Intraoperative Management of a Severely Kinked Endotracheal Tube and Difficult Airway

This figure is a lateral cervical radiograph of a nasally intubated 16-yr-old patient with Crouzon syndrome obtained after completion of cranial fossa surgery for Chiari malformation and returning to supine from a prone position. The standard endotracheal tube was severely kinked in the nasopharynx, as shown in the image, and the location of the kinking is indicated with a red arrow. This was likely caused by the warming of the endotracheal tube and the patient’s unique pharyngeal anatomy. The tracheal intubation of the patient was difficult, requiring 11 attempts due to midface hypoplasia, obesity, macroglossia, and cervical spine instability. After the start of surgery, elevated airway pressures and the inability to pass a suction catheter suggested kinking of the endotracheal tube. Due to extremely difficult intubation, endotracheal tube replacement was not attempted. Because the severely kinked endotracheal tube limited inspiratory and expiratory airflow, adequate tidal volume was achieved by increasing peak inspiratory pressure.¹  Intermittent measurement of plateau pressure with an expiratory hold yielded additional information about the pressure at the alveoli. Because expiration was passive, increasing the expiratory time facilitated exhalation and reduced the risk of breath stacking.²  A helium–oxygen mixture can also be used to improve ventilation by reducing gas density, increasing the likelihood of maintaining laminar flow across the point of obstruction, and improving bulk flow.³  If the patient can tolerate permissive hypercapnia, a reduction in minute ventilation is also an option to minimize turbulent flow. The use of a wire-reinforced tube is often recommended to prevent endotracheal tube kinking in such a patient.