Use of a bougie to prevent accidental dislodgment of endotracheal tube during bedside percutaneous dilatational tracheostomy.

Abstract

To the Editor: Inadvertent impalement of the endotracheal tube (ETT) or puncture of its cuff is perhaps the greatest concern during the formation of percutaneous dilational tracheostomy (PDT). The standard recommendation is that the ETT be withdrawn until the cuff lies at or immediately below the vocal cords (1–2). This maneuver may lead to accidental tracheal extubation and loss of airway during the procedure (3–4). We decided to assess the effectiveness of bougie in ETT in preventing the airway catastrophes and effect on ventilation during formation of PDT. In a prospective study, 30 patients receiving volume-controlled ventilation were included. A 70-cm long, malleable ureteric dilator (Microvasive) was used as a bougie. The bougie of 10F size was used for patients having 7.0 mm ETT and 12F was used for the patients having ETT sizes 8 mm and 9 mm. Introduction of the bougie in ETT was facilitated through central flap-hole of the catheter mount (Fig. 1). It was ensured that the distal end of the bougie should extend at least 6–8 cm beyond the distal end of the ETT. Under direct laryngoscopy, the ETT was then slowly withdrawn until the proximal end of the ETT cuff lay approximately 1.0 cm below the glottis. The PDTs were performed using a Portex tracheostomy kit(SIMS Portex; Hythe Kent, UK).Figure 1: A bougie in catheter mount and endotracheal tube.In none of the patients was ETT cuff puncture, ETT impalement, or accidental tracheal extubation encountered. In the patients who had 10F bougie through 7.0 mm ETT, the increase in mean airway pressure from the baseline was 6 cm H2O. In patients with 8.0 mm ETT and 12F bougie the mean increase in airway pressure was 6.5 cm H2O, whereas in the patients who had 9.0 mm ETT and 12F bougie the mean increase in airway pressure was 4.5 cm H2O. All patients were hemodynamically stable and none showed significant changes in Sao2 or Paco2. Presence of sufficient length of bougie beyond the distal tip of the ETT provided adequate withdrawal and repositioning of the ETT in the larynx with stability of the tube against extubation. The presence of bougie inside the tracheal lumen did not make the placement of tracheostomy tube difficult. In our opinion, the use of bougie could be a useful substitute for the bronchoscope. The latter is used in similar fashion and provides the added safety of actual visualization of tracheal puncture from within. Sushil P. Ambesh, MD Dinesh K. Singh, MD Nita Bose, MD