Case 86: An Airway Leak in the ICU

Abstract

A 16-year-old girl (85 kg, 5′ 2″) is on full ventilator support in the intensive care unit (ICU). She was involved in a motor vehicle accident (MVA) and has sustained multiple rib fractures with lung contusion, which necessitated endotracheal intubation. The ICU nurse tells you that the intubation proved difficult, but with a two-handed technique they were able to adequately oxygenate the patient. After several attempts, a bougie was blindly inserted into the trachea and the airway secured. It is now 1 h later and you are called because the nurse informs you that there is air coming out of the mouth on inspiration. The nurse tells you that the respiratory therapist had just increased the tidal volume. Vital signs are within normal limits, oxygen saturation 95 %, heart rate 105, and BP 130/80. You can hear air escaping from the patient’s mouth. A #7 endotracheal tube (ETT) is taped at 22 cm and a nasogastric tube has been inserted. The latter is attached to continuous suction. The cuff on the pilot tubing feels full but you put in another 3–5 ml of air. The cuff now feels very tight. But there is no improvement in the air leak. The patient is covered with a blanket, which you remove to examine the chest. There is equal bilateral air entry and the chest is clear to auscultation. There is no evidence of surgical emphysema or pneumothorax. The peak pressure generated by the ventilator is 32 cm H₂O. An ETT suction catheter goes through the whole length of the ETT. There are no secretions in the trachea.