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About Failure of Endotracheal
Tubes
Endotracheal Tubes are checked
before intubation, but still device failures have been documented
due to manufacturing defects, e.g. cuff valve failure. Other
complications associated with the use of re-sterilized tubes,
breakage of part of the tube or obliteration of the tube lumen by
a foreign body, e.g. mucous plugs have also been documented.
Despite the check steps or visual
inspection for physical defect, incidences of device failures are
commonly encountered.
Laryngoscopy was done on a
1-month-old male infant and intubation was performed using a 3-mm
id endotracheal tube (ETT) under vision. The child had no
significant other medical complaints. On connecting the ETT to the
circuit, the chest did not expand on ventilation, neither was
there any air entry on auscultation. So, laryngoscopy was done and
the position of the tube was assured; still the chest did not
expand on ventilation. After this, the tube was taken out and
without delay another tube of 3 mm id was connected. The baby was
ventilated successfully, and on checking the previous tube, it was
found that the T-connector of the ETT was obliterated. On
inspection, it was found that this was a manufacturing defect as
the tube was new. There were no complications due to this delay of
intubation.
In this case, ETT had obliteration
in the T-connector, which caused ventilation failure. This was a
manufacturing defect as the tube was neither being reused nor was
re-sterilized. Usually on inspection, the obvious defects of the
tubes are discovered but the defects which are visually not very
perceptible are missed. This incidence signifies the importance of
reviewing equipment defects for internal auditing purpose, so that
complications could be avoided, because negligence could cost a
life.
(Ref:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2943717/).
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