Acute endotracheal tube occlusion caused by use of an esophageal detector device: report of a case and a discussion of its utility.
An experienced intensivist performed an emergency endotracheal intubation on a 72-year-old woman without difficulty. The vocal cords were visualized during the intubation. An esophageal detector device was used to confirm correct airway placement. After aspiration of the device, it was impossible to easily ventilate the patient. The endotracheal tube was removed and found to be occluded by a mucus plug. It is postulated that aspiration of the syringe on the esophageal detector device suctioned the mucus plug from the bronchial tree into the endotracheal tube and precluded ventilation of the airway. This complication has not been previously reported. The utility and possible hazards of the esophageal detector device are discussed.
Wright
Robert S
RS
Department of Pulmonary and Critical Care Medicine, Santa Barbara Cottage Hospital, Santa Barbara, CA, USA. rwright@sansumclinic.org
Burdumy
Theodore J
TJ
D000368:Aged; D000402:Airway Obstruction / Q000209:etiology*; D017809:Fatal Outcome; D005260:Female; D006323:Heart Arrest / Q000209:etiology; D006801:Humans; D007442:Intubation, Intratracheal / Q000295:instrumentation*; D019300:Medical Errors; D013396:Suction / Q000009:adverse effects* / Q000295:instrumentation