AG CUFFILL (CMH2O)

Description of Event or Problem

ARRIVED BEDSIDE TO A SMALL AUDIBLE CUFF LEAK. INSPIRATORY VT [TIDAL VOLUME] WAS 430; EXP [EXPIRATORY] WAS 330. AFTER CHECKING CUFF PRESSURE MULTIPLE TIMES WITH THE AG CUFFILL SYRINGE MORE AIR WAS ESCAPING CUFF CAUSING A GREATER CUFF LEAK. INSP [INSPIRATORY] VT490 - EXP VT NOW 180. CALLED PROVIDER BEDSIDE TO INFORM A FAILED PILOT OR CUFF. ANESTHESIA WAS THEN CALLED FOR A TUBE EXCHANGE. A 6.5 ETT [ENDOTRACHEAL TUBE] WAS THEN PLACED IN AIRWAY WITH POSITIVE ETCO2 [END-TIDAL CARBON DIOXIDE] AND BREATH SOUNDS. WE INSPECTED THE FORMER AIRWAY AND ESTABLISHED THAT ETT WAS INTACT WITH NO LEAK. AFTER FURTHER INVESTIGATION WE ESTABLISHED THAT THE AG CUFFILL SYRINGE HAD FAILED TO MAINTAIN PRESSURE DUE TO A CRACK ON THE SIDE OF THE SYRINGE ALLOWING AIR TO ESCAPE.