To the Editor:—
We would like to report a case of intraoperative kinking of the endotracheal tube (ETT)1in a prone patient and a unique maneuver to restore its patency.
A 52-yr-old female was undergoing craniotomy for tumor resection in the prone position. A 7.5-mm polyvinyl ETT was placed without difficulty and secured at 21 cm at the teeth. The esophageal temperature was 36.6°C when peak airway pressures began to rise. Examination revealed an ETT that would not allow passage of a small flexible suction catheter beyond 19 cm, the point at which the pilot balloon line inserts. Extubation over a tube changer and then reintubating was considered, but rejected, because it was believed that even a smaller diameter tube changer would not fit through the kinked ETT. Given that the patient was prone and in pins with an open cranium, we felt it would have been difficult to return the patient to a supine position to troubleshoot the ETT obstruction.
A Berman intubating airway (Vital Signs, Totowa, NJ), often used as an aid to fiber-optic intubations, was spread longitudinally, lubricated, passed over the ETT, then slowly pushed into the mouth until the kinked area of the ETT was approximately in the middle of the Berman airway, thereby immediately relieving the kink. The case proceeded without further difficulty.
One need not remove the ETT connector, but should be careful not to pinch or tear the pilot balloon line. As can be seen in the figures, the Berman airway has a “hinged” side (fig. 1) and an open side. A partially inserted ETT is shown in figure 2. Because of dependent edema in airway tissues, lips, and tongue that often occurs after prolonged time in the prone position, one may deflate the ETT cuff and extubate through the Berman airway, leaving it in place to aid ventilation. The Berman airway comes in multiple sizes to accommodate larger or smaller ETTs.
*University of Utah School of Medicine, Salt Lake City, Utah. firstname.lastname@example.org