Cook Airway Exchange Catheter Research Articles

The retrograde tracheal intubation technique for difficult airway management: old but still working

Tracheal intubation performed with direct laryngoscopy remains a preferred choice for securing the airway. In maxillofacial surgery patients, difficult airway may require using alternative techniques. Retrograde tracheal intubation (RTI) technique is an effective and safe option for some of these cases. We report our experience with a modified RTI technique in a 72-year-old man (body mass index, 20.3) affected by a pleomorphic adenoma of the lower jaw extending to the oropharynx and rhinopharynx. Our RTI technique included a 17-G Fantoni modified tracheal needle, a 150 cm long Teflon guide wire (SG), and an 83 cm long Cook airway exchange catheter. Preserving spontaneous breathing with a combination of propofol and remifentanil infusion, we performed RTI using a 17-G Fantoni cricothyrotomy needle inserted between first and second tracheal ring. The patient remained breathing spontaneously for the duration of the procedure, and his vital signs were maintained within normal limits. This case report offers an opportunity to discuss our experience and use of retrograde tracheal intubation. The RTI can be an alternative to awake intubation, and maintaining proficiency and training is necessary to guarantee favorable outcomes.

Intubation with a tube exchanger on an intubation trainer. Influence of tube tip position on successful intubation

Securing the airway using a tube exchanger catheter is an important and useful technique in anesthesia. Its success is mainly hampered by tube tip impingement of laryngeal structures. Advancing the tracheal tube along its normal curvature via a tube exchanger catheter has a high risk of tube tip impingement mainly of right laryngeal structures. The authors achieved successful clinical experience by rotating the tracheal tube 90° anticlockwise (ventral tube tip position) before railroading the tube via a tube exchanger catheter or a fiber optic bronchoscope through the larynx. The aim of the study was to investigate the influence of the tracheal tube tip position while intubating an airway trainer over a tube exchange catheter. Volunteer anesthetists with varying years of professional experience were asked to intubate an intubation mannequin (Laerdal Airway Management Trainer) using the orotracheal route with an established tube exchange catheter (Cook Airway Exchange Catheter, 11F). Two different brands of tracheal tubes (Rüsch and Covidien, ID 7.0mm) were used in a randomized order, each with the tracheal tube tip at first positioned right (90°), then ventrally (0°), left (270°) and finally dorsally (180°), resulting in eight intubation attempts for each participant. To ensure the correct tube tip position the tube was withdrawn before every intubation attempt until the tube tip position was visualized. The oropharnyx, larynx, trachea and tube were sufficiently lubricated with silicon spray (Rüsch Silikospray). The tube and airway exchange catheter size selection were made according to the clinical trial of Loudermilk et al. Successful endotracheal intubation without resistance was recorded for each tube tip position and tracheal tube brand. In total 20 anesthetists (13 consultants and 7 residents) with a median of 9.5 years (range 3-37 years) of professional experience participated in the study. Overall 160 intubation attempts were performed, 2 participants showed no successful intubation attempts at all and 38 out of 160 intubation attempts (23.8 %) were successful. Intubation success with the tracheal tube tip placed ventrally (0°) was 60 % followed by the left (270°) and right (90°) tracheal tube tip positions with 27.5% and 7.5 % intubation success, respectively. With the tube tip placed dorsally (180°) none of the 40 intubation attempts were successful. Intubation attempts with the Rüsch tube were more successful (28.8 %) than those with the Covidien tube (18.8 %). Placing the tracheal tube tip ventrally, the Rüsch tube was twice as successful as the Covidien tube with 16 (80 %) versus 8 attempts (40 %, p = 0.011). There was no correlation between professional experience and intubation success (p = 0.362). Tube insertion via an airway exchange catheter or a fiberoptic bronchoscope is a basic technique in anesthesia. Knowledge about the difficulties and their prevention are essential for every anesthetist. The gap between the airway exchange catheter, the fiber bronchoscope and the tube diameters is one of the major reasons for tube tip impingement. This investigation showed that intubation success via a tube exchange catheter, as investigated in an intubation mannequin, is considerably influenced by the tracheal tube tip position. A 90° anticlockwise rotation, placing the tracheal tube tip ventrally, considerably increased intubation success. This is of particular importance if an anesthesia department has no appropriately sized tube exchange catheters or fiber bronchoscope for every age group of patients.

