Accidental Tracheal Extubation of a Patient in the

Prone Position
Dennis Thiel, MD, John Houten, MD, and Matthew Wecksell, MD
While undergoing emergency C6-C7 corpectomy and anterior and posterior fusion, our prone
patient in whom airway management had been difficult experienced unplanned tracheal extubation. Herein, we describe emergency airway management including reintubation and provide
suggestions for airway management in the prone-positioned patient.(A&A Case Reports
2014;2:202)

major concern in caring for patients undergoing

surgery while in the prone position is unintended
tracheal extubation. This occurred during posterior
cervical spinal fusion in a patient in whom airway management had been difficult. We follow the case presentation
with a discussion of the factors contributing to the event.
The patient provided written permission for the authors
to publish this report.

CASE PRESENTATION

A 62-year-old kyphotic man presented with increasing

upper extremity weakness and pain in his neck and C5-C7
discitis/osteomyelitis. The patient denied any additional
medical conditions beyond obesity and severe cervical
spine stenosis. He was brought to the operating room (OR)
for an emergency C6-C7 corpectomy and anterior fusion.
A cervical collar was in place, limiting his mouth opening
and neck extension. He had a Mallampati 3 airway, had
poor dentition, and an impressively large beard, which
the patient wore for religious reasons. After a discussion
involving both the patient and surgeon, in which we discussed the risks involved in potentially facing difficulty
with mask ventilation, the patient maintained his desire to
keep his beard.
Our plan for securing the patients airway started with an
awake fiberoptic intubation, with a laryngeal mask airway
(LMA) Supreme (LMA North America, San Diego, CA) readily available. Despite direct and rapid success passing a fiberoptic broncoscope (FOB) into his trachea, we were not able
to pass the Medtronic Nerve Monitoring (NIM, Minneapolis,
MN) endotracheal tube (ETT) past his glottis. At this point,
we induced general anesthesia, with the goal of facilitating
passage of the ETT. When this maneuver was unsuccessful, we experienced difficulty in ventilating the lungs via a
From the Department of Anesthesiology, Montefiore Medical Center, Bronx,
New York, NY.
Accepted for publication June 20, 2013
Matthew Wecksell, MD, is currently affiliated with Department of
Anesthesiology, Westchester Medical Center, Valhalla, New York, NY.
Funding: No funding.
This report was previously presented, in part, at the American Society of
Anesthesiologists 2012, case report poster.
The authors declare no conflicts of interest.
Address correspondence to Matthew Wecksell, MD, Department of
Anesthesiology, Westchester Medical Center, 100 woods Rd., Valhalla, NY
10595. Address e-mail to wecksellm@wcmc.com.
Copyright 2014 International Anesthesia Research Society
DOI: 10.1097/ACC.0b013e3182a528aa

20 cases-anesthesia-analgesia.org

mask, likely secondary to his long beard and airway anatomy. We then proceeded to direct laryngoscopy (DL) with
inline stabilization. We were unable to visualize any part of
his vocal cords (CormackLehane grade 1V) and placed an
LMA Supreme, which allowed ventilation of the lungs until
a GlideScope (Verathon, Bothell, WA) was brought into the
room. However, and unlike some other supraglottic airway
devices, the LMA Supreme does not allow for intubation
through its barrel, and tracheal intubation was then achieved
by passing the large cuffed NIM ETT under indirect visualization using the GlideScope. The patients hemoglobin oxygen saturation (Spo2) remained 100% throughout this period.
Tincture of benzoin was then applied to the patients face and
beard, after which we taped the ETT in place.
The surgeon proceeded with the planned anterior C6-C7
corpectomy and fusion. He then decided to continue the
case with a posterior fusion of C5-T2 as well, requiring a
midcase prone repositioning. At this time, the ETT was
resecured with extra tape to the patients face and forehead.
Using Mayfield pinning (Integra, Plainsboro, NJ), the head
was secured to the table, with the slack from the anesthesia
circuit secured upward onto the table.
At completion of placement of the pedicle screws and just
before attachment to the fusion plate, the surgeon requested
radiographic examination of the spine to confirm screw
placement. As the toroidal O-Arm machine (Medtronic,
Minneapolis, MN) was positioned around the patients head,
it came into contact with the ETT. Soon after, the ventilator
bellows were noted not to be refilling after each breath. The
ETT was visually checked, and, because there was no change
in the capnogram at this time, the ETT was deemed to still
be in place. However, because the pilot balloon was felt to
be underinflated, several milliliters air was added, after
which it was noted that the bellows were now completely
collapsed, with the apnea alarm sounding 30 seconds later.
Additional anesthesia staff was called into the room.
LMA placement was attempted with the patient still
prone to no avail, and it was decided to turn the patient
supine despite only the partial fusion and the open surgical field. The wound was covered with Ioban (3M, St.
Paul, MN), a stretcher was obtained, and the patient
placed supine.
The attending anesthesiologist attempted mask ventilation while the resident prepared an LMA and called for the
GlideScope to be returned to the OR, because it had been
removed for use in another location. As was the case on
initial tracheal intubation, ventilation was extremely difficult and minimally effective. An LMA was placed, allowing
January 15, 2014 Volume 2 Number 2

minimal exchange of end-tidal carbon dioxide. DL was

performed while waiting for the arrival of the GlideScope
but was again unsuccessful. On its arrival, the GlideScope
allowed placement of the ETT. The ETT was secured by
wrapping tape eccentrically around the back of the patients
head above his ears, because the surgical site precluded taping the posterior neck inferior to the ears. While the Spo2
decreased into the 60s for approximately 30 seconds, the
patient had otherwise remained hemodynamically stable.
Therefore, he was returned to the prone position, and the
surgery was completed uneventfully.
Due to our concerns of airway edema from multiple
instrumentations of the larynx and the surgeons concerns
about surgically induced edema around the airway, the trachea remained intubated in the surgical intensive care unit
but was extubated without incident the following morning.
No negative sequelae were evident from the brief period
of desaturation (approximately 6090 seconds). The patient
was discharged home several days later. On follow up several months later, the patient was still doing well with no
adverse effects from this event.

