The Tube is in But no Capnography

We had a case the other day for a patient that had just had a lung lobectomy of the right upper lobe three days prior. She was subsequently diagnosed with a chyle leak when they observed a milky fluid in her chest tube drain (See image on left).  Chyle is a fluid consisting of a mixture of lymphatic fluid (lymph) and chylomicrons that has a milky appearance. Chyle leaks are uncommon but can be an adverse result of trauma to the thoracic duct (lymphatic vessel) during thoracic surgery.  Interestingly, in order to help the surgeon identify the leak they feed the patient ice cream the night before the surgery and intraoperatively, anesthesia inserts an OG tube and delivers a half-pint of heavy whipping cream.  I never thought heavy whipping cream would ever be part of our arsenal. 

Coincidentally, I was involved in the anesthesia for both surgeries. This patient was a 365-pound female but surprisingly she was not a difficult intubation the first time.  The second time was a different story. We all assumed this would be a straight-forward intubation just as before, regardless we still had the videoscope in the room and ready to go if needed. The anesthesia personnel consisted of the resident, two anesthesiologists, and myself. After induction the resident did the laryngoscopy with a MAC 3 blade, had a grade I view, and advanced the endotracheal tube (ETT) past the vocal cords.  She did not get condensation return in the tube and capnography was negative. She listened for breath sounds and said she could hear breath sounds but the anesthesiologist said "you're not it" and pulled the tube. The anesthesiologist handed the tube and blade with the videoscope to the other anesthesiologist while we re-oxygenated the patient. The same thing happened. The other anesthesiologist took over and made the third attempt and got the same result. She asked for the bougie, passed the bougie through the vocal cords, removed the videoscope, advanced the ETT over the bougie and past the vocal cords, removed the bougie and got the same result, no condensation and no end-tidal CO2. In all of the cases we were able to move air in but with some resistance. The next attempt the anesthesiologist used a new ETT and left the videoscope in place while removing the bougie to make sure that the bougie wasn't taking the ETT out while it was being withdrawn.  After confirming that the ETT was in place the thoracic surgeon advanced the bronchoscope down the ETT and saw a significant amount of mucous. He suctioned several globs that were quite thick and near the carina.  After suctioning out the mucous we were finally able to get end-tidal CO2 on the monitor. The conclusion by the anesthesiologist and the surgeon was that the mucous was making a ball-valve at the tip of the ETT every time it was advanced. In other words, air could be pushed past the mucous in one direction but whenever air tried to go back through the tube the mucous would close off the tip. Thinking about this more this patient could easily have received significant barotrauma if the anesthesia team continued to force air in without getting air out in return.