Airway Exchange Failure and Complications with the Use of the Cook Airway Exchange Catheter®

There are limited data on rates of failure and airway injury with the use of airway exchange catheters. We performed a single-center retrospective analysis of airway exchange catheters to determine the incidence and associated factors for tube exchange failure and airway injury. Among 1177 cases, failed intubation during attempted tube exchange was noted in 73/527 (13.8%). Airway exchange failure rates were greatest during exchange catheter use for double-lumen tube insertion and when intubation was attempted over the catheter postoperatively. Pneumothorax was noted after 1.5% of attempted tube exchanges. Difficult tube exchange was encountered in 6 of 8 patients with pneumothorax.

Strategies of airway management for head and neck photo‐dynamic therapy

Photodynamic therapy (PDT) is a minimally invasive treatment modality which has great clinical implications, especially in head and neck oncology. Post-operative swelling is a well-documented consequence of PDT. It is paramount the airway remains patent for these patients. A tracheostomy remains the gold standard treatment modality for base of tongue tumours susceptible to post operative PDT inflammation, which can lead to a compromised airway. We have carried out a retrospective study to outline the airway management strategies employed for head and neck cancer patients treated with PDT and suggest recommendations for future management. This retrospective clinical study utilises 88 patients (53 males and 35 females) treated at the UCLH Head and Neck Center, London (between 2006 and 2013), for treatment of various lesions with superficial and/or interstitial PDT, when the airway could potentially be compromised. Of the 88 patients selected 60 had interstitial PDT (iPDT) and 13 had superficial PDT (sPDT). Fifteen patients were treated with both iPDT and sPDT. Among the iPDT patients 19 had a trachestomy; two patients a Quicktrach; four a Cook Airway Exchange Catheter (CEAC); one a percutaneous tracheostomy; one a needle tracheostomy and 33 patients did not receive any temporary airway pathways. Among the sPDT patients two had a trachestomy. Although the majority of patients did not suffer any major incidents, one sPDT patient required an emergency tracheostomy two days post-operatively. Airway management is vital when planning PDT treatment for tongue based tumours. Consider a more conventional approach when the lesion being targeted is located at a higher risk site: Floor of mouth/posterior tongue/tongue base or when multiple oral sites are being treated.

Difficult Airway Society guidelines for the management of tracheal extubation

We read with concern the letter from Ms Ogilvie 1 in reaction to the recently published extubation guidelines by the Difficult Airway Society (DAS) 2. Ogilvie, representing Cook Medical (Limerick, Ireland), manufacturers of the Cook Airway Exchange Catheter (AEC), indicated that this device “is not intended to remain in the airway…for an extended period of time…” following extubation of a difficult airway. One of us (RMC) was involved in the development of the AEC, and this is precisely how he had intended that it be used. Our ability to predict successfully those patients who will tolerate extubation is far from perfect. Comparing patients with difficult airways whose tracheas were re-intubated with or without an AEC, Mort demonstrated that the AEC was associated with a very significant improvement in the first attempt success rate, the time required to complete re-intubation, and a reduction in severe hypoxia as well as bradycardia 3. Only 21/51 (41%) of the re-intubations involving an AEC took place within 2 h of extubation while 30/51 (59%) occurred between 2 h and 10 h. Thus, the major safety advantages of extubation over a tube exchanger are likely to be missed if the device is used exclusively to perform an exchange or if it is removed shortly following extubation of the difficult airway. The undersigned, representing DAS and the Society for Airway Management, strongly reaffirm the recommendations of the DAS guidelines and discourage the premature removal of tube exchangers until the probability of a required re-intubation seems very remote.

Conversion of orotracheal to nasotracheal intubation using a fiberoptic bronchoscope in a patient with intraoral hematoma

Conversion of orotracheal to nasotracheal intubation using a fiberoptic bronchoscope in a patient with intraoral hematoma

Carinal resection using an airway exchange catheter-assisted venovenous ECMO technique

