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Use of the "Aretube" to facilitate ventilation during percutaneous tracheostomy

Hôpital du Parc, Sarreguemines, France, E-mail: farid.arezki{at}ch-parc-sarreguemines.fr

To the Editor:

During percutaneous tracheostomy, the endotracheal tube is usually withdrawn to a sub-glottic position, or replaced by a laryngeal mask airway.¹ This procedure has disadvantages and risks including:² air leaks with hypercarbia, hypoxia, bronchial inhalation, and accidental extubation.^3,4 A new airway device, the "Aretube" (Figure) has been developed recently to address some of these difficulties. The Aretube provides ventilatory assistance through intubation limited to one part of the larynx. The Aretube has a proximal orifice, and a distal orifice with two cuffs, the first of which has a 20-mL capacity, situated 1 cm from the distal end. The second cuff has a 100-mL cacacity and is situated approximately 1 cm proximal to the first. For correct positioning, the first cuff is placed in a supraglottic position immediately above the vocal cords, while the second cuff (once inflated) is sited in the oropharynx, thus fixing the device while applying gentle pressure on the first cuff. When inflated, the first cuff exerts pressure around the glottis, ensuring a good seal.

View larger version (31K): [in this window] [in a new window]   FIGURE The "Aretube": 1) the distal, supraglottic cuff; 2) the proximal, oropharyngeal cuff.

We have had successful initial experience with this new device. A percutaneous tracheostomy was indicated in a 68-yr-old male who required long-term ventilation for respiratory decompensation secondary to exacerbation of chronic obstructive pulmonary disease. His family was informed of the the risk-benefits of long-term ventilation and consented to the procedure. Withdrawing and positioning the end of the endotracheal tube in the larynx under direct laryngoscopy before the percutaneous tracheostomy resulted in bronchospasm and increases in airway pressures > 45 mmHg. Very rapidly, significant air leaks developed with oxygen desaturation and hypercapnia. The endotracheal tube was rapidly returned to the endotracheal position using laryngoscopy, and the bronchospasm was treated. In view of these difficulties, the new two-cuff tube was inserted using a Cook airway exchange catheter.⁵ While some bronchospasm occurred during this procedure with an increase in insufflation pressures, there were no longer audible air leaks and no episodes of oxygen desaturation. Using the "Aretube", a percutaenous tracheostomy was performed uneventfully, while EtCO₂ values remained < 51 mmHg.

In conclusion, the need to perform percutaneous tracheotomy as efficiently as possible to avoid hypoxia and alleviate hypercapnia may present a potential source of complications whenver there are difficulties in accessing the trachea. Preliminary expereience with the Aretube is encouraging. Clinical studies are warranted to confirm the efficacy and safety of the Aretube in comparison to current approaches to airway managemnt during percutaneous tracheotomy.

Footnotes

Accepted for publication December 20, 2006.

Competing interests: Dr. Arezki is the inventor of the Aretube, but holds no equity position in any company associated with its manufacture.

References

1 Ambesh SP, Sinha PK, Tripathi M, Matreja P. Laryngeal mask airway vs endotracheal tube to facilitate bedside percutaneous tracheostomy in critically ill patients: a prospective comparative study. J Postgrad Med 2002; 48: 11–5.[Medline]

2 Tarpey JJ, Lynch L, Hart S. The use of the laryngeal mask airway to facilitate the insertion of a percutaneous tracheostomy. Intensive Care Med 1994; 20: 448–9.[Medline]

3 Massick DD, Powell DM, Price PD, et al. Quantification of the learning curve for percutaneous dilatational tracheostomy. Laryngoscope 2000; 110: 222–8.[Medline]

4 Schwann NM. Percutaneous dilatational tracheostomy: anesthetic considerations for a growing trend. Anesth Analg 1997; 84: 907–11.[Medline]

5 Mort TC. Editorial comment to the article: Mishaps with endotracheal tube exchangers in ICU: two case reports and review of the literature. The Internet Journal of Anesthesiology 2002; 5(4).

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