Complete Endotracheal Tube Obstruction Due to Highly Viscous Secretions Immediately After Tracheal Intubation: A Case Report

Obstruction of the endotracheal tube (ETT) from secretions can cause severe respiratory distress and potentially life-threatening complications; therefore, prompt decisions and management are needed. Cases of ETT obstruction have been observed in patients who have been ventilated for extended periods but are rare in patients immediately after endotracheal intubation. Herein, we present a rare case of ETT obstruction after endotracheal intubation. A 90-year-old male was scheduled for open reduction and internal fixation (ORIF) under general anesthesia for a femoral fracture. The patient had a history of hypertension, chronic atrial fibrillation, chronic heart failure, and esophageal cancer. After the induction of anesthesia, viscous secretions were observed in the oral cavity when the larynx was exposed. Secretions were removed using Magill forceps and aspiration. An ETT was placed using a videolaryngoscope, and mechanical ventilation was initiated. Twelve minutes after intubation, although the airway pressure alarm did not sound, the capnographic waveforms disappeared; therefore, manual ventilation with 100% oxygen was initiated. However, ventilation was not possible. Suspecting obstruction of the ETT by secretions, tracheal suction was attempted; however, the suction catheter could not be inserted. The patient developed bradycardia and hypotension. Chest compressions were initiated, and the ETT was removed. Ventilation was possible after intubation using a new ETT, and the circulatory dynamics stabilized. The previous ETT was examined and found completely obstructed by highly viscous secretions. The patient was able to undergo the ORIF upon stabilization. The procedure was performed without complications or postoperative neurological deficits. Several potential causes of the ETT obstruction immediately after intubation were considered: upward migration of the bronchial secretions, progressive occlusion by secretions adhered to the ETT lumen, and a combination of these patterns. Capnographic waveform analysis played a critical role in identifying the obstruction, with key findings including the disappearance of the waveform. In cases where heavy secretions are anticipated, preparing a bronchoscope during anesthesia induction and careful monitoring with capnography are essential for the early detection and management of ETT obstruction.