Tongue flap: a challenge to the anesthesiologist

Sir, We report on a case of difficulty in extubating a patient due to failure of cuff deflation on an endotracheal (ET) tube (SHERIDAN CF s Endotracheal Tube, Hudson RCI, Durham, NC) caused by kinking and flattening of the pilot balloon tubing by the tube tie. A 77-year-old man underwent an elective extended right hemicolectomy for Dukes Stage C cancer of the colon. Induction and intubation with a size 9, cuffed oral ET tube, tied at 22 cm at the lips, were uneventful. Following surgery, he was transferred to critical care. At planned extubation, aspiration of air deflated the pilot balloon but there was resistance to ET tube removal. While considering what course of action to take, the patient extubated himself with the cuff fully inflated. Supplemental oxygen was given via a facemask. He complained of a mild sore throat, was not dysphonic, and was transferred to the ward that day. Examination of the ET tube revealed that the tie had been firmly fixed at the level where the pilot balloon tubing enters the main body of the ET tube. It was folded back along the tube, badly kinking it and squashing the lumen flat. Persisting luminal flattening made cuff deflation impossible even after tube tie release and straightening (Fig. 1). Pilot tube and cuff problems are frequent reasons cited for patients requiring re-intubation in critical care (1); leaks are many times more common than inability to deflate the cuff (2). Extubation with the cuff inflated is undesirable due to potential laryngeal trauma including vocal cord oedema and dislocation of the arytenoid cartilage. Difficulty in removing air from a cuff can be due to problems with the valve, as reported in a tracheostomy tube, or damage to the tubing connecting the pilot balloon to the cuff (3–7). Prevention includes recognition that damage can be caused to the pilot balloon tubing. In this case, tubing was damaged both by kinking and flattening of the lumen. Previous recommendations to avoid tying the tubing back on itself appear sound. If the level of the tie is close to where the tubing exits the ET tube, it may be better to include it within the tie but this case suggests that obstruction through luminal flattening may be caused by this method. Whether a difference exists between ET tubes from different manufacturers is not known. If sufficient concern exists, a clamp rather than a tie could be used. Resolution of the problem if it does occur includes cutting the pilot balloon tubing distal to the point of obstruction or puncture of the cuff via laryngoscopy, fibreoptic bronchoscopy or a cricothyroid approach (8).