Maria Rodriguez-Santiago
University of Puerto Rico School of Medicine
San Juan, PR
Disclosure information not submitted.
Karina Cancel-Artau, MD
Dermatology Resident PGY1
University of Puerto Rico, School of Medicine, United States
Disclosure information not submitted.
Christian Cintrón-González, MD
Emergency Medicine Resident PGY2
University of Puerto Rico, School of Medicine, United States
Disclosure information not submitted.
James Bryan-Diaz, MD
Internal Medicine Attending Physician
University of Puerto Rico, School of Medicine, United States
Disclosure information not submitted.
Ruth Santos-Rodriguez, MD
Pulmonology and Critical care Attending Physician
University of Puerto Rico, School of Medicine, United States
Disclosure information not submitted.
Title: Don’t Blame the Cuff, Blame the Balloon Palpation Method
Case Report Body
Introduction: Inflation of the endotracheal cuff looks like an innocuous part of the rapid sequence intubation process. Nonetheless, cuff overinflation can produce excessive membranous tracheal wall stretching causing ischemic necrosis leading to tracheal rupture (1). Recognizing common mistakes during rapid sequence intubation is imperative to prevent complications. This case presents a rare complication and serves to create awareness of the adverse effects of cuff hyperinflation.
Description: A 83-year-old female with Diabetes Mellitus and Hypertension was found unconscious lying on the floor by a family member for approximately 24 hours. She was intubated with a 7.5 mm endotracheal tube with a Satin-slip stylet in the scene for airway protection and admitted with the diagnostic impression of Right Frontal Intracerebral Hemorrhage (ICH). The following day, she presented with sudden tachypnea and hypoxia (Sat= 80%) despite having FiO2= 100% and PEEP=8 parameters on Mechanical ventilator. Chest CT with contrast showed overinflated endotracheal balloon cuff and pneumothorax/pneumomediastinum secondary to tracheal rupture (Image 1 and Image2). Conservative management including protecting airway with invasive ventilation and lowering positive airway pressure was provided. She was weaned off supplemental oxygen but inpatient complications secondary to the ICH and prolonged hospitalization leading to her death after 30 days.
Discussion: Historically, the balloon palpation method has been used but it has poor sensitivity recognizing cuff hyperinflation. Endotracheal cuff hyperinflation needs to be suspected when the mechanically ventilated patients show signs of obstruction such as, high peak inspiratory pressures, decrease lung compliance and difference between inhaled/exhaled tidal volumes (2). On CT, cuff hyperinflation is seen as tracheomegaly defined as a transverse tracheal diameter of >25 mm and >21 mm in men and women, respectively (3). A cuff pressure of 20-30 cm H2O inflated with a 5mL syringe is recommended for adequate seal (4). A cuff pressure > 30 cm H2O may reduce blood flow causing damage to the tracheal mucosal wall leading to its rupture (5). Therefore, a manual manometer should be part of the rapid sequence intubation protocol to reduce the risk of laryngotracheal complications.