A case of lost endotracheal tube

Dear Editor, Airway interventions are often performed in suboptimal circumstances. We describe a case of inadequate sedation and improper fixation of the endotracheal tube with undesirable consequences. A 35-year-old male with a past history of right parietal craniotomy had a road traffic accident and presented to Emergency Department with seizures, which were stabilized. During his in-hospital stay, he developed status epilepticus. The patient was intubated with a size 8.0 mm endotracheal tube (ET) secured with a bandage. ET placement was confirmed by five-point auscultation and chest rise. The patient was maintained on intravenous infusion Midazolam 0.1 mg/kg/h and antiepileptic and antiedema medications. Besides hyperkalemia to 5.8 mmol/L, bloodwork was unremarkable. Multiple parenchymal contusions were noted on noncontrast head computed tomography. No active neurosurgical intervention was deemed necessary. During rounds, the duty doctor was unable to find the ET. The bandage had the tube connector attached to the ventilator tubing but without the tube. The ventilator sounded the disconnection alarm and the pilot balloon with a cut pilot line lay beside the patient. The patient had stable vitals but was delirious. There was a suspicion that the ET had been swallowed, which was subsequently confirmed with an anteroposterior chest radiograph, which showed the displaced ET in the esophagus up to the stomach [Figure 1].Figure 1: Chest and Abdominal X rayAn emergent rigid esophagoscopy was performed, with a Glasgow Coma Score of 13 (E4V3M6), oxygen saturation of 98% on room air, blood pressure of 110/68, and sinus bradycardia with a heart rate of 48/min. After general anesthesia induction with Thiopentone sodium and atracurium and intubation with an 8.5 mm sized ET, rigid esophagoscopy was commenced and the intraesophageal ET was successfully extracted. On extraction, the cuff was deflated and the inflation line was broken with a missing pilot balloon. The esophageal mucosa was mildly ulcerated. The patient was reversed and moved to the ICU on Midazolam infusion. He was subsequently extubated after a 24-h seizure-free interval. Most esophageal foreign bodies transit through the gastrointestinal tract without consequence. 10–20% need endoscopic intervention and only 1% require surgery.[1] The type of intervention is determined by the urgency of removal and complications such as perforation.[2,3] In our case, the need for urgent endoscopic intervention was due to intraesophageal location of the displaced tube, which precluded the possibility of successful oral feeds. We attribute the unfortunate turn of events in our patient to several possibilities. First, accidental esophageal intubation by the Medical Resident was ruled out as the patient maintained oxygen saturation for a few hours. Midazolam dose was inadequate for sedation, and improper sedation could have led to active neck movements and inadvertent migration of the tube. There is evidence that even a properly placed ET can migrate with neck flexion and extension.[4] The broken inflation balloon of the extracted tube implied substantially forceful swallowing. Next, the bandage used to fix the tube could have easily allowed slippage of the ET. Lastly, our patient was delirious and may have reflexly swallowed the tube due to inadequate sedation. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.