Ventilatory Management During Intraoperative Airway Obstruction due to Endotracheal Tube Kinking

We present a case of polyvinyl chloride (PVC) endotracheal (ET) tube kinking and discuss the airway pressure changes, implications, and ventilation-based methods to functionally remedy the situation. The kink developed in the intraoral portion of an 8.5-cm PVC ET tube in a patient undergoing T3-T5 laminectomy in the prone position, heralded by a sudden increase in peak airway pressure. The kink was confirmed by attempted intratubal suction. Adequate ventilation was achieved with conversion to pressure control (PC) mode with an inspiratory-expiratory time (I:E) ratio of 1:1. An experiment was conducted using 8.5-cm PVC ET tube, ventilating a 2-L reservoir bag. A kink was artificially created on the ET tube and ventilated with volume control (VC) and then PC mode. Both modes delivered equal tidal volumes at equal plateau pressures, with higher peak pressures in VC mode. The PC mode with I:E 1:1 delivered higher tidal volume than I:E 1:2 and 2:1 at equal plateau pressures. Whereas previous reports of intraoperative ET tube kinking discussed the detection, diagnosis, cause, and management in scenarios where the tube is readily accessible, we highlight airway pressure characteristics and ventilator management of such a situation when an ET tube was not amenable to remedial solutions.