A Case in Which the Inflation Line Was Not Closed at the Tip of the Endotracheal Tube

Abstract

  We report a rare case in which the inflation line was not closed at the tip of the endotracheal tube, allowing the cuff to deflate. The patient was an 18-year-old male with Down syndrome who was scheduled to receive dental treatments under general anesthesia with nasotracheal intubation. Anesthesia was slowly induced, and an ivory PVC endotracheal tube with a soft-seal cuff (inner diameter, 5.5 mm ; Smith Medical Japan Inc., Tokyo, Japan) was inserted nasally into the trachea and fixed at a point 23 cm from the nostril opening ; the cuff volume was 5 mL. At this time, we observed that the pilot balloon was deflated and contained a droplet. The cuff had been inspected and was thought to have been normal prior to anesthesia induction. The tube was removed, and another nasotracheal tube was inserted into the trachea, after which successful anesthesia was achieved. When the cuff of the removed endotracheal tube was immersed in water, bubbles were discharged from the tip of the endotracheal tube when the cuff was expanded to some extent (Fig. 1-A). The manufacturer investigated the device and confirmed that a hole was present in the inflation line at the tip of the endotracheal tube (Fig. 1-B, C). An inflation line that is not closed at the tip of the endotracheal tube is a very rare event (Fig. 2, 3). When checking cuffs prior to use, an experienced anesthesiologist should inject air into the cuff until it is sufficiently inflated and then observe the cuff for a short period of time to ensure proper functioning.