Airway obstruction by dissection of the inner layer of a reinforced endotracheal tube in a patient with Ludwig's angina: A case report

Intraoperative airway obstruction is perplexing to anesthesiologists because the patient may fall into danger rapidly. A 74-year-old woman underwent an emergency incision and drainage for a deep neck infection of dental origin. She was orally intubated with a 6. 0 mm internal diameter reinforced endotracheal tube by video laryngoscope using volatile induction and maintenance anesthesia (VIMA) with sevoflurane, fentanyl (100 µg), and succinylcholine (75 mg). During surgery, peak inspiratory pressure increased from 22 to 38 cmH2O and plateau pressure increased from 20 to 28 cmH2O. We maintained anesthesia because we were unable to access the airway, which was covered with surgical drapes, and tidal volume was delivered. At the end of surgery, we found a longitudinal fold inside the tube with a fiberoptic bronchoscope. The patient was reintubated with another tube and ventilation immediately improved. We recognized that the tube was obstructed due to dissection of the inner layer.