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Year : 2009  |  Volume : 3  |  Issue : 1  |  Page : 39-40

Respiratory difficulties encountered during posterior fossa exploration

1 Department of Anesthesia, King Fahad Medical City, Riyadh, Saudi Arabia
2 Department of Neuroscience, King Fahad Medical City, Riyadh, Saudi Arabia

Correspondence Address:
Mohamad Said Maani Takrouri
Department of Anesthesia, King Fahad Medical City, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1658-354X.51834

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Date of Web Publication18-Jul-2009


This report describes an unusual case of obstruction of a reinforced endotracheal tube during posterior Fossa exploration to excise glioma tumor. An 11-year-old male child, scheduled for excision of a glioma in the prone position. The trachea was intubated using a 5.0-mm nylon reinforced latex endotracheal tube (TT). The anesthesiologist ventilated his lungs with a mixture of isoflurane 1.0 MAC in oxygen (35%) and medical air. It was observed that his peak airway pressure was 21 cm H2O at the beginning of anaesthesia, increased to 26 cm H2O over three hours. After that and over 30 min, the peak reached 35 cm H2O, while the end-tidal CO2 pressure was 45 mmHg then gradually increased to 100 mmHg. The anesthesiologists suspected partial obstruction of the tracheal tube (TT). However, the anesthesiologists could not pass a suction catheter through the TT. The anesthesiologist could not advance a suction catheter beyond 8 cm. Re-intubation of the trachea with a 5.5 mm PVC TT relieved the airway obstruction. The termination of surgery allowed to take a chest x­ray which revealed unimpressive marginal pneumothorax which was drained but did not relieved the difficulties. The recording of tissue oxygen saturation and end tidal CO2 were consistent with gradual subtotal obstruction which allowed oxygenation, and delivering inhalational agent but retention of carbon dioxide. In this report we described an unusual incidence of tracheal tube obstruction complicated by presence of small pneumothorax which was successfully treated.

How to cite this article:
Takrouri MM, Saqer MI, Al-Banyan A. Respiratory difficulties encountered during posterior fossa exploration. Saudi J Anaesth 2009;3:39-40

How to cite this URL:
Takrouri MM, Saqer MI, Al-Banyan A. Respiratory difficulties encountered during posterior fossa exploration. Saudi J Anaesth [serial online] 2009 [cited 2022 Jun 24];3:39-40. Available from:

   Introduction Top

SPECIFIC RISKS OF VENOUS air embolism, quadriparesis and peripheral nerve palsies are well feared complications of operating in sitting position in neurosurgery. Prone position during posterior fossa exploration in neurosurgery is adopted to reduce the risk of operating in sitting position [1]. It has inherited problems due to fixed and difficulty accessing the airway [2],[3],[4],[5],[6]. Reports indicated the occurrence of airway obstruction, accidental extubation and the rescue with LMA [7]. In this report we described an unusual incidence of tracheal tube obstruction complicated by presence of small pneumothorax which was successfully treated.

Case Report

An 11 years old male patient, weighing 27 kg, was presented as a case of posterior fossa brain tumor which was the cause of developing hydrocephalus with acute increase in intracranial pressure (ICP) necessitating external ventricular drainage (EVD) under general anaesthesia (GA). The patient was scheduled for excision of the tumor. On the preoperative visit he was found to have IDDM treated with insulin. His blood sugar was uncontrolled, he was suspected to have diabetic ketoacidosis necessitating pediatric intensive care unit admission (PICU). History of previous growth was normal. He had no known drug allergy or blood transfusions previously. He was classified as ASA III. On examination he had stable hemodynamic readings as follows, tissue oxygen saturation (SPO2) 99%, heart rate (HR) 90 beat/min, blood pressure (BP)110/63 mmHg and body temperature of 36.5 C°. Auscultation of the chest was negative for abnormalities or added sounds. Blood investigation was within the normal range. His blood sugar was controlled using sliding scale. On the day of surgery standard monitoring was applied then induction of anaesthesia was achieved with i.v. fentanyl 50 mcg, propofol 100 mg. and tracheal intubation was facilitated with cisatracurium 10 mg. Immediate pre­induction vital signs were BP: 120/70 mmHg, HR:78 b/min, and SPO2 100%, with similar reading after induction of anaesthesia The trachea was intubated using a 5.0-mm nylon reinforced latex tracheal tube (TT) and the lungs were ventilated with pressure controlled ventilator mode. The reading of end tidal CO2 (EtCO2) throughout was 34 mmHg. The airway pressure was maintained between 20-25 cm H2O. Arterial and central venous cannulations were performed. Hourly samples of blood sugar and arterial blood gases were taken. The patient then was positioned prone. Four hours later and while surgery was in progress EtCO2 started to increase from 33, 35, 40-60 mmHg and reached 100 mmHg. Airway pressure measurement at same time increased to a value of 40-45 cm H2O. It was decided to ventilate manually. While the patient was in prone position on auscultation there was no air entry. The suctioning from TT was tried without benefit. We suspected pneumothorax, obstruction, or dislodgement of TT.

