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LETTER TO EDITOR
Year : 2021 | Volume
: 37
| Issue : 2 | Page : 305-307
Edentulous patient and intraoperative endotracheal tube migration
Priya Rudingwa, C Madhanmohan
Department of Anaesthesiology and Critical Care, JIPMER, Puducherry, India
Correspondence Address:
Dr. C Madhanmohan
SF-2, Swarna Maliga Apartment, N0-1 Saradambal Nagar, Puducherry - 605 005
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/joacp.JOACP_280_18
Edentulous patients are known candidates for difficult mask ventilation due to lack of fat pad which prevents adequate seal;[1] besides this, absence of dentition deprives a firm surface for endotracheal tube fixation. This may result in further distal migration of the tube with a change of patient position causing endobronchial intubation. In female patients and in those with short stature these misplacement chances are increased further. In such cases, the presence of bronchial blockers inside the tube can cause its advancement further into the tracheobronchial tree, resulting in injury and ventilation problems. We describe a case where a similar problem was encountered with the endotracheal tube.
A 62-year-old female with carcinoma esophagus was scheduled to undergo thoracoscopic esophagectomy. She weighed 50 kg and had a height of 152 cm. She was fully edentulous and had no comorbidities. After securing trachea with a 7.5 mm internal diameter (ID) endotracheal tube (ETT) tube it was fixed at 19 cm and bilateral air entry was confirmed. Under fiberoptic bronchoscope (FOB) guidance tube was withdrawn and fixed at 18 cm with an elastic adhesive on both mandible and maxilla as the bevel was near to carina. A Coop Dech bronchial blocker was positioned in the right main bronchus and the cuff was inflated and fixed at the slot in the adapter at the machine end. After confirming the lack of air entry on the right side the cuff was deflated and the patient positioned in the left lateral position with the neck in neutral position. After confirmation of equal air entry, the anesthesia circuit was disconnected to enable lung deflation. The blocker cuff was inflated and circuit reconnected to the orotracheal tube and 100% oxygen was supplemented. The tidal volume was reduced to 6 ml/kg for one-lung ventilation (OLV) and with this 2–3 cm increase in airway pressure was noted. This was assumed to be due to a reduction in the ventilated lung volume post initiation of OLV. Once the thoracoscopic port was inserted the lung was not collapsed and on the application of suction to the lumen of bronchial blocker, the measured expired tidal volume showed reduction but without any collapse of the right lung. Migration of blocker into trachea was suspected and flexible bronchoscope was inserted which showed that the blue cuff was inside the bronchus. The surgeon had difficulty in exposure and thus insufflated CO2 but still, the lung collapse was inadequate. At this point, another opinion was sought for the inability to isolate the lung. On repeat fiberoptic evaluation, it was found that the tube had migrated into the right bronchus and the blocker was in one of the branches of bronchus intermedius.
The bronchial blocker cuff was deflated and the tube was withdrawn till three tracheal rings were visible and refixed at length of 18 cm at lips along with a Guedels airway [Figure 1]. The blocker was positioned in right bronchus and cuff inflated. The blocker lumen was suctioned and right lung could be fully collapsed with improvement in airway pressures. There was no misplacement of blocker throughout the procedure and the operating field was also satisfactory. The trachea was extubated next day in view of prolonged procedure and postoperative course was uneventful.
Figure 1: Fixation of the oral endotracheal tube along with a Guedels oropharyngeal airway to prevent migrationWith an increase in lifespan, we are more likely to encounter an edentulous patient in the day to day practice. From anesthetists' perspective, difficult mask ventilation is a known concern and measures are taken beforehand to manage it. Various modalities like oral airway, gauzes, nasal masks, and dentures have been used to make a good seal with the mask.[2] But once the airway is secured not much attention is paid to the position of the endotracheal tube. Asian population especially females with short height or with short neck are at higher risk for distal migration of tube as the presence of cuff prevents migration toward glottis. Varshney et al. in a study involving Indian population found that the mean tube tip to carina distance in cm was 2.28 (1.55) and 3.69 (1.65) in females versus males respectively with tube fixed at 20.67 and 19.35 cm at lip.[3] This distance was much shorter than the recommended distance of 3 cm from Carina, thus increasing chances of endobronchial migration.[4]
The absence of cheek fat pad, teeth, and alveolar tissue deprives firm support for the ETT fixation. The lax skin and tissue allow tube mobility. This problem might assume significance in laparoscopic surgeries, trendelenburg position and with bronchial blockers where the distal end of the tube reaches near to carina. The anticipation of this problem can help us to take measures like the placement of oral airway to fix the tube or even keeping patients dentures in place during the surgery to prevent the migration of tube, but these may cause airway obstruction intraoperatively or injury while laryngoscopy.[5]
In this case, due to lack of firm support to the ETT, its distal migration occurred with further movement of bronchial blocker into the upper lobe bronchus despite withdrawing the ETT prior to positioning thus preventing the collapse of the right lung. As blocker dislodgement into the trachea is more common with lateral positioning, with a resultant increase in airway pressure as seen in this case measures were taken toward that cause. Lack of suspicion toward tube endobronchial migration prevented troubleshooting in that direction. Only once FOB showed that blocker was in the position other causes were looked for persistent inflation of blocked lung.
In our case, the simple remedial measure of withdrawing the tube under FOB guidance followed by the fixing of the tube along with an oropharyngeal airway ensured excellent lung collapse throughout the procedure. With our experience, we wish to highlight another concern (besides difficult mask ventilation) with edentulous patients and how a simple measure can avoid problems intraoperatively. In addition, vigilant monitoring of the tube depth markers in edentulous patient is important to prevent its migration in the intraoperative period.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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