal electrodes for recurrent laryngeal nerve monitoring during thyroid and parathyroid surgery: New expanded options for neural monitoring.

Intraoperative neural monitoring is a useful adjunct for the laryngeal nerve function assessment during thyroid and parathyroid surgery. Typically, monitoring is performed by measurement of electromyographic responses recorded by endotracheal tube (ETT) surface electrodes. Tube position alterations during surgery can cause displacement of the electrodes relative to the vocal cords, leading to false positive loss of signal. Numerous reports have denoted monitoring equipment-related issues, especially endotracheal tube displacement, as the dominant source of false positive error. The false positive error may result in inappropriate decisions by the surgeon. This study tests the hypothesis that anterior laryngeal electrodes (ALEs) can help reduce this error. Placement of ALEs directly onto the thyroid cartilage represent an adjunctive and possible alternative method to standard ETT surface electrodes. Retrospective review. Fifteen consecutive patients undergoing thyroid and parathyroid surgery with intraoperative neuromonitoring using both ETT electrodes and ALEs were studied. Data collected included site of neural stimulation, laterality, and electromyographic parameters. With vagal and recurrent laryngeal nerve stimulation, the ALEs recorded mean vocalis muscle waveform amplitude within 83% of that recorded with standard ETT electrodes. The latency measurements with the anterior laryngeal and endotracheal electrodes were similar, with both electrodes recording significantly longer latency for the left vagus nerve as compared to the right vagus nerve. With superior laryngeal nerve stimulation, the ALEs recorded a 800% greater mean amplitude than the ETT electrodes. The ALEs demonstrated similar sensitivity to stimulation at low current as ETT electrodes and provided stable intraoperative monitoring information. Compared to ETT surface electrodes, the ALEs provide similar and stable electromyographic responses with equal sensitivity for recording evoked responses during neural monitoring in thyroid and parathyroid surgery. The ALEs offer significantly more robust monitoring of the external branch of the superior laryngeal nerve. Furthermore, ALEs are contained within the operative field, are totally surgeon controlled, and are unaffected by the potential vicissitudes of ETT position during surgery. 4 Laryngoscope, 128:2910-2915, 2018.

Comparison of EMG signals recorded by surface electrodes on endotracheal tube and thyroid cartilage during monitored thyroidectomy

A variety of electromyography (EMG) recording methods were reported during intraoperative neural monitoring (IONM) of recurrent laryngeal nerve (RLN) in thyroid surgery. This study compared two surface recording methods that were obtained by electrodes on endotracheal tube (ET) and thyroid cartilage (TC). This study analyzed 205 RLNs at risk in 110 patients undergoing monitored thyroidectomy. Each patient was intubated with an EMG ET during general anesthesia. A pair of single needle electrode was inserted obliquely into the TC lamina on each side. Standard IONM procedure was routinely followed, and EMG signals recorded by the ET and TC electrodes at each step were compared. In all nerves, evoked laryngeal EMG signals were reliably recorded by the ET and TC electrodes, and showed the same typical waveform and latency. The EMG signals recorded by the TC electrodes showed significantly higher amplitudes and stability compared to those by the ET electrodes. Both recording methods accurately detected 7 partial loss of signal (LOS) and 2 complete LOS events caused by traction stress, but only the ET electrodes falsely detected 3 LOS events caused by ET displacement during surgical manipulation. Two patients with true complete LOS experienced temporary RLN palsy postoperatively. Neither permanent RLN palsy, nor complications from ET or TC electrodes were encountered in this study. Both electrodes are effective and reliable for recording laryngeal EMG signals during monitored thyroidectomy. Compared to ET electrodes, TC electrodes obtain higher and more stable EMG signals as well as fewer false EMG results during IONM.