The surgeon was informed so he decided to stop the surgery. He started closing the wound since the first stage of surgery was over. Closing the wound took 10 min. The patient was then turned supine and chest X-ray was done which showed pneumothorax on the right side. The pediatric surgeon was informed, and after turning the patient he inserted a chest tube with slight improvement. The tube accidentally dislodged after chest tube insertion, it was immediately replaced with another TT which lead to dramatic improvement. The first endotracheal tube was found almost completely filled with clotted blood, sputum for almost half of its length.

   Discussion Top

Ventilatory difficulty in the prone position may become a serious complication leading to death. The differential diagnosis includes: airway obstruction due to blood or internal bubble or even corruption of the wall of TT. On the other hand thoracic complications like pneumothorax and broncho­spasm, pulmonary embolism may be alternative diagnosis. On the auscultation of both lungs in the reported case evidently there were strange coarse sounds but faint vesicular breathing sounds on manual ventilation, The insertion of chest tube did not lead to full entry of air into the lungs and it was obvious that the TT has certain obstruction allowing ventilation under high inflating pressure. The anesthesiologists were concerned of the consequences of this incident therefore they informed the surgical team of the new development. This would lead to the fact that during the initial few hours of the procedure, no problems were noted. The electrocardiographic changes observed were only sinus tachycardia and probably due to increased blood carbon dioxide and intra-thoracic pressure during manual ventilation. It is possible that manual ventilation forced gases into the lungs but that some valve mechanism due to the presence of long sputum plug which prevented complete free expiration. The administration of 100% oxygen, would also explain why the oxygen saturation did not decrease. It is interesting to note that oxygen saturation may not be an indicator of severe airway problems in accordance with similar case of intra- lumen obstruction [3]. This report of TT obstruction revealed the importance of close observation and anticipation of the problems by anesthesiologists. It showed that long operation in prone position in the presence of excessive secretion due to reduced consciousness in neurosurgical patients may lead to snowball of events.

   References Top

1.Porter J. M., Pidgeon C., Cunningham A. J. The sitting position in neurosurgery: a critical appraisal. Brit J Anaesth 2001; 82: 117-128.  Back to cited text no. 1    
2.Lin JA, Wong CS, Cherng CH. Unexpected blood clot­induced acute airway obstruction in a patient with inactive pulmonary tuberculosis during lumbar spine surgery in the prone position--a case report. Acta Anaesthesiol Taiwan 2005; 43:93-7.  Back to cited text no. 2  [PUBMED]  
3.Santos IA, Oliveira CA, Ferreira L. Life-threatening ventilatory obstruction due to a defective tracheal tube during spinal surgery in the prone position. Anesthesiol 2005; 103:214-15.  Back to cited text no. 3    
4.Populaire C, Robard S, Souron R. An armored endotracheal tube obstruction in a child. Can J Anaesth 1989; 36:331, 332.  Back to cited text no. 4    
5.Kopp KH, Wehmer H. Nitrous oxide induced intra-luminal tube obstruction during endotracheal intubation with armored tubes. Anaesthesist 1981; 30:577-9.  Back to cited text no. 5  [PUBMED]  
6.Tose R, Kubota T, Hirota K, et al. Obstruction of a reinforced endotracheal tube due to dissection of internal tube wall during total intravenous anesthesia. Masui 2003; 52:1218-20.  Back to cited text no. 6  [PUBMED]  
7.Umamaheswara Rao G.S., Ali Z., Ramkiran S., Chandrasekhar H.S. The dissection of a reinforced endotracheal tube causing near-fatal intraoperative airway obstruction. Anesth Analg 2006; 103:1624-25.  Back to cited text no. 7    


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