A classmate just shared this story with me. It happened today at his current clinical site.

Scenario:

the resident was doing a standard IV induction on a child. The resident was unable to ventilate the pt, OPA placed, unable to ventilate, proceeded to intubation - wide open glottis with tube directly visualized entering, unable to hear any breath sounds, no sounds over the epigastrum, no EtCO2.

Attending steps in convinced that it's bronchospasm, disconnects the circuit to give albuterol and upon doing so, notices the patient breathing quite easily through the ETT.

Ther was a manufacterer defect with the HME. The proximal side of the HME, the one that fits inside the circuit side, never had the inner circle cut out, therby causing a mechanical obstruction.

Photos to follow.