Chou H.-L.SHENG-YUAN RUANHUEY-DONG WU2020-08-122020-08-1220160025-7974https://www.scopus.com/inward/record.uri?eid=2-s2.0-84962189514&doi=10.1097%2fMD.0000000000003161&partnerID=40&md5=d8137b168976a28930e03201adac77eahttps://scholars.lib.ntu.edu.tw/handle/123456789/512294The universal bite block is increasingly used in orotracheally intubated patients. Here, we report a case of pilot tube dysfunction caused by a malpositioned universal bite block in an orotracheally intubated patient. We summarize the key points on identifying and managing a malpositioned universal bite block from this case and literature review. A 74-year-old woman was emergently intubated during an episode of hyperkalemia-related cardiac arrest. A universal bite block was used for fixing the endotracheal tube. After her condition stabilized, ventilator weaning was attempted; however, a positive cuff-leak test result was observed. The cuff-leak test revealed a lack of elasticity of the pilot balloon, which was completely deflated after 2mL of air was removed. Pilot tube dysfunction was highly suspected. The bite block was slightly pulled out, and 8mL of air was aspirated from the pilot tube. The patient was successfully extubated without stridor and respiratory distress. Our case highlighted that a malpositioned bite block may obstruct the pilot tube, causing unfavorable consequences. While fixing the bite block on an endotracheal tube, it is crucial to ensure that the takeoff point of the pilot tube is located within the C-notch of the bite block. ? 2016 Wolters Kluwer Health, Inc. All rights reserved.[SDGs]SDG3aged; air; Article; artificial ventilation; aspiration; balloon; bite block; breast cancer; breast surgery; case report; cuff leak test; diagnostic test; elasticity; endotracheal intubation; endotracheal tube; endotracheal tube cuff; endotracheal tube holder; female; heart arrest; human; hyperkalemia; intensive care unit; mechanical ventilator; physical examination; pilot study; priority journal; respiratory distress; resuscitation; trachea obstruction; valvular heart disease; adverse effects; device failure; devices; endotracheal intubation; extubation; heart arrest; hyperkalemia; medical error; Aged; Airway Extubation; Equipment Failure; Female; Heart Arrest; Humans; Hyperkalemia; Intubation, Intratracheal; Medical Errorsjournal article10.1097/MD.0000000000003161270152012-s2.0-84962189514