A Case in Which the Hole in the Inflation Line Was Not Closed at the Tip of the Tracheal Tube.

Abstract

We report a rare case in which the inflation lumen at the tip of an endotracheal tube (ETT) was open, leading to intraoperative air leakage and cuff deflation. A patient with Down syndrome undergoing planned dental treatment under general anesthesia was induced and nasally intubated with a cuffed ETT that was then inflated with 5 mL of air. Soon thereafter, it was noted that the pilot balloon was deflated and filled with water droplets. The patient was successfully reintubated with a new, replacement ETT. Upon removal, we examined the defective ETT and sent it onward to the manufacturer. Upon further assessment, the manufacturer reported that the inflation lumen was not properly closed during the manufacturing process because of damage that went undetected. Anesthesia providers should assess an ETT for damage prior to use, including ensuring the cuff is functioning properly.