Abstract
Purpose
To report a case of accidental esophageal intubation which could not be detected by capnography.
Clinical features
A 43-yr-old man with osteogenic sarcoma of the mandible underwent mandibulectomy radical neck dissection, reconstruction of the mandible and radiation therapy. He was scheduled for revision surgery to the mandible. He had a limited mouth opening and neck movement after operation and radiation. After the cuffed oropharyngeal airway (COPA™) was inserted, anesthesia was induced with sevoflurane, and fibreoptic nasotracheal intubation attempted, but it was impossible to insert the fibrescope into the trachea because of a deformed larynx. While equipment for tracheostomy was prepared, one last attempt was made to insert the tube blindly into the trachea. The capnograph showed apparently normal carbon dioxide waveforms, and the reservoir bag inflated and deflated regularly. However, immediately after inflation of the cuff of the tracheal tube the reservoir bag movement stopped and CO2 waveforms disappeared. Fibreoptic bronchoscopy showed that the tube was in fact in the esophagus. It was then noticed that the patient was still breathing spontaneously through the cuffed airway. The patient was awoken and tracheostomy performed. It was considered that egress of the expired gas was partially prevented by the cuffed airway, pooled in the oral cavity, aspirated down the esophagus during inspiration (likely to be due to negative intrathoracic pressure) and pushed out through the tube during expiration; inflation of the cuff prevented the gas entering the esophagus.
Conclusion
Under such exceptional circumstances, apparently normal carbon dioxide waveforms were observed despite esophageal intubation in a spontaneously breathing patient.
Résumé
Objectif
Signaler un cas d’intubation œsophagienne accidentelle non détectée par capnographie.
Éléments cliniques
Un homme de 43 ans présentant un ostéosarcome de la mandibule a subi une mandibulectomie, un curage ganglionnaire cervical radical, une reconstruction de la mandibule et une radiothérapie. À la suite de la reprise chirurgicale de la mandibule et la radiothérapie prévues, on a noté une ouverture buccale et des mouvements du cou limités. Après l’insertion d’une canule bucco-pharyngée à ballonnet (COPA™), l’anesthésie a été induite avec du sévoflurane et l’intubation nasotrachéale fibroscopique tentée, mais impossible à cause d’une déformation du larynx. Pendant la préparation du matériel de trachéotomie, un dernier essai a été fait pour insérer la sonde à l’aveugle dans la trachée. Le capnographe a montré un oscillogramme apparemment normal du gaz carbonique et le sac-réservoir se gonflait et se dégonflait régulièrement. Mais immédiatement après le gonflement du ballonnet de la sonde trachéale, le mouvement du sac-réservoir sést arrêté et les ondes du CO2 sont disparues. La fibroscopie a montré que la sonde était en fait dans l’œsophage. Notons que le patient respirait encore spontanément grâce à la canule à ballonnet. On a réveillé le patient et procédé à une trachéotomie. On a pensé que la sortie des gaz expirés avait été partiellement empêchée par la canule à ballonnet, accumulés dans la cavité buccale, aspirée dans l’œsophage pendant l’inspiration (sans doute par la pression intrathoracique négative) et refoulée au travers de la sonde pendant l’expiration; le gonflement du ballonnet a empêché l’entrée du gaz dans l’œsophage.
Conclusion
On peut observer, exceptionnellement, un oscillogramme apparemment normal du gaz carbonique malgré une intubation œsophagienne et une respiration spontanée.
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Asai, T., Shingu, K. Case report: A normal capnogram despite esophageal intubation. Can J Anaesth 48, 1025–1028 (2001). https://doi.org/10.1007/BF03016595
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DOI: https://doi.org/10.1007/BF03016595