A 39-year-old man with a history of alcohol abuse, morbid obesity, and obstructive sleep apnea was admitted to the ICU with multilobar pneumonia and respiratory failure. On ICU day 3, peak airway pressures were elevated and manual ventilation was difficult. A suction catheter could not be passed through the oral endotracheal tube (8 mm inner diameter). He was awakened from sedation and the endotracheal tube was removed. The endotracheal tube was noted to be almost completely obstructed with thick, purulent secretions. He required reintubation and eventual tracheostomy.
