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Correspondence |
1 Taipei
2 Singapore
To the Editor:
We read with interest the case report by McGuire et al.1 We agree that the jet ventilation/airway exchange catheter employed during endotracheal tube exchange in patients with a difficult airway,2 appears useful during elective tracheostomy. We describe a rapid method of re-establishing the airway in patients who suffered emergency airway loss during/after tracheostomy.
In the first patient, who had just undergone a reconstructive procedure over the face and neck, the tracheostomy tube became dislodged during transport. Attempted reinsertion failed due to severe neck edema. Two patients with neck tumours suffered airway loss during tracheostomy for prolonged intubation. Re-insertion of the tracheostomy tube was not possible and they could not be ventilated.
In all three cases, we successfully secured the airway simply with the use of a finger! The index or middle finger was inserted through the tracheostomy incision, the fingertip palpating through layers to locate the tracheal incision. Feeling the tracheal rings confirmed passage into the trachea. Alternatively, the cervical vertebral bodies may be located first, traced to the esophagus and trachea, and then along the trachea to locate the incision. Obviously, once the finger is in the trachea, there is no room for a tracheostomy or endotracheal tube. Therefore, a gum elastic bougie (Rüsch, Willy Riisch AG, Kernen, Germany) is guided into the trachea alongside the finger and placement confirmed by palpation. An endotracheal tube is then threaded over the bougie. The time taken to regain the airway was between 20 to 40 sec. Effective ventilation was re-established in all three patients and none suffered any neurological sequelae.
When faced with difficult airways, sometimes a simple manoeuvre is all that is required. The anesthesiologist fingers, sensitive and readily available, should not be forgotten, especially when more sophisticated equipment is not on hand.
References
1
McGuire G, El-Beheiry H, Brown D. Loss of the airway during tracheostomy: rescue oxygenation and re-establishment of the airway. Can J Anesth 2001; 48: 697–700.
2 Cooper RM. Extubation and changing endotracheal tubes. In: Benumof JL (Ed.). Airway Management. Principles and Practice. Mosby, 1995: 864–85.
3 Toronto, Ontario
We thank Cheng and Ng for their comments.
Our case report dealt with a different situation than Cheng and Ng described in their letter. Their cases describe loss of tracheostomy tubes soon after successful tracheostomy procedures; i.e., there was no false passage. They were able to establish the already existing normal passage from stoma to tracheal lumen with insertion of a finger. In our case, a diagnosis of a false passage was entertained after failure to ventilate the patient following the insertion of the tracheostomy tube. Accordingly, if the "finger technique" had been used in our case, a difficult situation would have been made even worse because: (1) there would have been no guarantee that the finger inserted in the fresh tracheostomy incision would not have entered the false passage and (2) inserting a finger may strip the inflamed tracheal mucosa (possibly already stripped during the insertion of the tracheostomy tube) even further, thus occluding the tracheal lumen.
We still suggest that during a tracheostomy procedure in intubated patients, the insertion of an airway exchange catheter into the endotracheal tube will act as a "road map" to re-establish a lost airway and will provide a route for rescue oxygenation.
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