The ETT is STUCK!!

[DreamMachine]

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[Quizzical]

deflate the cuff

 

[Planktonmd]

I have never seen this!
I am assuming there is no kinks in the tube since she is breathing comfortably.
So all I can think of is dry secretions around the tube gluing it to the airway.
I would just lavage with normal saline in the mouth and the pharynx then pull more!

Disclaimer: This case is not all that exciting, but it happened to us this week. I never saw this happen before. I just want to hear if anyone has any additional thoughts.




The SICU nurse calls you and states that "We have a patient here that is ready for extubation, but the respiratory therapist is unable to pull the ETT out. Can you please come here and give us a hand?"

You go to the ICU. You review the patient's chart.

The patient is 65 yo, S/P AAA repair POD#5. Her PMHx includes the typical, CAD/PVD/DM/HTN. You call your partner who was there for the initial intubation. He states the ETT went in easy and she was an easy intubation. The patient is awake, breathing well, and strong. She is not on any drips. No signs of edema on physical exam. She is clearly ready for the ETT to be removed. She weighs 65 kg and the ETT is a 7.5mm. No leak with the cuff down.

You try to pull the tube, but its stuck. You try twisting it, but that doesn't help.

What would you do next?

 

[deleted126335]

Disclaimer: This case is not all that exciting, but it happened to us this week. I never saw this happen before. I just want to hear if anyone has any additional thoughts.




The SICU nurse calls you and states that "We have a patient here that is ready for extubation, but the respiratory therapist is unable to pull the ETT out. Can you please come here and give us a hand?"

You go to the ICU. You review the patient's chart.

The patient is 65 yo, S/P AAA repair POD#5. Her PMHx includes the typical, CAD/PVD/DM/HTN. You call your partner who was there for the initial intubation. He states the ETT went in easy and she was an easy intubation. The patient is awake, breathing well, and strong. She is not on any drips. No signs of edema on physical exam. She is clearly ready for the ETT to be removed. She weighs 65 kg and the ETT is a 7.5mm. No leak with the cuff down.

You try to pull the tube, but its stuck. You try twisting it, but that doesn't help.

What would you do next?

Does the patient have an n/g tube? The n/g could be knotted around the ETT. Seen that once.

 

[dhb]

Why was she still intubated on POD 5?

 

[countingdays]

Her post-op course was more complicated than I revealed. She was brought back to the OR once. At the time of extubation, however, she looked good to go.

Is this going to turn into a subglottic stenosis case?

Am I missing something or does it sound risky to pull a tube when the swelling is so bad that someone who is at the gym 7 days a week like Dream can't pull it out?

 

[seinfeld]

Our CRNAs use 7.5 ETT in females. In residency, I typically used a 7.0 ETT. Of course, you have to look at the patient you have in front of you. But from now on, I will make sure to think twice before allowing a 7.5 ETT in a female. Prior to this, I didn't think it was a big deal.

I would urge caution in this statement. I have too often been faced with a patient requiring a Bronch post op but the initial intubation was <7.5 ETT and had to do a tube exchange in order to bronch.

Having never heard of a tube getting stuck, i would guess its much more frequent to need a bronch.

My general approach is for Outpts or cases with very little risk of postop intubation i use a 7.0, but for any major abdominal, major vascular or emergency surgery they all get 7.5 or larger. Obviously if it doesnt fit , it doesnt fit.

 

[seinfeld]

thanks for the avatar lets see if i can figure out how to do it

 

[deleted21609]

Obvious future peds anesthesiologist is obvious. 😉

At least he skipped the joke about your inability to pull it out! 😉

 

[poresofkohn]

Disclaimer: This case is not all that exciting, but it happened to us this week. I never saw this happen before. I just want to hear if anyone has any additional thoughts.




The SICU nurse calls you and states that "We have a patient here that is ready for extubation, but the respiratory therapist is unable to pull the ETT out. Can you please come here and give us a hand?"

You go to the ICU. You review the patient's chart.

The patient is 65 yo, S/P AAA repair POD#5. Her PMHx includes the typical, CAD/PVD/DM/HTN. You call your partner who was there for the initial intubation. He states the ETT went in easy and she was an easy intubation. The patient is awake, breathing well, and strong. She is not on any drips. No signs of edema on physical exam. She is clearly ready for the ETT to be removed. She weighs 65 kg and the ETT is a 7.5mm. No leak with the cuff down.

You try to pull the tube, but its stuck. You try twisting it, but that doesn't help.

What would you do next?