DISCUSSION

We feel that there were several contributing factors to the

unplanned prone extubation. First, the patients beard not
only made ventilation difficult, it also precluded taping
the ETT to his facial skin. Some anesthesiologists suggest
using the beard itself as part of the securement solution, by
grooming the beard into sections, and then taping or tying
the ETT with suture onto this more organized hair.1 Because
our patient refused facial shaving, this technique may have
been beneficial during this case.
Furthermore, secretions from the patients mouth interfered with the adhesive properties of the tape and the added
weight of the NIM tube (with electrical cords for electromyographic monitoring) and heat and moisture exchanger
while hanging below the patient likely contributed to the
ETT gradually being pulled down. Finally, after noticing that there was a circuit leak and that the pilot balloon
felt underinflated, additional air was injected into the ETT
cuff and likely forced an already supraglottic ETT into the
mouth. This resulted in the complete loss of ventilation
occurring as the tip of the ETT moved above the vocal cords.

Emergency Airway Management of the

Prone-Positioned Patient

While the traditional manner of airway management afthaner unintended tracheal extubation of the prone-positioned
patient involves returning the patient to the supine position, this introduces some delay in a high acuity situation.
The literature suggests that a return to the supine position
may not be necessary as a first-line response due to the efficacy of LMA placement while the patient remains prone.29
Given the familiarity, availability, and ease of use of
LMAs, many anesthesiologists are electing to use them in
patients positioned prone. A review by Abrishami et al.2
of studies and case reports describing emergency LMA
use in prone patients yielded a summary of 526 cases. The
LMA was successfully inserted 87.5% of the time with first
attempt improving to 100% success by the second attempt.

January 15, 2014 Volume 2 Number 2

However, in only 83% of cases was proper ventilation possible with the LMA. Additional case reports support this
experience in neonatal, pediatric, and adult patients.35
The placement of LMAs in prone patients is not restricted
to emergencies. Ng et al.6 reported a series of 73 patients
in whom insertion of the LMA occurred after induction.
Additionally as part of a retrospective audit, Brimacombe
et al.7 reported the use of ProSeal LMAs in 245 patients. All
attempts were successful, though 8 of 254 required a gum
elastic bougie to aid in LMA placement during a second effort.
Hung et al.10 describe using a FOB to facilitate emergency intubation in the prone-positioned patient. Others
have had success as well with FOB intubations in the prone
patient.1113 However, due to the additional time and equipment needed, an LMA would likely remain the most frequently used first choice. Also, once a supraglottic airway
is successfully placed, it may be used as a conduit for a
fiberoptic intubation, provided it is a device supporting
such a maneuver. In our case, an intubating laryngeal airway, rather than an LMA Supreme, may have been a better
choice to have readily available at the start of the procedure.
Some have used a traditional DL in the prone-positioned
patient.14 Other reasonable options include video laryngoscopy. However, success in using any of these devices
depends on the experience of the anesthesiologist as well
as the availability of the equipment, and in the end, the best
treatment is prevention of circumstances leading to tracheal
extubation such as those occurring in our patient. Several
methods of securing ETTs to patients before moving to the
prone position have been proposed. These include using
extra tape and dressings, commercial ETT holders, suturing the ETT to the cheek or around a tooth, or to a nasally
routed pediatric orogastric tube.1518
Remembering to tighten all circuit/tube connections can
lesson the occurrence of disconnect, which could be confused for actual extubation. Some practitioners even prefer
to tape all the circuit/tube connections together,15 though
we do not recommend this as the tape may obscure a partial
disconnect of the taped components. We also prefer using
tape to secure the anesthesia circuit to either the OR table or
the Mayfield frame to prevent the weight of the circuit from
pulling on the ETT.
Failure of the original airway securement device or technique is a common cause of accidental extubation. Oral
secretions and other fluids from the surgical fields can
loosen the tape adhesive. Two techniques frequently used at
our institution, and in this case, can help prevent this. First,
after adequately securing the ETT with tape (usually >1
piece is required), an occlusive dressing is applied over the
tape edges. We use Tegaderm (3M, St. Paul, MN) dressings
in a variation of a technique originally described by Mikawa
et al.16 Secretions have a much harder time, penetrating the
Tegaderm to the tape itself.
In addition, before surgical preparation (if a cranial or
cervical spine procedure), we often apply towels or small
adhesive surgical drapes (1010; 3M, St. Paul, MN) on the
sides of the head to prevent excess fluid from the surgical prep, or blood from the procedure, to track down the
patients head, and directly onto our ETT. Of course, if
the ETT is secured by means other than tape, these additional precautions are not needed. Finally while there are

cases-anesthesia-analgesia.org

21

Accidental Extubation in the Prone Position

commercial tube holders available to assist in securing the

tracheal tube, in a study by Carlson et al.,19 of 4 commercial
tube holder devices, only 1 of 4 prevented extubation better
than tape.

CONCLUSION

Difficult airways are by their very definition challenging

encounters. An added degree of difficulty is found when
tracheal extubation occurs in the prone-positioned patient.
Our review of the literature suggests that physicians should
incorporate the use of an LMA to their rescue efforts in the
prone-positioned patient.E
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