Cause of Device-Related Incident
Device factors; User errors

Clinical Specialty or Hospital Department
Anesthesia; CCU / ICU / NICU; Emergency Medicine; Nursing; OR / Surgery; Pulmonary / Respiratory Therapy

Device Factors
Design / labeling error

Document Type
Hazard Reports

External Factors
*Not stated

Mechanism of Injury or Death
Monitoring failure; Suffocation

Support System Failures
*Not stated

Tampering and/or Sabotage
*Not stated

User Errors
*Not stated; Incorrect clinical use

Tubes, Tracheal [14-085]

Tracheal Tube Kinking

Hazard [Health Devices Sep 1978;7(11):292-3]


Since our hazard report on kinking of flexible tracheal tubes (Health Devices, Vol. 6, p. 126), we have received two more reports of incidents with a specific brand of cuffed tracheal tubes. Ripoll et al. published another report detailing this problem.(1) These subsequent reports reinforce our original recommendations for users who wish to take advantage of the flexibility of these and other tubes.

A member hospital reported that a patient extubated his tracheal tube so that it was coiled in his mouth as he was being rolled onto his side for bathing. Whether those manipulations or a cough previous to rolling generated the necessary force for extubation is unknown. The patient was not heavily sedated, his arms were restrained, and he had also been using his tongue to push on his tracheal tube. This tonguing may have contributed to extubation. High insufflation pressures were not used.


The extubations reported by Ripoll et al. had results similar to the first report but may have been caused by higher inspiratory pressures. Complications followed one extubation that resulted in the tube tip's lodging in the esophagus.

The second incident reported to ECRI involved a neurosurgical patient who was anesthetized and intubated in the supine position. After the tube was placed in a satisfactory position and secured, the patient was gradually placed in a sitting position with flexed neck. A lateral cervical radiograph had just been taken when the anesthetist reported inability to ventilate the patient. Cuff deflation and return to the supine position failed to eliminate the problem, so the tracheal tube was removed and intubation was repeated with a spiral reinforced tube.

Although such incidents are infrequent, they can be hazardous. To help prevent them, we repeat below our original recommendations with a few modifications.


  1. If you use a flexible tracheal tube, x-ray it at least daily after intubation to ensure that the tip has not slowly displaced upward away from the carina and started to kink the tube.
  2. Immediately investigate changes in ventilator function or difficulties in inserting an aspirating catheter to determine if they are caused by a displaced tracheal tube.
  3. Watch for visual signs of a leaking airway during manipulations that flex or hyperextend the neck. They may indicate a dislodged tracheal tube. If heavy sedation or neck restraint is not warranted and the patient appears agitated, watch more closely.
  4. Alternatively, if you cannot devote the necessary attention to tube positioning, use a nasotracheal or stiffer oral tracheal tube that requires greater force to kink. Keep in mind, however, that nasotracheal tubes introduce new problems in that they are more difficult to insert, more irritating, and narrower than orally inserted units. Also, currently available stiffer tracheal tubes are more likely than soft types to cause mucosal trauma.
  5. Check and record the last visible number on the tube, indicating tube length from the tip, before taping it, so that any repositioning or reintubation will result in the correct tube position (assuming that care is taken to keep the number visible and not cover it with tape).
  6. Monitor the cuff pressure and maintain it at the manufacturer's recommended level or at the generally recommended level of 25 mm Hg or less. Unexpected changes may indicate migration of the tube into another area of the trachea or into the larynx.


  1. Ripoll I, Lindholm CE, Carroll R, et al. Spontaneous dislocation of endotracheal tubes. Anesthesiology 1978;49:50-2.


Tubes, Tracheal [14-085]

Cause of Device-Related Incident

Device factor: Design/labeling error

User error: Incorrect clinical use

Mechanism of Injury or Death

Monitoring failure; Suffocation

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