A randomized comparison of the prone ventilation endotracheal tube versus the traditional endotracheal tube in adult patients undergoing prone position surgery

Endotracheal tube displacement or dislocation is a severe complication that can occur in patients who require prone position ventilation. We hypothesized the prone position tube (PPT) would reduce the incidence of displacement of an endotracheal tube in an adult prone operation compared to a traditional tube (TT). A total of 80 adult patients undergoing neurosurgery or spine surgery were recruited. Sixty patients with prone position ventilation were randomly divided into the traditional routine endotracheal tube group (Group TT, n = 30) and the prone position ventilation endotracheal tube group (Group PPT, n = 30). The primary outcome measures were the incidence of the endotracheal tube displacement during surgery, and the secondary outcomes were symptoms of sore throat, dysphagia and dysphonia during follow-up in the post-anesthesia care unit (PACU). The incidence of tube displacement was significantly lower in the PPT group (0 [0%] of 30 patients) compared to the TT group (22 [73.3%] of 30 patients; odds ratio [OR] 0.73, 95% CI 0.591–0.910; P = 0.005). There was no statistical difference in sore throat, dysphagia and vocal function between the two groups (P > 0.05) during follow-up. Compared to the traditional tube, the improved prone positon tube reduced the incidence of displacement of the endotracheal tube. This study was registered with ClinicalTrials.gov on April 29, 2015 (No. NCT02449356).

Effect observation of two endotracheal-tube methods

Objective To observe the effect of two endotracheal-tube methods and to seek better endotracheal-tube method. Methods Totally 60 orotracheal intubation patients from September to December 2015 in neurology intensive care unit (NICU) were randomly divided into the experimental group and the control group. Patients in the experimental group were given new type endotracheal intubation fixed bracket, while patients in the control group were given tape fixed method. We compared the condition of facial skin allergy and injury, effect of tracheal intubation fixed method, and the incidence of ventilator associated pneumonia of patients in two groups. Results In the experimental group, the incidence rate of facial skin irritation and damage was 6.7%; the incidence rate of displacement of endotracheal tube was 6.7%, and they were both lower than the data in the control group (χ2=35.749, 28.081; P 0.05). Conclusions The new type of endotracheal intubation fixed method can significantly reduce the incidence rate of facial allergy and damage. It is safe and effective, and it also can increase the patient′s oral comfort. It is worthy of clinical promotion. Key words: Tracheal intubation; Fixed method; Facial injury

Endotracheal tube displacement during head and neck movements. Observational clinical trial

Study ObjectiveMeasure the displacements of endotracheal tube (ETT) tip displacement during head and neck movements. DesignObservational study. SettingEar-nose-throat (ENT) and neurosurgery operating room. PatientsWe performed a maximal head-neck movement trial on 50 adult patients, American Society of Anaesthesiologists 1 or 2. Patients with body mass index >35 kg · m−2, height <150 cm, airway malformations, pulmonary diseases, difficulties in neck flexion or extension, previous ENT surgery or radiotherapy, gastroesophageal reflux, or dental instability were excluded from the study. InterventionsENT and neurosurgery. MeasurementsWe measured the change in distance between the ETT tip and the carina, using a fiberscope through the ETT. ResultsAfter intubation, a wide disparity of tube tip distance to the carina in the neutral position was noted with a median of 5.0 (3.5-7.0) cm. Cephalad tube movement was documented following maximal head and neck extension in 34 (68%) patients and right head rotation in 25 patients (50%). Caudal tube displacement was due to maximal head and neck flexion in 38 patients (76%) and left head rotation in 25 patients (50%). Selective right main bronchus intubation was noted in 2 (4%) patients after maximal head extension. ConclusionMaximal head and neck movements led to unpredictable tube displacements. Proper reassessment of tube positioning after head and neck movement of intubated patients is therefore mandatory.

Post-operative pneumothorax with subcutaneous emphysema in a pre-eclamptic patient.

