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LETTERS TO EDITOR
Year : 2020  |  Volume : 14  |  Issue : 2  |  Page : 283-284

In response to the comment on too much of anything is bad: An unusual case of a stuck endotracheal tube with deflated cuff


Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India

Correspondence Address:
Dr. Habib Md Reazaul Karim
Faculty Room A001, Block A, All India Institute of Medical Sciences, Raipur - 492 099, Chhattisgarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sja.SJA_25_20

Rights and Permissions
Date of Submission08-Jan-2020
Date of Acceptance09-Jan-2020
Date of Web Publication5-Mar-2020
 


How to cite this article:
Karim HM, Panda CK. In response to the comment on too much of anything is bad: An unusual case of a stuck endotracheal tube with deflated cuff. Saudi J Anaesth 2020;14:283-4

How to cite this URL:
Karim HM, Panda CK. In response to the comment on too much of anything is bad: An unusual case of a stuck endotracheal tube with deflated cuff. Saudi J Anaesth [serial online] 2020 [cited 2020 Jul 2];14:283-4. Available from: http://www.saudija.org/text.asp?2020/14/2/283/280062



Dear Editor

We thank Kumar et al. for their insightful comments on our letter.[1],[2] The authors give excellent points towards the reason for forming the unusual ring at the proximal end of the cuff.[2] We agree with the point that while pulling out the tube, the minimal residual air might have squeezed to that end, and when the cuff was deflated, it gave rise to the ring. However, in this regard, it is to be noted that the trachea is not an absolutely rigid structure, and the tracheal ring is deficient posteriorly. Hence, when there is minimal air in the cuff, with traction on the cuff, the air is unlikely to be distributed homogeneously and only in one direction. Nevertheless, when the two factors combine, i.e., pulling the tube leading to accumulation of air towards the proximal end, as suggested by the authors, and too much deflation of the cuff, as mentioned by us, could lead to the situation. Therefore, our point indicating that too much of deflation in a stuck tube can pose an additional problem cannot be summarily rejected.

The 180° rotation we mentioned in our letter is the rotation of the machine end of the tube, which was, of course, not specifically mentioned in our manuscript, and the author rightly indicates that a thermo-elastic polyvinyl chloride tube is unlikely to get a similar amount of rotation at the other end. However, a few points the authors mention regarding patient safety and hastiness need attention. First, the 7 mm ID tube was inserted in the second attempt, because the 7.5 mm ID tube was hard to negotiate in the first attempt, not impossible. Second, to be safer, we only inflated the cuff with an additional 1 ml (over and above the minimal residual volume in the deflated cuff), which is very minimal. The cuff pressure, measured as a part of routine practice in our institute, was found to be not high to cause excessive pressure and edema of the tracheal wall. Third, the 7 mm ID tube was well fit, and there was a leak around the cuff at the leak test, which is already mentioned. Fourth, fiberoptic videoscopic examination was done, which is also apparent from the figure, and it has been mentioned in the manuscript, and we could find no abnormality. The blood tinge only at one point of the nearly hexagonal ring was possibly due to minor injury while the tube was tried to rotate and pull simultaneously. Too much of deflation of the cuff also made this ring sharp and more capable of causing injury. We agree with the author that such a typical ring is not usual in low-pressure high volume cuff, and multiple factors might have worked to have so.

There is no doubt that the authors comment enlightened us and will do so for the readers too. However, our case does indicate that we should be cautious in over-enthusiastic deflation of the cuff in a difficult to extubate case.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Panda CK, Karim HM. Too much of anything is bad: An unusual case of stuck endotracheal tube with deflated cuff. Saudi J Anaesth 2019;13:156-7.  Back to cited text no. 1
    
2.
Kumar A, Dutta A, Sood J. Comment on a published article: Too much of anything is bad: An unusual case of a stuck endotracheal tube with deflated cuff. Saudi J Anaesth 2020;14:130.  Back to cited text no. 2
  [Full text]  




 

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