Unforeseen Malfunction of Flexometallic Endotracheal Tube in Pediatric Nasal Intubation: A Critical Incident Report

Sir, The malfunction of flexometallic equipment, previously unreported for pediatric patients to our knowledge, warrants thorough examination to enhance awareness and prevent potential complications in similar scenarios. To note, it is not very uncommon to have kinking of the flexometallic tube frequently in adult patients due to positioning.[1-3] Evidence does exist in the literature about the kinking of the flexometallic endotracheal tube during nasal intubation in adults.[4] We present a noteworthy and similar unforeseen incident that occurred during a procedure involving nasal intubation with a flexometallic endotracheal tube (ETT) in a pediatric patient. During routine full mouth rehabilitation of a 4-year-old child, we encountered a situation when the nasal intubation process with 4 mm internal diameter flexometallic cuffed ETT was followed by inadequate ventilation with higher pressures during ventilation, although there was no spasm or desaturation. Prompt action was taken to reexamine serially from machine end to patient end, identified a constriction point just outside the nostrils [Figure 1]. ETT was removed and the patient was reintubated with a polyvinyl chloride (PVC) tube size 4.0 to complete the surgery uneventfully. The removed ETT was inspected, revealing unforeseen issue–multiple kinks along its length [Figure 2].Figure 1: Pinch point in the portion just outside nostrilsFigure 2: Multiple kinks along the length of the removed flexometallic endotracheal tubeThis incident raises an important concern. It highlights the necessity for practitioners to be aware of potential malfunctions/kinking of flexometallic tubes, which goes against the safety feature of an armored tube.[5] The lack of prior knowledge about the propensity of flexometallic tubes to kink suggests a gap in understanding or documentation within the medical community. The ethylene oxide (ETO)-sterilized flexometallic tube is sometimes reused in many institutes. Repeated sterilization makes the tube prone to kinking due to the weakening of its framework.[1] Improper storage with stacked up under heavy equipment also contributes to kinking. In this case, it is likely caused by improper storage. Understanding this is crucial for implementing preventive measures as storage racks were made in each operation theatre (OT) for proper storage of endotracheal tubes in our institute and ensuring the safety of pediatric patients undergoing similar procedures. Sharing this incident with the broader medical community is paramount for continuous improvement in the technique of checking the flexometallic ETT. Complete tube should be examined carefully and not just the cuffs as mostly practiced, which will ensure patient safety. 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.