Sir, A 30-year-old female patient presented with severe pre-eclampsia for emergency caesarean section. On the operating table, she had a blood pressure (BP) of 176/98 mm Hg, pulse rate 102/min, oxygen saturation (SpO2) 99% and air entry was equal bilaterally. Rapid sequence induction and intubation were performed; gentle laryngoscopy was performed and cuffed endotracheal tube (ETT), 7.5 internal diameter was inserted aided by a stylet. The depth of anaesthesia was maintained with O2, nitrous oxide, isoflurane and muscle relaxant vecuronium (total dose of 6 mg) was used. The monitors used were electrocardiograph, pulse oximeter, non-invasive BP, and end-tidal carbon dioxide (CO2) monitor. The patient was ventilated on closed circuit with mechanical ventilation (volume control mode with respiratory rate [RR] 12/min, tidal volume of 450 ml, without positive end-expiratory pressure (PEEP), with mean airway pressure of 14 cm H2O). Intra-operative period was uneventful. The surgery was completed in 1 h. Postoperatively, the neuromuscular blockade was reversed with neostigmine 2.5 mg intravenous (iv), glycopyrrolate 0.5 mg iv. Due to inadequate reversal of neuromuscular blockade as suspected by poor respiratory efforts, the reversal drugs were supplemented. Arterial blood gas report showed normal partial pressure of oxygen and potential of hydrogen. However, CO2 retention was present, so we continued to manually assist her ventilation. After 10 min, her respiratory efforts were adequate, but her protective airway reflexes were blunted and she was tolerating the ETT well. Therefore, we decided not to extubate the trachea. While shifting the patient to recovery room on T piece, she had a violent coughing and retching episode after which she became restless and developed bradycardia with SpO2 decreasing to 82%. We then noticed palpable crepitus all over the chest, face and doubtful air entry on chest auscultation. As we suspected displacement of ETT, we extubated the trachea. She was unable to maintain adequate respiratory efforts. Hence, we paralysed her and reintubated her trachea. Thereafter, her vital signs stabilised. Air entry on the left side was decreased. She was shifted to the Intensive Care Unit (ICU) for mechanical ventilation. A chest X-ray was done in the ICU, which showed left-sided pneumothorax with subcutaneous emphysema. An intercostal chest drain was inserted and patient. The patient was maintained ventilatory support without delay (volume control mode with RR 14/min, TV 450 ml, PEEP of 0 cm H2O, inspiratory to expiratory ratio (I: E ratio) of 1:2 and peak airway pressures limited to 24 cm H2O). We could not find any obvious airway rent as assessed by fibreoptic bronchoscopy. The patient's relative did not give consent for computed tomography of thorax. After 24 h of stay in the ICU, the patient's vital signs got stabilised with normal respiratory parameters. The patient's trachea was extubated. After 24 h of cessation of air column movement, the intercostal chest drain was removed. Pneumothorax with subcutaneous emphysema in the immediate postoperative period can be spontaneous or iatrogenic. Spontaneous causes include rupture of undiagnosed bullae, spontaneous post-violent cough airway tear, alveolar rupture and post-emetic rupture of the oesophagus.[1,2,3] Iatrogenic causes include trauma to the pharynx, trachea during traumatic intubation, over inflation of ETT cuff, repeated intubation attempts, re-positioning of ETT without deflating the cuff, stylet protruding beyond ETT tip, patient movement or coughing during intubation/extubation and patient head and neck movement after intubation.[4] In our patient, adequate precautions were taken to prevent these iatrogenic causes. Decrease in SpO2 and bradycardia did not occur in the intra-operative period during which positive pressure ventilation was provided, so the aetiology being rupture of undiagnosed bullae due to positive pressure ventilation is unlikely. There are patient and surgical factors such as congenital tracheal anomalies, chronic use of steroids, chronic obstructive pulmonary disease, thoracic and laparoscopic surgeries.[4] None of these factors are involved in our case. Even though, we could not find any obvious airway rent while doing fibreoptic bronchoscopy, a possibility of airway injury cannot be completely ruled out. There is a high probability that either the violent coughing or retching episode in the post-operative period or ETT displacement due to violent head and neck movement during transfer to the recovery room could have led to an airway or oesophageal rent. We would like to create an awareness that airway trauma can lead to pneumothorax with subcutaneous emphysema in a pregnant patient due to fragile oedematous airway mucosa. We, therefore, reemphasise the importance of gentle laryngoscopy and intubation, maintenance of cuff pressure, administration of anti-emetics, smooth reversal, extubation and care of ETT while shifting the patient. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

