Unusual Case of Breathing Circuit Obstruction: Plastic Packaging Revisited

To the Editor:—

Most of the preventable incidents in anesthesia practice involve human error, with breathing circuit disconnections featuring prominently. Overt equipment failures constitute a small proportion of preventable incidents, but equipment design is contributory in many categories of human error. 1–4We herein report a case of a breathing circuit obstruction resulting from failure to completely remove the transparent packaging.

A 36-yr-old, 185-cm, 86-kg healthy man with no history of previous anesthesia underwent uneventful induction of general anesthesia for endoscopic sinus surgery conducted in a standard manner with midazolam, fentanyl, propofol, and vecuronium. Tracheal intubation was accomplished with an 8.0-mm-ID oral cuffed endotracheal tube. Proper endotracheal tube placement was confirmed by auscultation of bilateral breath sounds and end-tidal carbon dioxide. Endotracheal tube depth was confirmed and secured. At the request of the surgeon, the breathing circuit was briefly disconnected and the table was rotated 180 degrees. The existing 90-degree gas sampling connector was removed, and a straight gas sampling connector (SIMS Portex, Inc., Fort Myers, FL) was removed from its plastic packaging and placed in-line. Chest excursion immediately ceased and the ventilator failed to cycle. Hand ventilation with the anesthesia machine was attempted and failed. An Oxygen E-Cylinder with a Mapleson circuit (Vital Signs, Totowa, NJ) was used to ventilate the patient without difficulty with intravenous propofol infusion to maintain anesthesia. Auscultation of the chest revealed normal breath sounds. Careful inspection of the breathing circuit revealed a taut, transparent diaphragm of plastic packaging obstructing the straight connector at its interface with the breathing circuit (fig. 1). The clinician’s thumb had inadvertently retained this transparent obstruction on removal from its packaging. Following removal of the obstruction, the circuit was reconnected and the case proceeded uneventfully.

In summary, we suggest that as an additional measure of safety, packaging for airway components be considered both for its visibility and potential for airway circuit obstruction (fig. 2). We contacted the manufacturer (Portex, Inc., Keene, NH) and MEDWATCH (the U.S. Food and Drug Administration Safety Information and Adverse Event Reporting Program) to alert them of our experience.