A CASE REPORT ON LEAKAGE THROUGH ENDOTRACHEAL TUBE DUE TO UNNOTICED MANUFACTURING DEFECT

Abstract

Leakage around an endotracheal tube is a common problem in the intensive care unit or operation theatres. A wide range of consequences can result if the leak is not properly managed. Tracheal re-intubation because of air leak after a successful tracheal intubation is quite common in practice

A 38-year-old female patient, ASA Grade I came to outpatient department with complaint of pain in right upper abdomen, vomiting since 2 months. Patient was thin built with weight of 48kg. All routine investigations were normal except haemoglobin which was 8g/dl. After two units PRBC transfusion patient was posted for elective laparoscopic cholecystectomy. After Pre-oxygenation and Premedication was done and 3 minutes of bag and mask ventilation, patient was successfully intubated with a 7 mm internal diameter endotracheal tube and secured at 21 cm on the ETT tube. A few minutes later while positioning the patient, an air leak was audible from the mouth.

 The structural defect leading to air leak may be there in a newly opened ETT or may be caused by repeated use of re-sterilised tube. Small cuts and holes on the convex surface of the ETT and near the entry point of the inflation tube usually go undetected by routine in vitro test. Anaesthesiologist should be aware of such conditions, after a diagnosis of exclusion, change of the tube should be done.