A rare case of endotracheal tube cuff leakage with no detectable decrease in cuff pressure

Keiichi Nagasawa; Masayuki Nishibata; Sarah Kyuragi Luthe; Tomoyuki Kawamata

doi:10.1186/s40981-024-00754-9

A rare case of endotracheal tube cuff leakage with no detectable decrease in cuff pressure

JA Clin Rep. 2024 Nov 12;10(1):71. doi: 10.1186/s40981-024-00754-9.

Authors

Keiichi Nagasawa¹, Masayuki Nishibata², Sarah Kyuragi Luthe¹, Tomoyuki Kawamata¹

Affiliations

¹ Department of Anesthesiology, Wakayama Medical University School of Medicine, Wakayama, 641-8510, Japan.
² Department of Anesthesiology, Wakayama Medical University School of Medicine, Wakayama, 641-8510, Japan. masapai@wakayama-med.ac.jp.

Abstract

Background: Common causes of air leakage around an endotracheal tube include insufficient endotracheal tube cuff inflation and damage to the cuff, while damage to the pilot balloon or pilot balloon tubing is relatively rare.

Case presentation: A 74-year-old female with vertebral osteomyelitis was scheduled for an extreme lateral interbody fusion followed posterior fixation. A fiber-optic light was utilized as part of the surgical illuminator. A sudden decrease in tidal volume and airway pressure was noted intraoperatively. We suspected leakage around the endotracheal tube cuff; however, no decrease in cuff pressure was detected. Despite the normal cuff pressure, we decided to inject a small amount of air which led to a significant increase in the cuff pressure. Upon careful inspection of the endotracheal tube, we discovered that the pilot balloon tubing was damaged as a result of thermal energy emitted by the fiber-optic light, which had ignited the surgical drape. The pilot balloon tubing was partially severed in which the section proximal to the endotracheal tube cuff was burned and punctured, causing the cuff leak. Meanwhile, the section proximal to the pilot balloon had melted and occluded the lumen, resulting in a falsely normal cuff pressure reading followed by an elevated cuff pressure when a small amount of air was injected into the pilot balloon during troubleshooting. Appropriate ventilation was resumed after extubation and re-intubation with a new endotracheal tube.

Conclusions: We experienced an endotracheal tube cuff leakage caused by a damaged pilot balloon tubing due to thermal energy of the fiber-optic light. Our case report emphasizes the importance of suspecting damage to the endotracheal tube cuff and inflation system despite a normal cuff pressure reading, given that the measurement may be falsely elevated depending on the specific location of the damage. In addition, all operating personnel should be familiarized with safety warnings and cautions related to handling.

Keywords: Cuff leak; Endotracheal tube; Fiber-optic light; Ignition source; Pilot balloon tubing; Surgical fire.