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.
- 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.
- Immediately investigate changes in ventilator
function or difficulties in inserting an aspirating catheter to determine if
they are caused by a displaced tracheal tube.
- 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.
- 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.
- 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
- 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.
- Ripoll I, Lindholm CE, Carroll R, et al.
Spontaneous dislocation of endotracheal tubes. Anesthesiology
Tubes, Tracheal [14-085]
Cause of Device-Related Incident
Device factor: Design/labeling error
User error: Incorrect clinical use
Mechanism of Injury or
Monitoring failure; Suffocation