Tube Exchanger for Laryngeal Mask-Based Percutaneous Tracheostomy in the Intensive Care Unit

Abstract

To the Editor: During percutaneous dilatational tracheostomy with the PercuTwist technique, the endotracheal tube is typically withdrawn until the cuff lies at the level of the vocal cords (1). The risks of endotracheal tube or cuff puncture or displacement can be avoided by using a laryngeal mask airway (LMA) (2). However, the LMA may be difficult to place, or may not provide adequate ventilation (3,4). In 5% of cases, fiberoptic examination through the LMA fails to visualize the trachea (4). This can be addressed by using a tube exchanger to guide LMA insertion, and subsequently guide the fiberoptic bronchoscope. This approach is consistent with the recommendations for using a tube exchanger to provide a “safe extubation strategy” for difficult intubation (5). The guidelines are given in the table and accompanying Figure 1.Table 1: Work-Up for Safe Airway Management with the Use of an Endotracheal Tube Exchanger During LMA-Based Fiberoptic-Guided Percutaneous Tracheostomy in Patients Receiving Postoperative Intensive CareFigure 1.: A. The tube exchanger is advanced into the trachea through the endotracheal tube. B. The endotracheal tube is withdrawn leaving the tube exchanger in place. C. The LMA is advanced, guided by the tube exchanger. D. After checking adequate ventilation through the LMA, the fiberoptic bronchoscope is inserted alongside the tube exchanger.Federico Bilotta, MD, PhD Departments of Anesthesiology, Critical Care, and Pain Medicine Federico Giovannini, MD Departments of Anesthesiology, Critical Care, and Pain Medicine University of Rome “La Sapienza” [email protected] Federico Conforto, MD Department of Anesthesiology Ospedale S. Giovanni Raffaella Pinto, MD Department of Anesthesiology University of the “Sacred Heart” Giovanni Rosa, MD Departments of Anesthesiology, Critical Care, and Pain Medicine University of Rome “La Sapienza” Rome, Italy