Intra-operative management of an occluded south polar endotracheal tube in a child posted for cleft palate repair

Background: Endotracheal tube obstruction by a mucus plug causing ball-valve effect is a rare but significant complication of invasive ventilation, since mucociliary clearance is impaired. High peak and plateau pressures, with rising EtCo2 levels are classical features (1). Endotracheal tube obstruction causes complications including cardiovascular instability, pneumothorax and pulmonary edema.(2) Early detection of intraoperative airway events is essential to prevent postoperative sequelae. Case Report: A 2 year old child, posted for Cleft Palate repair under general anaesthesia, was previously considered for the same procedure 4 weeks prior but was deferred due to cough with expectoration. He was treated for the URTI. During pre-anesthetic evaluation, the mother gave no current history of symptoms of URTI. Auscultation and Xray were clear. Pediatric fitness was obtained. Intraoperatively, an hour after induction, there was a steady rise in EtCO2, Peak Pressures and decrease in SpO2. Immediate decision to extubate and then reintubate was taken. Upon extubation a large mucus plug was seen obstructing the ETT.