Ventilation failure due to endotracheal tube T-connector defect

Despite the check steps or visual inspection for physical defect, incidences of device failures are commonly encountered. A 1-month-old male infant weighing 3.2 kg was presented for pyloromyotomy in the elective OT due to infantile hypertrophic pyloric stenosis. Apart from the lump in the upper abdomen, there were no significant other medical complaints. Inside the operation theatre, the monitors were connected and then the patient was premedicated and preoxygenated using Jackson Rees modification of Ayre’s T tube circuit. Induction was done with ketamine, and after checking for adequate chest expansion, succinylcholine was given. After relaxation, laryngoscopy was done and intubation performed using a 3-mm id endotracheal tube (ETT) under vision. On connecting the ETT to the circuit, the chest did not expand on ventilation, neither was there any air entry on auscultation. So, laryngoscopy was done and the position of the tube was assured; still the chest did not expand on ventilation. After this, the tube was taken out and without delay another tube of 3 mm id was connected. The baby was ventilated successfully, and on checking the previous tube, it was found that the T-connector of the ETT was obliterated. On inspection, it was found that this was a manufacturing defect [Figure 1] as the tube was new. There were no complications due to this delay of intubation.

Ventilation failure due to endotracheal tube T-connector defect DOI: 10.4103/0019-5049.68382 Sir, Despite the check steps or visual inspection for physical defect, incidences of device failures are commonly encountered. A 1-month-old male infant weighing 3.2 kg was presented for pyloromyotomy in the elective OT due to infantile hypertrophic pyloric stenosis. Apart from the lump in the upper abdomen, there were no significant other medical complaints. Inside the operation theatre, the monitors were connected and then the patient was premedicated and preoxygenated using Jackson Rees modification of Ayre's T tube circuit. Induction was done with ketamine, and after checking for adequate chest expansion, succinylcholine was given. After relaxation, laryngoscopy was done and intubation performed using a 3-mm id endotracheal tube (ETT) under vision.
On connecting the ETT to the circuit, the chest did not expand on ventilation, neither was there any air entry on auscultation. So, laryngoscopy was done and the position of the tube was assured; still the chest did not expand on ventilation. After this, the tube was taken out and without delay another tube of 3 mm id was connected. The baby was ventilated successfully, and on checking the previous tube, it was found that the T-connector of the ETT was obliterated. On inspection, it was found that this was a manufacturing defect [ Figure 1] as the tube was new. There were no complications due to this delay of intubation.
ETTs are checked before intubation, but still device failures have been documented due to manufacturing defects, [1] e.g. cuff valve failure. [2] Other complications associated with the use of resterilised tubes, [3] breakage of part of the tube [4] or obliteration of the tube lumen by a foreign body, e.g. mucous plugs have also been documented. In our case, the 3-mm id ETT had obliteration in the T-connector, which caused ventilation failure. This was a manufacturing defect as the tube was neither being reused nor was resterilised. Usually on inspection, the obvious defects of the tubes are discovered but the defects which are visually not very perceptible are missed. First, the authors need to specify in their technique, as to how did they confirm the optimum position of the inflating balloon of Foley's catheter. It seems they have done it blindly. Blind inflation of the balloon can lead to deformities in the cuff of PLMA and may lead to worsening of the existing seal and possible misplacement of PLMA.
Second, by inflating the balloon beyond the tip of PLMA; the tone of upper oesophageal sphincter could be further decreased leading to increased risk of aspiration.
Third, the aim of provision of drainage tube in PLMA is to provide a channel for gastric suctioning and a vent for air. There are chances that the openings of foley's catheter abut against the walls of esophagus. In presence of an inflated balloon above it, a regurgitating patient is at risk of developing increased oesophageal pressures and a possibility of oesophageal rupture cannot be ruled out. Further, there is no provision for suctioning the gastric contents using this technique.
Lastly, on what basis the authors have labeled the technique superior and safer is not clear. The article does not mention anything about the measurements of the seal and leak pressures and their comparison without the inflation of balloon. The authors fail to mention, as to how many cases have been done using this technique and need to provide a comprehensive data comparing the positions of cuff, variations in seal and leak pressures apart from relevant data as the cases may be.

Sir,
We wish to report a case of radical gastrectomy, planned for combined general and epidural, but completed under continuous segmental thoracic epidural anaesthesia alone. A 72-year-old, 70-kg male who earlier underwent endoscopic biopsy, diagnosed as adenocarcinoma stomach, was posted for radical gastrectomy. In preoperative evaluation, the cardiorespiratory system was normal. His airway evaluation revealed a mallampatti class III and decreased atlanto occipital extension. The other airway parameters were within acceptable limits. He was a non-diabetic but a mild hypertensive, hence was on treatrment with amlodipine. His routine investigations including an X-ray of the chest, and ECG and heart echo were normal. The plan was to insert a thoracic epidural catheter and a central line before administering general anaesthesia. A central line was placed in the right internal jugular vein and an 18 G epidural catheter was inserted in the T5-T6 interspace. Routine difficult airway equipments were kept ready. After pre-oxygenation, the patient