Indian J. Anaesth.
SURESH, SRIPADA,2004; 48 (4): :DIFFICULT
VIJESH 307-308 EXTUBATION
DIFFICULT EXTUBATION – A Case Report
Dr. Suresh Y. V.1 Dr. Sripada G. Mehandale2 Dr. Vijesh K. S.3
SUMMARY
A female patient aged 35 years underwent hemithyroidectomy. At the end of surgery there was difficulty in removing the endotracheal
tube. Transfixation of tube to the tracheal wall was thought of and confirmed with the help of image intensifier. Extubation was possible
after re-exploration and suture removal.
Keywords : Laryngoscopy, Difficult extubation, Endotracheal tube, Image intensifier.
Introduction
Airway management is an integral part of
anaesthesiologist’s routine. Protocols are available for the
management of difficult intubation. However there are only
limited reports dealing with difficult extubation. We present
one such rare incidence of difficult extubation.
Case report
A female aged 35 yrs, weighing 62 kg was scheduled
for hemithyroidectomy. Preanaesthetic evaluation was
normal with a regular pulse, at a rate of 70 min-1, BP
130/80 mm of Hg and no signs of thyrotoxicosis. Airway
assessment revealed Mallampati class 1. Patient had a
multinodular goiter with all the borders well made out.
No tracheal shift was detected. Systemic examination was
unremarkable. All the investigations were within normal
limits. No tracheal compression or deviation was seen in
the neck radiogram. Patient was accepted under ASA
grade II physical status. Endotracheal anaesthesia with
controlled ventilation was planned. After overnight fasting
and premedication, monitors [ECG lead II, pulse oximeter,
NIBP] were connected. Patient was induced with
inj. thiopentone 300 mg and intubation was facilitated with
inj. suxamethonium 75 mg. Patient could be easily intubated
with 36F-Armoured ETT [Laryngoscopy grade Ð].
Anaesthesia was maintained with nitrous oxide, oxygen and
halothane using Bain’s circuit. Patient underwent partial
thyroidectomy, which lasted for two hours. After completion
of surgery, neuromuscular blockade was reversed with inj.
neostigmine 2.5 mg and inj. atropine 1.2 mg. Once adequate
spontaneous respiration was established, ETT cuff was
deflated and extubation was attempted. Extubation was not
1. M.D., Asst. Prof.
2. M.D., Asst. Prof.
3. D.A., Tutor
Department of Anaesthesiology, K.S. Hegde Medical
Academy, Deralakatte, Mangalore - 574160
Correspond to :
Dr. Suresh Y. V.
(Accepted for publication on 05-06-2004)
307
possible as tube was getting hitched below the vocal cords.
The patient was awake and hence anaesthesia was
reestablished with nitrous oxide, oxygen and halothane on
spontaneous respiration. After ruling out common causes
for difficult extubation, transfixation of the tube to the
surrounding structures was thought of. With the help of
image intensifier, the movement of the tracheal tube with
the movement of trachea was demonstrated, indicating that
the tube was transfixed. Surgical reexploration of the
operative area was done. When one of the sutures, which
was used for ligating an artery was released, the endotracheal
tube inside the trachea could be moved and extubation was
possible. Patient was re-intubated with 8.5 mm cuffed
endotracheal tube. Subsequent procedure and extubation were
uneventful.
Discussion
Difficulty in removing a tracheal tube at the end of
surgery is a rare but potentially fatal problem.1 Complications
of difficult extubation include trauma to the larynx or trachea
and it may even result in death if the tube is forcibly
removed.1,2
Most common cause of difficult extubation is failure
of cuff to deflate or failure of the deflating mechanism.3
Other causes include forceful intubation with an inappropriate
large tube or too large a cuff that may be held tense by the
cords.2
If there is resistance to extubate, possibility of
suture being passed through the tube should be considered,
especially if the surgery is in the region of neck or after
completion of pneumonectomy. Majority of the reports of
difficult extubation due to fixation of the tracheal tube to
the adjacent structures is in association with orotracheal
surgery.4,5,6 There are reports where Kirschner wire was
pushed between the endotracheal tube and the cuff inflating
port and also a nasogastric tube got entangled with the
cuff inflating tube in the pharynx.4,5 In another instance of
difficult extubation involving endobroncheal tube during
pneumonectomy, forceful extubation resulted in a fatal
308 INDIAN JOURNAL OF ANAESTHESIA, AUGUST 2004

outcome. Postmortem examination revealed that surgeon References

had accidentally sutured Carlen’s double lumen tube to
pulmonary artery.1
In our case difficult extubation was due to
transfixation of endotracheal tube to the tracheal wall during
thyroidectomy which was confirmed by using image
intensifier. Absence of free movement of the tube inside
the trachea clinched the diagnosis for us. Though it is
recommended that when extubation is difficult, fiberoptic
bronchoscopy may be performed,2,3 in most of the centers
the necessary equipment may not be available. However,
image intensifier is commonly available and hence very
useful.
1. Dryden GE. Circulatory collapse after pneumonectomy
(an unusual complication from the use of a Carlens catheter)
a case report. Anesth Analg 1977; 56: 451-452.
2. Hilley MD, Henderson RB, Giesecke AH. Difficult extubation
of the trachea. Anesthesiology 1983; 59: 149-150.
3. Hartley, Vaughan RS. Problems associated with tracheal
extubation. Br J Anaesth 1993; 71: 561-568.
4. Fagracus L. Difficult extubation following naso-tracheal
intubation. Anesthesiology 1978; 49: 43-44.
5. Lee C, Schwartz S, Mok MS. Difficult extubation due to
transfixation of the nasotracheal tube by a Kirschner wire.
Anesthesiology 1977; 46: 427.
6. Skaar GS, Alfonso AE, King BD. An unusual problem in
nasogastric extubation. Anaesth Analg 1976; 55: 302-303.

PEER REVIEW RECOGNITION – 2004

The ‘Indian Journal of Anaesthesia’ ISA and I would like to express our gratitude to the individuals listed below
for their contribution to the publication of various issues of IJA of the year 2004. These persons have dedicated their time
and expertise in reviewing manuscripts, abstracts and books submitted to the journal in order to ensure publication of a high
quality, peer reviewed journal.
– Dr. P.F. Kotur, Editor

‘Indian Journal of Anaesthesia’ acknowledges heart felt ‘Thanks’ to the following Peer-reviewers
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