The effectiveness of an endotracheal tube holder

The security of the endotracheal tube (ETT) is important in the anesthesia and intensive care settings. Recently, an ETT holder instead of an adhesive tape is frequently used to provide the fixation of the ETT. There are some studies that focused on the effectiveness of the ETT holder in preventing displacement of ETT compared to an adhesive tape (1, 2). I have experienced the use of an ETT holder (E-holder, KS medical, Bucheon, Korea) in many different anesthesia settings and recognized its usefulness and convenience other than ETT security in the following specific settings. Firstly, the ETT holder is definitely effective for patients undergoing procedures that frequently require the adjustment of ETT (or double lumen tube) location including thoracic surgery. The location of double lumen tube needed for lung separation can be modified for effective ventilation during anesthetic induction or surgery, and after position changes. The tube can be easily relocated to the proper place for lung separation and effective ventilation by unlocking/relocking the button of the ETT holder under flexible bronchoscopic guidance (Fig. 1A), which can facilitate the operative procedure to be performed easily and quickly. Secondly, the ETT holder can be useful in procedures requiring the prone position (3). Especially, it is useful in all circumstances requiring the adjustment of ETT in the prone position. For instance, it is definitely useful for patients with Duchene muscular dystrophy undergoing scoliosis surgery under prone position. Adolescent patients with Duchene muscular dystrophy frequently have tracheobronchial malacia. If so, the airway pressure can be elevated due to the narrowing of the lesion of malacia when changed to the prone position (4). To overcome this problem, a reinforced ETT should be relocated so that it passes the narrowed tracheal lesion under flexible bronchoscopic guidance (Fig. 1B). However, the approach for this management is somewhat challenging with the patient in the prone position, and especially, the release and refixation of ETT with an adhesive tape is very difficult. The ETT can be easily relocated to the proper place to overcome the narrowing part of trachea by unlocking/relocking the button of the ETT holder, which can prevent the risk of respiratory complications associated with ventilatory difficulty and secure the safety of patients. Thirdly, the ETT holder is effective in keeping the ETT in a midline position. This is especially so when a flexible laryngeal mask airway (Flexible LMATM, Wooyoung meditech, Seoul, Korea; FLMA) is used because maintaining a midline position of LMA is very important in securing ventilation without leakage (Fig. 1C, 1D). Although an adhesive tape without a bite block or oral airway may enable an FLMA to be kept in a midline position, there is still a risk of airway obstruction associated with the patient biting an FLMA. Moreover, considering that an FLMA displays a tendency to be pushed out from the pharyngolaryngeal region if it is positioned so that only a low grade sealing is achieved, a tight fixation of the FLMA using the ETT holder is very important. I suggest that the ETT holder can enhance the convenience of anesthesiologists while providing more useful anesthetic management to patients in the above anesthesia settings.

Analysis of the incidence of postintubation injuries in patients intubated in the prehospital or early hospital conditions of the hospital emergency department and the intensive care unit.