>
Bingo, Bango.
Perhaps the tube didn't go in as easy as you were led to believe?

 

[proman]

>
Bingo, Bango.
Perhaps the tube didn't go in as easy as you were led to believe?

The airway changes a lot after a week of having a piece of plastic stuck to it. A 7.5 ET tube should fit the vast majority of women out there. Outer diameters of ET tubes vary based on manufacturer. A 7.5mm ID correlates to a 30F outer, or about 10mm. Even a small 35F double lumen (which also fits the vast majority of women) is 12-13mm outer diameter.

I'm more curious as to what part of the tube was stuck. I'd imagine it was the cuff that was adherent, and maybe a sign of tracheal mucosal injury from ischemia.

 

[poresofkohn]

The airway changes a lot after a week of having a piece of plastic stuck to it. A 7.5 ET tube should fit the vast majority of women out there. Outer diameters of ET tubes vary based on manufacturer. A 7.5mm ID correlates to a 30F outer, or about 10mm. Even a small 35F double lumen (which also fits the vast majority of women) is 12-13mm outer diameter.

I'm more curious as to what part of the tube was stuck. I'd imagine it was the cuff that was adherent, and maybe a sign of tracheal mucosal injury from ischemia.

>
Interesting, I didn't know that. (Bolded)
I also didn't see it was POD 5 until just now. Cuff pressures are usually documented with each "vent check" typically Q2H, I wonder what hers were.

 

[coprolalia]

>
Interesting, I didn't know that. (Bolded)
I also didn't see it was POD 5 until just now. Cuff pressures are usually documented with each "vent check" typically Q2H, I wonder what hers were.

Of course you didn't know that. Why would anyone expect you to know that?

I had a similar situation, suprisingly, fairly recently and was called to our cardiac unit. The patient was awake and had a Hi-Lo EVAC tube in, 8.0. They'd already tried to extubate, but couldn't and "wanted anesthesia present" in case they lost the airway.

I got there and, basically, said, "Hang on a second."

We got the bronch cart, took a look, and naturally there was a lot of biofilm inside the internal lumen of the tube. After lavaging a few times (the patient was given a little midaz/fent while we did this), it appeared that the subglottic portion of the ETT was "gummed up" (for lack of a better term) just inferior to the glottic aperture, from what we could see through the tube.

There was no cuff leak, but this was a "**** or get off the pot" situation (i.e., the guy was otherwise 100% ready to be separated from mechanical ventilation and didn't necessarily need a trach, which was what the thought process was among the other services consulted).

So, I say, "Is the guy okay to have steroids?" I get yes as the response.

I say, "Give him 4mg of Decadron x 6 doses. Keep him sedated. I'll come back this time tomorrow."

Next day, get the bedside trach stuff ready. Grab me a well-lubbed 7.0 and 6.5 ETT tube, just a regular Hi-Lo. Keep the bronch cart handy. Still no cuff leak.

I sedate the guy again with 1mg of midazolam, spray the back of his throat with cetacaine, and do a DL with the Glidescope. Grade 1 view. Can see the tube going nicely straight trough the aperture.

At this point, I take some lidocaine on a long syringe nebulizer, and spray it around the cords and in the retropharynx. We drop the cuff. No leak still. But, I gently rock the tube in-and-out - with the Glidescope still in place. The guy is uncomfortable and pretty much awake, but able to tolerate this. In this case, it still felt tight and everyone could see on the Glidescope sceen the glottis rocking back and forth.

I pull the tube.

Yes, it required some force. Next, I rapidly remove the Glidescope. We immediately put him on a aerosolized face mask at 50% FiO2. He coughs a few times. That damn tube was so gummed up with secretions, both inside and out. Completely disgusting.

No blood. No airway compromise. They guy flew like a 747. People are STILL talking about it around the hospital.

I'm going to write this up as a case report. If it gets published and you guys read it somewhere, I've just outed myself on this forum. So be it. This was one of the coolest friggin' things I've done so far as a doctor.

-copro

 

[Arch Guillotti]

They guy flew like a 747. People are STILL talking about it around the hospital.

I'm going to write this up as a case report. If it gets published and you guys read it somewhere, I've just outed myself on this forum. So be it. This was one of the coolest friggin' things I've done so far as a doctor.

-copro

What are they talking about? How you are going to write a case report on how you turned a straightforward situation into a complictaed one?😀

 

[coprolalia]

What are they talking about? How you are going to write a case report on how you turned a straightforward situation into a complictaed one?😀

The tube was stuck. The guy was going to (potentially) get unsafely extubated. I might've saved him a trach.

