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 Table of Contents  
Year : 2021  |  Volume : 4  |  Issue : 2  |  Page : 139-140

External reinforcement of cuffed endotracheal tube to prevent kinking during prolonged head-and-neck surgery

Department of Anaesthesiology, Regional Cancer Centre, Trivandrum, Kerala, India

Date of Submission03-May-2021
Date of Acceptance26-May-2021
Date of Web Publication10-Aug-2021

Correspondence Address:
Dr. Divya V Gladston
Department of Anaesthesiology, Regional Cancer Centre, Trivandrum - 695 011, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/arwy.arwy_26_21

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How to cite this article:
Gladston DV, CN S, Amma RO, Koshy RC. External reinforcement of cuffed endotracheal tube to prevent kinking during prolonged head-and-neck surgery. Airway 2021;4:139-40

How to cite this URL:
Gladston DV, CN S, Amma RO, Koshy RC. External reinforcement of cuffed endotracheal tube to prevent kinking during prolonged head-and-neck surgery. Airway [serial online] 2021 [cited 2021 Dec 2];4:139-40. Available from: https://www.arwy.org/text.asp?2021/4/2/139/323572

Endotracheal tubes (ETTs) are made from polyvinyl chloride (PVC) and softened with a plasticiser called di-2-ethyl hexyl phthalate,[1] which makes them more flexible and easier to process by changing their mechanical properties. Head-and-neck surgeries are often associated with a difficult airway, and a nasotracheal route of intubation is usually preferred. Besides allowing the surgeon and anaesthesiologist to share the airway intraoperatively, the nasal route also allows the ETT to be retained following surgery to maintain a secure airway in the postoperative period. The ability to monitor the patency and position of ETT is limited as there is competition for space at the head end, which can result in accidental extubation.[2] Unexpected kinking of the ETT is a common problem encountered during the intraoperative period in head-and-neck surgeries and those requiring prone position,[2] resulting in raised airway pressures, inability to deliver proper tidal volume, carbon dioxide retention and haemodynamic instability. Anatomical variations, positional changes during surgery, small-sized ETT, pressure over the ETT by surgeon and thermal softening of ETT in the presence of a forced air warmer further contribute to kinking of ETT.[3] In our institution, we soften the ETT before nasal intubation by immersing in hot water to decrease trauma to nasal mucosa which further increases the chance of kinking.[4] As temperature increases, the mechanical integrity of the ETT decreases, making the ETT more susceptible to kinking. Emily performed a mechanical analysis of factors that predispose to kinking of ETTs.[5] A repeatable mechanical testing was done to determine the compression force and distance required to kink an ETT under different conditions. They found that ETT kinking occurs within 3 mm of compression distance and kinking is correlated to drops in the tidal volume as observed on the force versus distance curves.

Although flexometallic tubes or reinforced tubes are kink resistant,[6] one case of kinking of a reinforced tube was reported in an edentulous patient.[7] Due to their bulky design, reinforced tubes can traumatise the airway during nasal intubation, whereas Ring Adair Elwyn tubes can result in accidental extubation. Both these tubes are more expensive and are often not available in many hospitals. Various devices such as the Thomas tube holder are available to hold the ETT in position, minimise kinking and facilitate periodic visual inspection. Other management techniques include readjustment of the circuit support arm of the anaesthesia machine, needle cap placement,[8] reducing extra length of ETT by cutting few centimetres from the machine end, use of Berman intubating airway[9] or placement of cotton pads under the ETT.[6] Some of these preventive techniques are not universally accepted by surgeons who object to 'additional cumbersome equipment at the head end'. Yamashita and Motokawa described a technique to prevent kinking of a paediatric PVC ETT by reinforcing it externally with an additional bigger size tube.[10] Aqil and Al-Saeed suggested the use of ordinary paper tape at the point of potential ETT kinking.[6] Published data regarding on-table reinforcement of ETT with commonly available products are limited.

A simple, easy and cost-effective technique can be used to overcome these problems during the perioperative period. After intubation and securing the airway with an adhesive plaster, the mark at the nares where the tube should be fixed is noted. The exposed portion of the tube is reinforced with an adhesive elastic tape of 15 cm × 2 cm [Figure 1]. The adhesive elastic bandage is wound around the ETT, starting just proximal to the point of fixation and going up to the connection to the breathing circuit. The wrapping is done in a spiral manner with 20%–30% overlap between the layers. This technique does not add weight to the ETT nor does it cause any discomfort to the surgeons while performing head-and-neck surgeries as it does not interfere with their sphere of activity. A force acts along the wrapped ETT perpendicular to the fixation of ETT which prevents kinking. Kinking produced by airflow and thermal softening due to forced air warmer can be prevented by enhancing the strength of the flexible PVC ETT using this technique. Concerns regarding sterility of the wrap should also be taken into account as it comes within the operating field, especially in head-and-neck surgeries. A limitation of this technique is that only extraoral and extranasal kinking can be decreased, and it does not decrease the need for intraoperative vigilance.
Figure 1: Reinforcement of endotracheal tube using a 15 cm × 2 cm strip of adhesive elastic tape

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the forms, the patient has given his consent for images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Chiellini F, Ferri M, Latini G. Physical-chemical assessment of di-(2-ethylhexyl)-phthalate leakage from poly (vinyl chloride) endotracheal tubes after application in high risk newborns. Int J Pharm 2011;409:57-61.  Back to cited text no. 1
Hübler M, Petrasch F. Intraoperative kinking of polyvinyl endotracheal tubes. Anesth Analg 2006;103:1601-2.  Back to cited text no. 2
Park J, Lee K, Wang W, Jung SW, Ho J, Lim CH. Intraoral kinking of an endotracheal tube during position change in a patient with tracheal deviation. Case Rep Int 2018;7:1-4.  Back to cited text no. 3
Shanahan E, Yu CV, Tang R, Sawka A, Vaghadia H. Thermal softening of polyvinyl chloride nasotracheal tubes: Effect of temperature on tube navigability. Can J Anaesth 2017;64:331-2.  Back to cited text no. 4
Emily Y. Mechanical Analysis of Endotracheal Tubes. The Ohio State University; 2018. Available from: https://kb.osu.edu/handle/1811/86879. [Last accessed on 2021 May 08].  Back to cited text no. 5
Aqil M, Al-Saeed A. A simple solution to unexpected kinking of endotracheal tube. Saudi J Anaesth 2013;7:344-6.  Back to cited text no. 6
Haas RE, Kervin MW, Ramos P, Brown J. Occlusion of a wire-reinforced endotracheal tube in an almost completely edentulous patient. Mil Med 2003;168:422-3.  Back to cited text no. 7
Chan FC, Kawamoto HK, Bradley JP. 18-gauge needle cap as adjunct to prevent kinking of endotracheal tube. J Craniofac Surg 2012;23:1856.  Back to cited text no. 8
Ogden LL, Bradway JA. Maneuver to relieve kinking of the endotracheal tube in a prone patient. Anesthesiology 2008;109:159.  Back to cited text no. 9
Yamashita M, Motokawa K. A simple method for preventing kinking of 2.5-mm ID endotracheal tubes. Anesth Analg 1987;66:803-4.  Back to cited text no. 10


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