Managing Oral RAE Tube Malpositioning After Neck Extension

Cleft lips and palate are orofacial deformities that require surgical repair in childhood to promote speech development, facial growth, and improved aesthetics. In these cases, preformed oral Ring-Adair-Elwyn (RAE) endotracheal tubes (ETTs) are frequently used for airway management during general anesthesia. Due to its acute U-shaped curve, the oral RAE ETT was our first choice. However, the ability to adjust the intubation depth can be limited because of the preformed curve, and insertion length is fixed based on the internal tube diameter. During neck extension after intubation, the ETT moves away from the carina, which can cause the ETT cuff to compress the vocal cords. Therefore, oral RAE ETTs are associated with a risk of inadvertent ETT malpositioning. Our study assessed ETT positioning in 186 patients in whom oral RAE ETTs were initially used, and we found an 8% incidence rate of inadvertent ETT malpositioning after head and neck extension. In such cases, we replaced the malpositioned oral RAE ETT with a wire-reinforced ETT, which we feel was ideal to serve as a secondary option. Wire-reinforced ETTs tolerate extreme flexion without kinking and can withstand high pressure without collapsing. Although oral RAE ETTs can be advantageous for cleft lip and palate surgery, they can become malpositioned after neck extension and should be assessed accordingly. Consideration for using a wire-reinforced ETT as a replacement is warranted in such instances.