LIFE-THREATENING INTRAOPERATIVE OBSTRUCTION OF A WOODBRIDGE-TYPE ENDOTRACHEAL-TUBE CAUSED BY A BALLOON HERNIA CAUSING TOTAL BLOCKAGE OF THE LUMEN

Ten minutes after placement of a new Woodbridge-type endotracheal tube that had previously been tested for leakage of the cuff and patency of the lumen, a total blockage occurred. Subsequent examination of the tube revealed that the inner layer hat "dissected". The cause of the incident is presumed to be an unrecognized manufacturing fault. Although, in view of the high standard of quality assurance employed by the manufacturer of these endotracheal tubes, such an event would appear to be a very rare occurence, prompt detection of the complication is required to prevent a fatal anaesthesia-related complication.