Shearing of a Frova Intubating Introducer by a Bronchocath double lumen tube

Abstract

Intubation with a double lumen tube (DLT) may be more difficult than an equivalent intubation with a single lumen tracheal tube. The larger size of the tube can make an otherwise good view of the glottis obscured. The gum elastic bougie is well established as an aid to intubation but it is generally too short to be of use with DLTs. Newer versions of the bougie have been developed which are longer, disposable and may have a central lumen to allow oxygenation in difficult circumstances. These can be used to assist both tracheal and endobronchial intubation. We report a case demonstrating a problem using one such bougie, the Frova Intubating Introducer (Cook (UK) Ltd, Letchworth, UK) used to aid the insertion of a DLT. A 59-year-old female was listed for right thoracotomy and right upper lobectomy for bronchial carcinoma. On airway examination she was Mallampati grade 3. Following induction of anaesthesia, laryngoscopy revealed a grade 2 Cormack and Lehane view of the glottis. An initial attempt to pass a 37 FG left-sided Bronchocath (Mallinckrodt, Athlone, Ireland) was hindered by prominent dentition and the decision was made to use the bougie (Frova Intubating Introducer) to avoid dental trauma and aid intubation. The bougie was preloaded on the DLT via the bronchial lumen and the ensemble passed through the cords into the trachea without difficulty. Removal of the bougie did not require any more force than would be expected. Clinical assessment of the DLT showed that the bronchial lumen was in fact in the right main bronchus and an attempt was made to reposition the DLT using a fibreoptic bronchoscope. On bronchoscopy via the bronchial lumen two thin blue fragments of plastic were seen within the right main bronchus (Fig. 1). It became apparent that these were thin shavings from the bougie. The site of shaving was a ledge within the Bronchocath tube. Initial attempts to remove these with suction and then biopsy forceps via the bronchoscope were unsuccessful. The DLT was removed and the patient re-intubated with a single lumen tube and later a second DLT but attempts to remove the fragments by both anaesthetists and surgeons were again unsuccessful. Surgery proceeded and following the right upper lobectomy, the foreign bodies were removed by the surgical team, via the right bronchial stump, using a fibreoptic bronchoscope with biopsy forceps. The chest was closed and the patient woken and extubated at the end of the case. Fragments of Frova Intubating Introducer produced by shaving of the plastic. Several techniques for placement of DLTs have been described [1-4]. These frequently involve the use of some type of stylet or bougie, with or without fibreoptic verification. Although this case may be the first in the literature with regard to the Frova Intubation Introducer, similar problems have been described with other intubating aids [5]. The fact that this had happened at all was noticed only once the fibreoptic scope was used. Clearly, a fibreoptic scope is not used to assess all intubations, and it is feasible that this may have happened before without being noticed. Such particles may then lodge in the smaller bronchi, which may then cause small airway collapse and make the lung more prone to infection. Longer intubation aids such as the Cook Exchange catheter may be useful in certain circumstances but they do not possess the same degree of ‘memory’ as the older gum elastic and newer bougie versions. The production of a disposable yet hard wearing bougie, which is compatible with DLT use, is required. This case was reported to Cook (Australia and UK) who have stated that these intubating aids will now carry a warning of this potential hazard.