To the Editor, Airway management during tracheal resection is one of the great challenges confronting anesthesiologists, especially when carinal resection is involved. When ventilation through the mainstem bronchi is not an option due to surgical exposure, extracorporeal oxygenation techniques become a vital tool. Venovenous extracorporeal membrane oxygenation (VV-ECMO) is a preferred mode of assuring adequate oxygenation in patients with normal right ventricular function. However, its oxygenation efficacy is lower than either cardiopulmonary bypass (CPB) or venoarterial ECMO (VA-ECMO). We describe herein a case where an airway exchange catheter (AEC) was effective in assisting oxygenation during carinal resection with VV-ECMO. A 52-yr-old male presented with hoarseness, chronic cough, and hemoptysis. Flexible bronchoscopy revealed a squamous cell carcinoma located in the distal trachea just proximal to the carina and occluding about 50% of the tracheal lumen. The patient’s medical history was significant for hypertension, gastroesophageal reflux disease, and lumbar disc displacement. Preoperative pulmonary function tests showed a reduced FEV1/FVC ratio compatible with mild airflow obstruction, normal diffusion capacity, and normal measured lung volumes. Mediastinoscopy and distal tracheal and carinal resection with primary anastomosis were planned. In the operating room, after thoracic epidural catheter placement, general anesthesia was induced slowly with titration of sodium thiopental while the patient maintained spontaneous respiration. Once an adequate level of anesthesia was obtained using additional volatile anesthetic, a single-lumen endotracheal intubation was performed under direct laryngoscopy. Pancuronium was administered after adequate ventilation had been confirmed. Traditional lung isolation techniques were not an option due to the presence of the mass lesion at the carina and both main stem bronchi. Thus, the VV-ECMO was planned to assure adequate gas exchange during surgery. While the patient was in the supine position, mediastinoscopy was performed, followed by VV-ECMO cannula placement. The VV-ECMO was instituted via femoral and right internal jugular venous access with a flow rate of 3 L min. In order to assure proper cannula positioning to avoid recirculation phenomenon, the surgical team measured the location of the cannula tips from the insertion site. The patient was then repositioned into the left lateral decubitus position. The trachea and carina were dissected via the extended right thoracotomy incision. After the surgeon obtained adequate exposure to the trachea and carina, ventilation was stopped and VV-ECMO was initiated. With the VV-ECMO, the oxygen saturation persisted close to 80% (Table). At this point, a decision was made to insufflate supplemental oxygen to the patient’s lungs. With its flexibility and small size, a 14 Fr 100-cm soft-tip Cook Airway Exchange Catheter (Cook Medical, Bloomington, IN, USA) was inserted via the endotracheal tube into the right bronchus with a 6 L min oxygen insufflation through its lumen (Figure). We decided not to use a bronchial blocker due to the increased resistance to the gas flow and the possibility of lung overinflation from gas entrapment with the inflated balloon. Upon the completion of the right bronchial anastomosis, W. Keeyapaj, MD (&) Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, MA, USA e-mail: kworasak@yahoo.com

Retrograde Intubation Using a Frova Intubating Introducer in a Patient with a Tracheostomy

