Intraoperative emergency management of endotracheal tube pilot line rupture in orthognathic surgery: A case report

This case report presents an innovative technique for maintaining ventilation in a nasotracheally intubated patient during orthognathic surgery complicated by a non-iatrogenic endotracheal tube (ETT) pilot line leak. This complication occurred during a Le Fort-type maxillary osteotomy, a procedure with restricted airway access that makes ETT replacement challenging and risky. The report addresses a rare intraoperative ventilation issue using an improvised repair approach when commercial repair kits were unavailable, thus expanding options for managing similar complications. The patient, a young adult undergoing orthognathic surgery, developed ventilation compromise, identified intraoperatively as a pilot line rupture. The resulting air leak raised significant risks, including pulmonary aspiration, inadequate anesthesia, and hemodynamic instability. Diagnostic efforts confirmed the pilot line as the leak source, ruling out damage to the pilot balloon or cuff. An emergency repair was performed by making an incision below the rupture site, cannulating the pilot line with a 22-gauge IV catheter, and connecting the catheter to a syringe to reinflate the cuff. This maneuver restored effective ventilation, allowing surgery to proceed safely and without further complications. The patient's recovery was uneventful. This case highlights the critical importance of accurately diagnosing the air leak location in endotracheal ventilation and choosing the simplest, safest intervention to maintain airway integrity. In scenarios lacking commercial repair kits, a quick, improvised repair using readily available materials can prevent ETT replacement, reducing the risks of hypoxia, bronchoaspiration, and bleeding complications. The successful resolution relied on prompt leak identification, adherence to emergency airway management protocols, and a focus on patient safety. This technique provides a valuable alternative for handling unexpected ventilation challenges during complex head and neck surgeries, demonstrating a safe, effective solution in critical situations.