BackgroundIntubation is still one of the best methods to secure the airway. In the case of prehospital or early hospital conditions when factors such as urgency, stress, or inaccuracy of the undertaken activities are involved, the risk of causing complications, for instance, edema or postintubation injuries, increases, especially while dealing with a difficult intubation. The risk of improper inflation of the endotracheal tube cuff also increases, which is considered in this study.ObjectiveThe aim of this study was to evaluate the prevalence of postintubation complications, such as postintubation injuries or edema, in a research sample, and to examine whether such complications occur more often, for example, while using a guidewire. In this study, we also evaluated the injuries associated with the inflation of the endotracheal tube cuff.Materials and methodsThis study was performed on a group of 153 patients intubated in prehospital conditions. The tests were carried out in three clinical sites that received patients from prehospital care. Postintubation injuries were revealed and photographed using videolar-yngoscope, such as the C-MAC and the McGrath series 5. The endotracheal tube cuff pressure was measured using a pressure gage manual (VBM Medizintechnik GmbH). The quantitative analyses of differences between incidence of variables were assessed using χ2 test for P<0.05. Analyses have been carried out using the Statistica software.ResultsIn the group of 153 patients, postintubation injuries occurred in 17% of cases. The dependency between using the guidewire and the occurrence of the hematomas and loss of mucosa was statistically significant (P<0.01). In nearly half (42%) of the patients the endotracheal tube cuff pressure was excessively inflated over 30 cm H2O, and in two cases, endotracheal tube displacement was observed on account of poor cuff inflation (<20 cm H2O).ConclusionThe highest percentage of overfilled cuffs were observed in the admission room. In the other wards, it was observed in 25% of cases. Even though only six cases of poor cuff inflation were noticed, the relationship between the leakage and the clinical conditions of patients is worth examining. The results would help in taking additional measures to reduce the risk of complications.

Endotracheal tube positioning during neck extension in thyroidectomy.

To evaluate the effect of body mass index and neck length on endotracheal tube movement during neck extension in thyroidectomy. A prospective study was conducted of 30 patients undergoing thyroidectomy during an 8-month period. Patient characteristics were recorded and endotracheal tube displacement was determined. Mean body mass index was 27.8 kg/m2 (range, 17.5-34.7 kg/m2) and mean neck circumference was 43.2 cm (range, 28-56 cm). The mean (± standard deviation) upward displacement of the endotracheal tube during neck extension was 7.17 ± 5.87 mm. Patients with a larger body mass index had a significantly greater amount of tube displacement (R2 = 0.67, p < 0.0001), as did patients with a smaller neck length (R2 = 0.48, p < 0.0001). Neck extension results in upward displacement of the endotracheal tube. The amount of displacement is significantly higher in patients with a larger body mass index or shorter neck length. This has particular relevance for nerve monitoring in thyroidectomy.

Feasibility of MDCT for Predicting Left Double Lumen Endotracheal Tube Displacement during Supine to Lateral Repositioning of Patients

Feasibility of MDCT for Predicting Left Double Lumen Endotracheal Tube Displacement during Supine to Lateral Repositioning of Patients

Shifts in Endotracheal Tube Position Due to Chest Compressions: A Simulation Comparison by Fixation Method

BackgroundEndotracheal tube placement during resuscitation is important for definite tracheal protection. Accidental extubation due to endotracheal tube displacement is a rare event that can result in severe complications. ObjectiveThis study evaluated how endotracheal tube displacement is affected by tape vs. tube holder fixation using a manikin and auto-chest compression machine simulation. MethodsThe endotracheal tube was placed in either a shallow or a deep position, with the tube cuff at the center of the glottis or 26 cm from the incisors in an advanced lifesaving simulator. Trials were performed five times in each setting with: no fixation; Durapore® tape fixation; Multipore® tape fixation; and Thomas tube holder® fixation. After 10 min of automated chest compressions, endotracheal tube shift was measured. Statistical analysis was performed with one-way repeated analysis of variance or χ2 test, with p < 0.05 considered significant. ResultsIn the shallow setting, endotracheal tube extubation occurred in all trials with no fixation, Durapore, and Multipore. In contrast, no extubation occurred in the Tube holder trials (p < 0.05). In the deep setting, no extubation was confirmed in any trial. Relative to no fixation (0.56 ± 0.11 cm), endotracheal tube shift was significantly less in the Durapore tape, Multipore tape, and Tube holder groups (p < 0.05). Of the three fixation methods, Tube holder (0.04 ± 0.05 cm) showed significantly less shift (p < 0.05) relative to Durapore (0.28 ± 0.04 cm) and Multipore (0.32 ± 0.08 cm). ConclusionEndotracheal tube displacement occurs less with Tube holder fixation than with Durapore tape or Multipore tape during simulation of continuous chest compressions.