To the Editor The Frova intubating introducer with an angled flexible tip and rigid internal stylet was designed for difficult orotracheal intubations. Here we report the novel use of the Frova intubating introducer for retrograde intubation via a caudally directed tracheostomy tract in a patient in whom antegrade intubation had been unsuccessful. A 59-year-old male quadriplegic patient with a tracheostomy was diagnosed with tracheoesophageal fistula and admitted to the operating room for fistulectomy. The patient had undergone cervical spine surgery after a car accident 9 years ago and presented with severely wasted neck and limbs, a large tongue, and a <1-cm mouth opening. For the fistulectomy, oronasotracheal intubation was needed because the tracheoesophageal fistula was just 1 cm above the tracheostomy site. We attempted nasal fiberoptic bronchoscope-guided intubation under light sedation, but the narrowness of the oral cavity and a large amount of secretions made it difficult to pass the fiberoptic bronchoscope beyond the tongue base. We therefore decided to try retrograde intubation through the tracheostomy opening. We attempted to insert a Cook airway exchange catheter (Cook Critical Care, Letchworth, Hertfordshire, UK) ordinarily used as a “guidewire” for retrograde intubation, via the tracheostomy tract several times, but the tip failed to advance cephalad. Alternatively, we inserted a Frova intubating introducer (Cook Critical Care) with a rigid internal stylet into the tracheostomy tract, and after advancing the angled tip 5 cm in the cephalad direction, the stylet was removed. We kept advancing the Frova intubating introducer into the pharyngeal space. The distal tip emerged from the left nostril, and then retrograde intubation was successfully conducted by using the introducer as a guide. Insertion of a flexible guide for retrograde intubation via a tracheostomy with a caudal orientation of the internal tracheal lumen results in advancement of the guide further into the trachea rather than cephalad through the larynx. In our case, because the Cook airway exchange catheter, initially used as a guide, was flexible and did not have an angled tip, it could not be advanced in the cephalad direction via the caudally directed tracheostomy tract, causing our initial attempt at retrograde intubation to fail (Fig. 1). However, the Frova intubating introducer is made of more rigid polyethylene and has a length of 65 cm, an outside diameter of 4.7 mm, a tip portion of approximately 2 cm with a flexible angle of 65°, and an internal stylet that can be inserted for rigidity up to the distal 5 cm.1 These features account for why we were able to advance the Frova intubating introducer in the cephalad direction via a caudally oriented tracheostomy tract (Fig. 2). Retrograde intubation using an intubating introducer via a tracheostomy is not a recommended technique and could result in creation of a false passage, vocal cord injury, retropharyngeal hematoma, and tissue damage.2 Because our patient had maintained a tracheostomy for over 8 years, the risk of a false passage was relatively low.Figure 1: The Cook airway exchange catheter was unable to be advanced in the cephalad direction via a caudally oriented tracheostomy tract with a hyperacute angle.Figure 2: A, The Frova intubating introducer with an angled flexible tip and rigid internal stylet. B, (a) The angled tip of the Frova intubating introducer is inserted in the cephalad direction. (b) The Frova intubating introducer is advanced while carefully applying lever-like force in the caudal direction. C, The Frova intubating introducer is successfully advanced in the cephalad direction with a retraction movement while removing the internal stylet at the same time.PATIENT CONSENT STATEMENT Published with the written consent of the patient's family and the approval of the Institutional Review Board (ref. 4–2011-0554) of Yonsei University Health System. Shin Hyung Kim, MD Yong Seon Choi, MD, PhD Young Jun Oh, MD, PhD Department of Anesthesiology and Pain Medicine Anesthesia and Pain Research Institute Yonsei University College of Medicine Seoul, Korea [email protected] ACKNOWLEDGMENTS The authors are grateful to Dong-Su Jang, Research Assistant, for his help with the figures in the article.

Airway management using O2flush via Cook airway exchange catheter® for microlaryngeal surgery

Airway management using O₂flush via Cook airway exchange catheter® for microlaryngeal surgery

Case Scenario: Perioperative Airway Management of a Patient with Tracheal Stenosis

TRACHEAL stenosis is a rare but a life-threatening condition and is caused by congenital problems, postintubation injury, trauma, tracheal tumor, and compression of the trachea by tumor. Although accurate prevalence of this condition is unknown, an incidence of 4.9 cases per million per year is estimated for postintubation tracheal stenosis. A stenosis commonly occurs at the cuff of the tube (intrathoracic trachea) or at the level of the tracheostomy stoma (extrathoracic trachea). Anesthesia of a patient with tracheal stenosis is challenging for anesthesiologists. Depending on the severity and location of the stenosis and the type of surgical procedure, there may be a variety of choices for perioperative airway management such as a facemask, laryngeal mask airway, an tracheal intubation tube, cardiopulmonary bypass, and extracorporeal membrane oxygenation. The American Society of Anesthesiologists practice guidelines for management of the difficult airway primarily focus airway problems caused at the extrathoracic airway and may not be helpful, particularly for managing patients with intrathoracic tracheal stenosis. In this case scenario, we present a patient with severe intrathoracic tracheal stenosis, who required surgery for a lumbar fracture in the prone position. Various airway management strategies and the actual management used are discussed.

