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Proper preparation of the Trachlight^TM and endotracheal tube to facilitate intubation

Orlando R. Hung, MD FRCPC^*, Juliana S. Tibbet, MD, Ronald Cheng, MD^* and J. Adam Law, MD FRCPC^*

^* Dalhousie University, Halifax;
University of Toronto, Toronto, Canada, E-mail: hungorla{at}dal.ca

To the Editor:

While the Trachlight^TM (Laerdal Medical Corp., Wappingers Falls, NY, USA) has been shown to be an effective and safe device for tracheal intubation,¹ occasionally following the retraction of the internal stiff stylet, the tip of the endotracheal tube (ETT) seems to get "hung up" and cannot be readily advanced into the trachea. This is likely due to the fact that when an ETT is loaded along its natural curvature onto the Trachlight^TM, the tip of the ETT has a tendency to bend anteriorly upon retraction of the internal stiff stylet (Figure A). With this anterior bending, the tip of the ETT may be trapped or pushed against the anterior aspect of the cricoid ring or tracheal cartilaginous rings, making it difficult to further advance the ETT into the trachea. We would like to report two modified preparations of the Trachlight^TM and ETT which may help to overcome this difficulty.

View larger version (91K): [in this window] [in a new window]   FIGURE The degree of anterior bending of the endotracheal tube (ETT) following the retraction of the internal stiff stylet of the TrachlightTM. The tip of the ETT has a tendency to bend more anteriorly if the ETT is loaded along its natural curvature onto the TrachlightTM (A) as compared to the reverse loading of the ETT onto the TrachlightTM (B).

Over the last six months, we have used these modified preparations of the Trachlight^TM and ETT for successful tracheal intubation in 160 patients. The "hang up" occurred in only two of the intubations (1.25%). This contrasts with our previous experience (from the log book of one of the authors, ORH) in which a "hang up" during Trachlight^TM intubation occurred in 12 of 82 patients (14.6%). Thus, it appears that softening and reverse loading of the ETT can help to over-come the "hang up" while using the Trachlight^TM.

It should be emphasized that this concept of reverse loading of the ETT is not a novel one. Similar reverse loading has previously been described with the use of a regular ETT for intubation through the Fastrach (intubating) laryngeal mask airway. Joo et al. found that blind tracheal intubation through the Fastrach can readily be achieved with the inverted insertion (i.e., with the concave surface facing backward) of a polyvinyl chloride endotracheal tube.² They attributed their success, in part, to the more anatomic direction of the tube on emergence from the Fastrach laryngeal mask airway with the inverted tube insertion technique.

A similar "hang up" is often seen during tracheal intubation using the Bullard laryngoscope or the Glidescope together with a styletted ETT. It is our experience that softening of the ETT together with the reverse loading of the ETT on the stylet can also substantially minimize the problem with "hang ups" encountered during tracheal intubation with these devices. In order to optimize the effectiveness of reverse loading, we recommend that the bending of the ETT (70°–90^o) be employed immediately prior to intubation. Otherwise, we have found that within a short period of time, the ETT will untwist itself around the well lubricated stylet.

In conclusion, the ease of Trachlight^TM intubation or intubation using other devices can be enhanced by warming as well as reverse loading of the ETT onto the device or an accompanying stylet.

Footnotes

Accepted for publication September 9, 2005.

References

1 Hung OR, Pytka S, Morris I, et al. Clinical trial of a new lightwand (Trachlight) to intubate the trachea. Anesthesiology 1995; 83: 509–14.[Medline]

2 Joo H, Rose K. Fastrach--a new intubating laryngeal mask airway: successful use in patients with difficult airways. Can J Anaesth 1998; 45: 253–6.[Abstract]

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