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Year : 2022  |  Volume : 1  |  Issue : 1  |  Page : 42-43

An uncommon site of breathing circuit leak: Crack-ing the code!!

Department of Anesthesiology, Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly, Uttar Pradesh, India

Date of Submission07-Sep-2021
Date of Acceptance06-Dec-2021
Date of Web Publication20-May-2022

Correspondence Address:
Dr. Akhilesh Pahade
Department of Anesthesiology, Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly - 243 202, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jica.jica_2_21

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How to cite this article:
Pahade A, Mowar A, Singh V, Karki G. An uncommon site of breathing circuit leak: Crack-ing the code!!. J Ind Coll Anesth 2022;1:42-3

How to cite this URL:
Pahade A, Mowar A, Singh V, Karki G. An uncommon site of breathing circuit leak: Crack-ing the code!!. J Ind Coll Anesth [serial online] 2022 [cited 2023 Jan 27];1:42-3. Available from: https://www.jicajournal.in//text.asp?2022/1/1/42/345595


Integrity of the breathing circuit is important for patient ventilation. Even minor source of leak can be a source of unsolicited jitters for an anesthesiologist in charge, as this can result in hypoventilation, hypoxia, and intraoperative awareness. If undetected may even be fatal for the anesthetized patient, resulting in uninvited justifications and litigations. Most modern-day anesthesia machines are efficient enough and can detect leaks up to even a few milliliters. Few can even precisely guide the location of the leak if significant. Ventilation circuit leaks can be prevented by conducting a leak test. However, the use of accessories such as angle connectors and catheter mounts installed after the leak test helps them escape the leak test and be a source of trouble.

We report a case of ventilator leak from an unusual site that escaped all safety preoperative tests.

A 22-year-old ASA-I, male patient scheduled for shoulder arthroscopy was wheeled into the operating room, and all standard monitors were connected, anesthesia was induced after completing a complete system check (including leak test) of anesthesia machine and endotracheal tube (ETT), which showed a leak of 20 mL. Trachea was intubated with an 8.0 mm cuffed ETT, bilateral air entry was confirmed, and ETT was fixed. A brand new catheter mount was placed between the ETT and main circuit. However, a “leak in the system” alarm popped up, prompting us to search for a source of leak which was absent a few moments earlier. All possible sites of the leak were analyzed including peritubular leak, and a new breathing circuit was installed to no avail. While the patient was getting ventilated effectively when an AMBU bag was attached to the tube, system leak used to pop up every time the circuit was connected. Tracking a hissing sound of air leak took us at the ETT–catheter mount junction. A small crack in the catheter mount was noted, and the catheter mount replaced resulting into our problems being sorted [Figure 1]. Oxygen saturation was maintained throughout the crisis period.
Figure 1: Catheter mount with uncommon site of leak

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Hemlata et al. have reported broken ETT connector as a source of leak detected after intubation.[1] Disintegration of the ETT connector while extubating and getting stuck to catheter mount was reported by Snyder.[2] Patel has reported leaks from the concertino type catheter mount due to near-complete transection of the catheter mount tubing, which resulted into impossible ventilation. This can be prevented by meticulous preoperative check of catheter mount in open state and including catheter mount in the mandatory preoperative leak test.[3] In our case, damage was either during manufacturing or transportation and storage, which went unrecognized due to the catheter mount not being part of leak test. Few manufacturers subject their catheter mounts to pressure checks before release and also advise checking all connections and performing pressure and leak tests before use.[4]

Through this communication, authors want to emphasize the importance of preuse check of each component of the breathing circuit and, if possible, integrating accessories such as catheter mount and angle connectors in preoperative leak test. Anesthesiologist should be ever vigilant to detect such unexpected malfunctions and finally check the expiry date of all products before using them.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Hemlata, Verma S, Siddiqui AK. Broken endotracheal tube connector as a cause of ventilation failure. Indian Anaesth Forum 2019;20:49-50.  Back to cited text no. 1
Snyders S. Broken tracheal tube connector. Anaesthesia 2001;56:1122-3.  Back to cited text no. 2
Patel A. Impossible ventilation: The leaking catheter mount. Eur J Anaesthesiol 1999;16:578-9.  Back to cited text no. 3
Maude Adverse Event Report: Fisher & Paykel Healthcare Limited Catheter Mount Bzo; 2011. Available from: https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/detail.cfm?mdrfoi__id=1979634. [Last accessed on 2021 Jul 29].  Back to cited text no. 4


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