Tube obstruction after surgery in a prone position

Mechanical ventilation with an endotracheal tube is frequently used in the ICU setting (including paediatric ICUs, or PICUs). Although complications seldom occur, they can be life-threatening. We report on the case of a 10-year-old boy who developed pneumomediastinum and extensive subcutaneous emphysema due to severe tube obstruction caused by kinking of the endotracheal tube. The kinking probably occurred while positioning the patient in the prone position for surgical intervention. We describe the mechanism that possibly underlies the emergence of the air leak, and emphasize the importance of correct tube fixation and the avoidance of tube rotation while positioning a patient from a supine to a prone position and vice versa. Moreover, we would like to stress the importance of addressing seemingly trivial clinical signs promptly and properly to prevent further complications.