Today you are anesthetizing a 58-yr-old man (82 kg and 5′11″) with a cerebellar tumor. He is otherwise healthy and classified as an American Society of Anesthesiologists physical status 2. General anesthesia is induced uneventfully and the patient is turned prone after having been placed in a Mayfield pin holder. The patient’s head is 180 degrees away from the anesthesia machine. The neck is flexed so that there is a 1-finger gap between the mentum of the mandible and the sternal notch. You would prefer to have 2 fingers, but the surgeon says he needs the flexion to do the operation. The operation proceeds uneventfully for 6h, when there is an increase in the peak inspired pressure from 24 to 42 cm H2O over a 2–4 minute period. All the other parameters have not changed. You call for help, and one of your colleagues comes to your aid. With his help you confirm bilateral air entry with no adventious sounds. You inspect the endotracheal tube at the mouth and confirm that it has not moved and is still taped at 22cm H2O. Your colleague places the patient on 100% oxygen and after a few minutes you attempt to pass a suction catheter through the endotracheal tube (ETT), but it only goes in 15–20 cm. You manipulate the ETT, but there is no improvement. Your colleague suggests you let the endotracheal cuff down (the cuff could have herniated into the lumen), but even then you are unable to pass the suction catheter. You diagnose a partial kink in the ETT. The vital signs are still within normal limits, but the peak airway pressure has gone down to 48 cm H2O. You are concerned. You can now ventilate the patient, but should the kink be total this could have serious consequences for the patient. There are 30–45 min left and the surgeon is unhappy to reposition the patient’s neck before the end of the surgery and about your request to turn the patient supine and reintubate the trachea. You get a laryngeal mask airway ready in case you are unable to ventilate the patient. What else could you do to improve the ventilation without extending the neck or turning the patient supine?
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