Abstract

Introduction: Endotracheal tube (ETT) cuff integrity is essential for effective ventilation, prevention of aspiration, and maintenance of airway pressures during general anaesthesia. Although ETT cuff–related complications are uncommon, cuff herniation or structural failure can result in significant air leaks, inadequate ventilation, and hypoventilation Case Report: A 54-year-old female (ASA physical status I) was scheduled for elective lumbar decompression at L4–L5 and L5–S1 levels under general anaesthesia. Preoperative evaluation revealed no significant comorbidities, normal airway assessment, and unremarkable laboratory investigations. After standard monitoring was established, general anaesthesia was induced uneventfully. Tracheal intubation was performed using a standard-sized cuffed ETT, and correct placement was confirmed by bilateral chest auscultation, and appropriate airway pressures. The cuff was inflated to achieve an adequate seal, and the patient was mechanically ventilated with stable tidal volumes and normal peak airway pressures. The patient was then carefully positioned prone. Soon after prone positioning, a progressive reduction in delivered tidal volumes accompanied by a significant ventilatory leak was observed. Peak airway pressures remained low, and capnography showed reduced end-tidal carbon dioxide values. Circuit disconnection, ventilator malfunction, and tube displacement were systematically excluded. Additional cuff inflation was attempted but failed to resolve the leak. Given the persistent ventilatory compromise and restricted airway access in the prone position, the decision was made to return the patient to the supine position. Direct laryngoscopy revealed herniation of the ETT cuff proximal to the vocal cords. The tube was immediately replaced with a new cuffed ETT. Following re-intubation, normal tidal volumes, airway pressures, and capnography were restored. The patient was repositioned prone, and the remainder of the surgery proceeded uneventfully. Extubation was smooth, and the postoperative course was unremarkable. Conclusion: Endotracheal tube cuff herniation, though uncommon, should be considered when sudden ventilatory leaks or reduced tidal volumes occur intraoperatively, particularly during prone-position spine surgeries. Early recognition, prompt airway reassessment, and immediate replacement of the ETT are crucial to ensure patient safety and prevent hypoxia-related complications.

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