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Delayed endotracheal tube obstruction by

mucus plug in a child

Article in Chinese medical journal May 2009

DOI: 10.3760/cma.j.issn.0366-6999.2009.07.019 Source: PubMed

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870 Chin Med J 2009;122(7):870-872

Case report
Delayed endotracheal tube obstruction by mucus plug in a child
XUE Fu-shan, LUO Mao-ping, LIAO Xu, LIU Jian-hua and ZHANG Yan-ming

Keywords: airway management; endotracheal tube obstruction; mucoid impaction; general anesthesia; children

E ndotracheal intubation is a common technique of

airway control for surgical procedures requiring
general anesthesia.1,2 Unfortunately, having an
circuit exhibited no abnormality. In addition, no change in
position of ETT was confirmed by depth mark at the
incisor teeth. The chest auscultation revealed bilaterally
endotracheal tube (ETT) in place does not guarantee a diminished breath sounds, faint inspiratory wheezing and
patent airway and the ETT itself may become a source of limited expansion of the chest wall despite high inflation
airway obstruction.3 We reported a pediatric case of pressures. Deflation of the cuff and slight withdrawal or
delayed ETT obstruction due to mucus plug. advancement of the ETT did not result in either improved
ventilation or a significant leak around the ETT. Then a
CASE REPORT well lubricated suction catheter marked to the length of
the ETT was passed down the ETT lumen and the
A 6-year-old boy was scheduled for repair of hypospadias resistance to advance the suction catheter was
under general anaesthesia. There were no unusual encountered just below the cuff. The laryngoscopy
findings in preoperative tests, including hematological showed that the oropharyngeal section of the ETT was
tests, electrocardiography and chest radiography. In not abnormal, but some mucus on inner wall of the ETT
addition, no history of recent upper respiratory tract close to the glottis was seen. Under laryngoscopy, the
infection was elicited from the parents and the childs ETT was removed and reintubation was performed with
lungs were noted to be clear to auscultation immediately another size 5.5 Murphy cuffed ETT. A patent airway was
prior to operation. A smooth intravenous (IV) induction successfully established and ventilation was easy with a
of anesthesia was performed with propofol, fentanyl and PAP of 15 cmH2O and clear breathing sounds. After the
vecuronium. Direct laryngoscopy revealed a laryngeal child was stabilized, observation with a fiberoptic
view of grade I and the trachea was intubated with a 5.5 bronchoscope (FOB) via the new ETT showed some
mm Murphy cuffed polyvinyl chloride ETT (Hudson secretions in the trachea but no other abnormalities. After
Respiratory Care Inc; USA). After intubation, the intratracheal suction through the FOB, the remainder
capnographic monitoring was established and bilateral air of the anaesthesia and surgery proceeded uneventfully.
entry was confirmed by chest auscultation. The ETT was
fixed at the 15 cm mark. The patient was then Inspection of the first ETT showed a significant adhesion
mechanically ventilated at a peak airway pressure (PAP) of pale thick secretions on inner wall of its anterior part
of 15 cmH2O and PETCO2 was kept around 2530 mmHg. (about 6 cm long). An inspissated mucus plug of about 8
Anesthesia was maintained with oxygen, 60% nitrous mm long was tightly accreted on inner wall of the ETT
oxide and 1%2% isoflurane. and had obstructed 85% of the ETT lumen between the
cuff and Murphy eye (Figure).
Approximately 15 minutes after start of surgery, copious
amounts of secretions were noted in the oral cavity and DISCUSSION
controlled with atropine 0.2 mg IV. Forty minutes later,
the gradual increases in PETCO2 and PAP were noticed, Mucoid impaction results from the inspissation of mucus
which was kept under careful observation. On unchanged and other secretions within the airway and can cause the
ventilator settings, PETCO2 and PAP rose to 53 mmHg partial or even complete airway obstruction. It often
and 37 cmH2O from 41 mmHg and 28 cmH2O over 10 occurs in the bronchi and bronchiole,4 but may also
minutes, respectively, though the anesthetic level was appear in the ETT.5 It is reported that in the pediatric
deepened by increasing the inspired concentration of
isoflurane and complete muscular paralysis was provided DOI: 10.3760/cma.j.issn.0366-6999.2009.07.019
Department of Anesthesiology, Plastic Surgery Hospital, Chinese
with IV supplemental vecuronium. Capnography revealed Academy of Medical Sciences & Peking Union Medical College,
prolongation of the expiratory upstroke of PETCO2 trace, Beijing 100144, China (Xue FS, Luo MP, Liao X, Liu JH and
suggesting obstruction of the gas flow. On changing to Zhang YM)
manual ventilation, a significant resistance to ventilation Correspondence to: Prof. XUE Fu-shan, Department of
was encountered. Anesthesiology, Plastic Surgery Hospital, Chinese Academy of
Medical Sciences & Peking Union Medical College, Beijing
100144, China (Fax: 86-10-88772106. Email: fruitxue@yahoo.
After nitrous oxide was discontinued, a full scale, com.cn or [email protected])
examination for the anesthetic machine and breathing XUE Fu-shan and LUO Mao-ping contributed equally to this work.
Chinese Medical Journal 2009;122(7):870-872 871

