Cuff leak from the endotracheal tube

A 56-year-old woman with advanced multiple sclerosis was admitted with pyelonephritis, septic shock, and respiratory failure. She was trans-laryngeally intubated with a 7.5 mm inner diameter endotracheal tube through the mouth. Her course was characterized by hyperactive delirium and agitation. On ICU day 4, the exhaled tidal volume was noted to be less than the set tidal volume on volume assist-control ventilation, and the pilot balloon was soft despite multiple insufflations of air. She was sedated with midazolam and she was reintubated using a tube changing catheter. Examination of the first endotracheal tube revealed that the pilot balloon tube was compromised, likely from the patient repeatedly biting on it (arrow).