|LETTER TO EDITOR
|Year : 2021 | Volume
| Issue : 2 | Page : 139-140
External reinforcement of cuffed endotracheal tube to prevent kinking during prolonged head-and-neck surgery
Divya V Gladston, Soumya CN, Rajasree Omanakutty Amma, Rachel Cherian Koshy
Department of Anaesthesiology, Regional Cancer Centre, Trivandrum, Kerala, India
|Date of Submission||03-May-2021|
|Date of Acceptance||26-May-2021|
|Date of Web Publication||10-Aug-2021|
Dr. Divya V Gladston
Department of Anaesthesiology, Regional Cancer Centre, Trivandrum - 695 011, Kerala
Source of Support: None, Conflict of Interest: None
|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, 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. Unexpected kinking of the ETT is a common problem encountered during the intraoperative period in head-and-neck surgeries and those requiring prone position, 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. 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. 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. 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, one case of kinking of a reinforced tube was reported in an edentulous patient. 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, reducing extra length of ETT by cutting few centimetres from the machine end, use of Berman intubating airway or placement of cotton pads under the ETT. 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. Aqil and Al-Saeed suggested the use of ordinary paper tape at the point of potential ETT kinking. 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.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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