| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
Correspondence |
The Ottawa Hospital, Ottawa, Canada, E-mail: dneilipovitz{at}ottawahospital.on.ca
To the Editor:
Changing an endotracheal tube (ETT) in critically ill patients with severe airway edema is challenging and potentially life threatening. We describe an alternative to tube exchange for an ETT that was too short in length.
A 170 cm tall pregnant 35-yr-old female at 30 weeks gestation was involved in a motor vehicle accident. Although initially awake, her condition deteriorated. Awake intubation using direct laryngoscopy by attending anesthesiologists was successful on the third attempt with a 7.0-mm internal diameter (ID) tube;the Cormack grade was 3. The ETT was cut below 26 cm for unknown reasons.
Emergency laparotomy confirmed placental abruption, fetal death and upper abdominal bleeding. Splenectomy and packing was done. Despite these procedures and massive transfusion, the patient continued to hemorrhage and experienced three episodes of pulseless electrical activity. The following day she was profoundly edematous but obeyed commands.
On the chest radiograph, the ETT was 4.6 cm above the carina but could not be advanced because the connection was at the patient’s lips. A periodic air leak was noted and the possibility of tube exchange was considered. Redundant tubing in the mouth was ruled out by direct examination of the oral cavity and bronchoscopy. A tracheotomy was considered but neck edema and cervical spine precautions would have made the procedure challenging. It was decided not to use tube exchange catheter because of upper airway edema, unintentional tracheobronchial injury and possible inability to re-insert an ETT.1 Attempts to pass an ETT beside the existing tube via a bronchoscope2 were considered unlikely to be successful. Another option, telescoping a second ETT over the existing tube, was proposed.
A 9.5-mm ID ETT could easily telescope over a 7.0-mm tube. Securing the tubes together was accomplished by use of nylon ties applied by a cable tie gun. Once secured, the tubes could not be pulled apart. In the operating room, with a difficult airway cart and Sander’s jet ventilator present, preparation for tracheotomy was made. After preoxygenation, the connector of the existing tube was removed. A tube exchange catheter was placed in case of inadvertent removal and to serve as a ‘stent’ to prevent tube compression during nylon tie placement. The in situ tube was lubricated and a cut upper half of a 9.5-mm ETT was easily advanced and secured by nylon ties (Figure
). The procedure was well tolerated. Final positioning was performed under bronchoscopic guidance. No further airway leak occurred. The added extension was shortened to match the length of suction catheters.
|
It is unfortunate that this problem arose since there is no compelling reason to cut endotracheal tubes.3 The added dead space or airway resistance is negligible. Although longer tubes are more likely to be inserted deeply or bend, these problems are easily rectified. Creation of a longer ETT was achieved through the connection of two tubes by a cut ETT connector.4,5 These cases used the combined tubes for a short period of time. It is questionable whether the cut ETT connector could be secured for long-term use. To our knowledge, this is the first description of a telescoping technique to lengthen an in situ ETT. This technique may prevent the need to replace a tube that is too short, especially when the risks of tube exchange are substantial. We suggest telescoping of a tube over the first only after all alternative options have been considered and complete discussion with all staff have been conducted.
Footnotes
Accepted for publication January 10, 2007.
References
1 Benumof JL. Airway exchange catheters: simple concept, potentially great danger. Anesthesiology 1999; 91: 342–4.[Medline]
2 Rosenbaum SH, Rosenbaum LM, Cole RP, Askanazi J, Hyman AI. Use of flexible fiberoptic bronchoscope to change endotracheal tubes in critically ill patients. Anesthesiology 1981; 54: 169–70.[Medline]
3 Moyser LV. To cut or not to cut. Anaesthesia 1993; 48: 832.[Medline]
4 Muraika L, Heyman JS, Shevchenko Y. Fiberoptic tracheal intubation through a laryngeal mask airway in a child with Treacher Collins syndrome. Anesth Analg 2003; 97: 1298–9.
5 Holzman RS. A tracheal tube extension for emergency tracheal reanastomosis. Anesthesiology 1989; 70: 170– 1.[Medline]
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