intubation with small size ETT can facilitate the

occurrence of this adverse airway incident.5

It is well known that airway obstruction during surgery

may occur from many causes.3 When difficulty in
ventilation occurs in an intubated patient, therefore, a
quick differential diagnosis must be performed by a well
formulated systematic approach. In this case, early
detection of the airway obstruction was aided by
increased PAP and PETCO2, waveform change of
Figure. A size of 5.5 mm polyvinyl chloride ETT showing a capnography and difficulty in manual ventilation.
significant adhesion of pale thick secretions on inner wall of its According to the algorithm for management of airway
anterior part (about 6 cm long, A). Magnified view of an obstruction in anesthetized patients,3 we firstly inspected
inspissated mucus plug with the length of about 8 mm from the anesthetic machine, breathing circuit and ETT placement.
occluded endotracheal tube (B).
Subsequently auscultation of the lungs was performed
and characterized by bilaterally diminished breathing
ICU, partial ETT obstruction by mucoid impaction occurs sounds with faint inspiratory wheezing. In addition,
in about 20% of children who are endotracheally deflation of the cuff did not result in either improved
intubated for long terms.6 After reviewing the medical ventilation or a significant leak around the ETT,
literature, however, we have found no case report of ETT excluding the ETT obstruction secondary to cuff
obstruction by mucoid impaction during surgery in the herniation and the lumen compression by cuff
anesthetized pediatric patient. overinflation. Then we attempted to pass a suction
catheter down the ETT to differentiate between an ETT
The upwards movement of an existing mucus plug in the obstruction and other causes of increased inspiratory
lower airway has been reported to be a reason of the ETT pressure. Because of the failed passage of a suction
obstruction during surgery,4,7 but it is not likely to be a catheter through the ETT, a diagnosis of the ETT
contributing factor in our case, because the child had no obstruction was made. It is generally recommended that if
history of a recent respiratory tract infection and the the ETT is partially obstructed but the patient can still be
preoperative chest radiography showed no unusual ventilated and well oxygenated, an examination with a
findings. Also this event is more likely to occur during FOB may be performed to determine the detailed cause of
the induction of anesthesia characterized by bucking and the difficult ventilation or the sites and severity of the
breathholding or after a change of body position and airway obstruction.3 As the mucus on inner wall of the
signs of the airway occlusion often emerge suddenly.4 ETT close to the glottis was seen during the laryngoscopy
This case of the ETT obstruction undoubtedly involved and the ETT obstruction by mucoid impaction was highly
exsiccation of thick secretions from the trachea to form suspected in our case, the endoscopy was not performed
the mucus plug within the ETT. to prevent accidental dislodgment of the occluded
materials in a caudal direction.
In children who undergo endotracheal intubation and
general anesthesia, several factors can increase the risk After the diagnosis of an ETT obstruction is established,
for developing thick secretions within the trachea. it is necessary to reopen the airway. Although different
Dehydration by the fasting and low inspired humidity can methods are available to remove the obstructed materials
increase the viscosity of secretions, leading to from the ETT, such as suction, forceps extraction, balloon
inspissation and a reduction in mucociliary flow.5 In embolectomy and FOB passage,7,8 we think that
clinically used doses, atropine and inhalational anesthetic reintubation is the most appropriate next step to establish
drugs may cause mucus to become viscid and impair a patent airway if direct laryngoscopy is not difficult. If
mucous transport.4 In addition, the inflation of an ETT the initial laryngoscopy and intubation are difficult,
cuff may not only decrease mucous velocity in the however, the ETT exchange using a FOB should be used
trachea,6 but also can prevent normal effluence of as first option. Briefly, a new ETT is threaded over the
secretions within the trachea and cause the aggregation of FOB. After the FOB has passed the glottis and
secretions in the upper trachea. Because of continuous downwards into the middle of the trachea alongside the
flow of dry inspired gases during anesthesia, secretions obstructed ETT, the obstructed ETT is carefully
that flow initially into the anterior part of the ETT may withdrawn and the new ETT advanced over the FOB into
form a membranous thin layer of dried mucus on its inner the trachea.9
wall. With gradual accumulation of secretions, a mucus
plug is formed within the ETT lumen. When the mucus In summary, we have presented an unusual case of ETT
plug becomes large enough to obstruct most of the lumen obstruction by mucoid impaction in a healthy child
of the ETT, signs of airway obstruction emerge. In an undergoing scheduled surgery under general anesthesia.
anesthetized pediatric patient, moreover, infrequent According to the experience from successful management
airway suctioning, use of the nonrebreathing circuit and of this case, we emphasize that when difficulty in
872 Chin Med J 2009;122(7):870-872

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treatment is promptly taken to prevent further morbidity of endotracheal tubes in children: incidence, etiology,
or mortality. significance. Crit Care Med 1979; 7: 227-231.
6. Sackner MA, Hirsch J, Epstein S. Effect of cuffed
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