I dunno. Everyone at my hospital thinks it was a pretty studly plan, and it worked out well. Maybe not case-report material and, yeah, I'm not terribly motivated to write it up anyway. Maybe if I had a student or a resident...

-copro

 

[Bertelman]

What are they talking about? How you are going to write a case report on how you turned a straightforward situation into a complictaed one?😀

^1

Bet they never ask copro back for extubation unless they want it done the next day.

 

[coprolalia]

^1

Bet they never ask copro back for extubation unless they want it done the next day.

I hope so! 👍

-copro

 

[Arch Guillotti]

The tube was stuck. The guy was going to (potentially) get unsafely extubated. I might've saved him a trach.

I dunno. Everyone at my hospital thinks it was a pretty studly plan, and it worked out well. Maybe not case-report material and, yeah, I'm not terribly motivated to write it up anyway. Maybe if I had a student or a resident...

-copro

OK. So this patient was going to get a trach because his ETT was stuck. Once he got the trach what was going to happen to the ETT?

 

[IceDoc]

I'm more curious as to what part of the tube was stuck. I'd imagine it was the cuff that was adherent, and maybe a sign of tracheal mucosal injury from ischemia.

Not seen with my own eyes, but I heard this first hand from the person who did this. He removed a cuffed Shiley from the tracheostomy site. However, the Shiley did not have a cuff attached to it when he removed it; and it clearly had been a cuffed one. Basically the cuff had adhered to the trachea, and the cuff had failed and became detached from the airway. I think it worked out OK, but losing a floppy piece of plastic inside a trachea is not my idea of fun.

 

[poresofkohn]

Of course you didn't know that. Why would anyone expect you to know that?

I had a similar situation, suprisingly, fairly recently and was called to our cardiac unit. The patient was awake and had a Hi-Lo EVAC tube in, 8.0. They'd already tried to extubate, but couldn't and "wanted anesthesia present" in case they lost the airway.

I got there and, basically, said, "Hang on a second."

We got the bronch cart, took a look, and naturally there was a lot of biofilm inside the internal lumen of the tube. After lavaging a few times (the patient was given a little midaz/fent while we did this), it appeared that the subglottic portion of the ETT was "gummed up" (for lack of a better term) just inferior to the glottic aperture, from what we could see through the tube.

There was no cuff leak, but this was a "**** or get off the pot" situation (i.e., the guy was otherwise 100% ready to be separated from mechanical ventilation and didn't necessarily need a trach, which was what the thought process was among the other services consulted).

So, I say, "Is the guy okay to have steroids?" I get yes as the response.

I say, "Give him 4mg of Decadron x 6 doses. Keep him sedated. I'll come back this time tomorrow."

Next day, get the bedside trach stuff ready. Grab me a well-lubbed 7.0 and 6.5 ETT tube, just a regular Hi-Lo. Keep the bronch cart handy. Still no cuff leak.

I sedate the guy again with 1mg of midazolam, spray the back of his throat with cetacaine, and do a DL with the Glidescope. Grade 1 view. Can see the tube going nicely straight trough the aperture.

At this point, I take some lidocaine on a long syringe nebulizer, and spray it around the cords and in the retropharynx. We drop the cuff. No leak still. But, I gently rock the tube in-and-out - with the Glidescope still in place. The guy is uncomfortable and pretty much awake, but able to tolerate this. In this case, it still felt tight and everyone could see on the Glidescope sceen the glottis rocking back and forth.

I pull the tube.

Yes, it required some force. Next, I rapidly remove the Glidescope. We immediately put him on a aerosolized face mask at 50% FiO2. He coughs a few times. That damn tube was so gummed up with secretions, both inside and out. Completely disgusting.

No blood. No airway compromise. They guy flew like a 747. People are STILL talking about it around the hospital.

I'm going to write this up as a case report. If it gets published and you guys read it somewhere, I've just outed myself on this forum. So be it. This was one of the coolest friggin' things I've done so far as a doctor.

-copro

>
I'm not sure whether or not anyone expected me to know that or not. What makes you so sure of what other people know or don't know? O....thats right, its your huge inflated ego. Unlike you, I don't have some raging insecurity that forces me to try and convince those around me that I know everything about everything, like you do even when you havent a clue. I'm perfectly willing to acknowledge my limitations (esp. as a practitioner) and work to broaden them. I hope santa brings you a big piece of humble pie this year, because outside of the OR, you aint s**t buddy. BTW - those kids callin' you daddy yet?