Journal of Pediatric Critical Care

: 2021  |  Volume : 8  |  Issue : 5  |  Page : 259--260

Where is it leaking?

AR Mullai Baalaaji, Joseph Kavitha, Thuruvas Pandurangan Vigneshwaran, CV Saleema 
 Pediatric Intensive Care Unit, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India

Correspondence Address:
Dr. A R Mullai Baalaaji
Pediatric Intensive Care Unit, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu


How to cite this article:
Mullai Baalaaji A R, Kavitha J, Vigneshwaran TP, Saleema C V. Where is it leaking?.J Pediatr Crit Care 2021;8:259-260

How to cite this URL:
Mullai Baalaaji A R, Kavitha J, Vigneshwaran TP, Saleema C V. Where is it leaking?. J Pediatr Crit Care [serial online] 2021 [cited 2021 Nov 27 ];8:259-260
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Full Text

An 8-year-old girl was admitted to the Pediatric Intensive Care Unit for severe ketoacidosis due to suspected inborn error of metabolism. She had been intubated with 5.5 size cuffed Portex® endotracheal tube (ET) and was on controlled ventilation initially. With supportive care, she started to improve and was given sedation holiday on day 4 of admission to assess for weaning readiness. She did not need sedative infusion and remained awake and calm. A few hours later, there was a noticeable leak in the ventilator graphic. The ventilator circuit was checked and found intact. The pilot balloon, cuff inflation line remained intact and cuff pressure maintained at 20 cm H2O. Lip level marking of ET tube had not changed, and there was bilateral equal air entry. Careful examination revealed that audible gush was noted around oral cavity. We planned for reintubation, as the exact reason of leak could not be ascertained. Upon extubation, a hole could be identified in the ET that was presumably caused by trauma due to biting of the tube [Figure 1].{Figure 1}

Common reasons for new-onset circuit leak include unrecognized disconnections in the ventilator circuit, partial or complete tracheal extubation, incompetent pilot valve/balloon, line assembly leak, or damage. Damage to the ET is a relatively infrequent problem faced. There are previous reports of loss of integrity of ETs in adult patients and in operation theaters, with routine ET tube as well as reinforced tubes, but reports in children are scarce.[1],[2] Oral airways and bite blocks are used occasionally when children are agitated and risk injuring oral cavity or ETs. However, there are instances of pilot balloon malfunction as well due to bite block.[3] The index child did not need bite block and remained calm and cooperative, so the damage to ET tube came as a surprise. This report reiterates the need to consider the possibility of ET damage in addition to the usual causes when faced with circuit leak alarm and inability to ventilate.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.


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2Chalkeidis O, Kalakonas A, Chaidutis C, Chotoumanidis C. Endotracheal tube cutting during neurosurgical operation. Eur J Anaesthesiol 2009;26:533-4.
3Adams JR, Hoffman J, Lavelle J, Mireles-Cabodevila E. Pilot balloon malfunction caused by endotracheal tube bite blocker. Respir Care 2014;59:e22-4.