An Unforeseen Complication of EZ Blocker in a Case of Difficult Airway: A Case Report

A 61-year-old male patient, suffering from non-small cell lung carcinoma and multiple comorbidities, was posted for left upper lobectomy. The initial plan for lung isolation by double-lumen tube failed due to a difficult airway. After successful placement of the EZ blocker through a single-lumen tube (SLT), nasogastric tube (Ryle’s tube) insertion was attempted. It was difficult, requiring multiple attempts with laryngoscope and Magill’s forceps. All this movement had caused 3 cm displacement of the SLT. Repositioning of this tube then caused an unanticipated complication where the EZ blocker was found to be folded inside the trachea. The SLT and EZ blocker was taken out together over an airway exchange catheter, and new SLT and subsequently new EZ blocker was reinserted. The rest of the perioperative period was uneventful. Learning point: Any movement of the primary tube should be done bronchoscopy-guided or after due consideration of EZ blocker fixation at the multiport adapter.