Utility of the Portex Introducer, Ivory Type, as a Tube Exchanger

This study compared the Portex introducer, ivory type (PII) (Portex Tracheal Tube Introducer; SIMS Portex, Hythe, Kent, England), and Cook Airway Exchange Catheter (CAEC) (Cook, Letchworth, Hertfordshire, England) with regard to success rate of and time required for tracheal intubation by use of each device by oral and maxillofacial surgeons on a manikin. The subjects comprised 17 oral and maxillofacial surgeons who intubated the trachea of the manikin with each device. The PII or CAEC was inserted into the trachea of the manikin and advanced 26 cm from the upper incisor, and the time required for intubation was measured. The subjects were then asked to rate the difficulty of intubation using a 10-cm visual analog scale. The mean intubation time, averaged over 3 attempts, was significantly shorter for the PII (7.92 +/- 3.15 seconds) than for the CAEC (11.44 +/- 3.98 seconds) (P < .001). The rate of successful intubation with the PII (88.2%) was significantly greater than that with the CAEC (37.3%) (P < .001). With regard to the overall difficulty of intubation, as rated by the 10-cm visual analog scale, the PII (median, 45 mm [10th-90th percentile, 32-53 mm]) was considered less difficult than the CAEC (median, 66 mm [10th-90th percentile, 52-84 mm]) (P < .001). Intubation is faster, more sure, and easier by use of the PII as a tube exchanger than with the CAEC. This may be particularly important for patients undergoing oral and maxillofacial surgery as a result of anatomic changes in the airway, because edema or hematoma in the upper airway often leads to failed intubation. We conclude that the PII is useful as a tube exchanger.

Fiberoptisch unterstützte endotracheale Intubation durch die Larynxmaske im Kindesalter

Fibre optic-assisted tracheal intubation through the laryngeal mask airway is a simple and safe procedure for securing the airway in the paediatric patient with unexpected and known difficult tracheal intubation. Therefore, fibre optic-assisted tracheal intubation through the laryngeal mask airway represents a standard airway technique and must be part of clinical education and also regular training. However, the removal of the laryngeal mask airway over the tracheal tube is impaired by the short length of the tracheal tube, easily resulting in tube dislocation from the trachea. Among several techniques to overcome this problem, the Cook airway exchange catheter offers a reliable method not only for safe removal of the laryngeal mask over the tracheal tube but also for insertion of an adequate tracheal tube, particularly in paediatric patients. This is particularly important for cuffed tubes as the pilot balloon of the cuffed tube is too large to pass through laryngeal mask airway tubes size 2.5 and smaller. This presentation demonstrates fibre optic-assisted tracheal intubation through the laryngeal mask airway in children step-by-step and discusses its clinical implications. A list with compatible sizes of laryngeal mask airways, tracheal tubes and airway exchange catheters is also provided.

413: Coma and seizures due to gas embolus following extubation

We report a 27 year old man who developed coma and focal seizures due to cerebral gas embolus during extubation in ICU. Recent open pyeloplasty had been complicated by post-operative haemorrhage and difficult intubation (Grade 2–3 laryngoscopic assessment). Prior to extubation the patient was alert and interactive with no neurological deficits. As a precaution, a Cook airway exchange catheter was used and inadvertently advanced during extubation. The patient suddenly lost consciousness, began sweating profusely, his teeth clenched around the catheter and airway protection was compromised. Rapid re-intubation was achieved by ‘rail-roading’ the ETT over the catheter. Oxygen saturation remained >95% throughout the event. However, the patient remained comatose despite the administration of flumazenil, naloxone and phenytoin. He was tachycardic, had subcutaneous emphysema and subsequently developed left limb focal motor seizures with secondary generalisation. CT scans showed diffuse cerebral oedema. With conservative management the patient improved over several weeks. On discharge there was a mild left hemiparesis with some cognitive dysfunction and disinhibiton. Convalescent MRI showed mild to moderate diffuse atrophy and right frontal and periventricular hyperintense foci.

Retrograde intubation with epidural catheter and Cook airway exchange catheter

Retrograde intubation with epidural catheter and Cook airway exchange catheter

Unforeseen Esophageal Misplacement of Airway Exchange Catheter Leading to Gastric Perforation

We would like to highlight a case of gastric perforation secondary to the misplacement of an airway exchange catheter (AEC).An AEC was used as a bridge to full extubation in a patient with a known difficult airway secondary to external radiation to the face for an orbital basal cell carcinoma. Uneventful general anesthesia proceeded with an awake fiberoptic intubation using a 7.0-mm single-lumen endotracheal tube. Placement position was verified by visualizing the carina and secured at 22 cm to the lip. Once fully awake with intact neuromuscular function, the patient was underwent extubation over a 14.0-size Cook AEC (Cook Critical Care, Bloomington, IN) secured with tape at 35 cm at the lips to allow a margin of safety from accidental dislodgment. The patient’s vitals were stable throughout emergence and extubation. Oxygen, 2 l/min, was insufflated through the Cook AEC via a Luer connector for transfer to postanesthesia care unit. The patient was noticed to have an occasional belch during transfer. On arrival, oxygen through the Cook AEC was discontinued, and he was placed on oxygen via facemask. The plan was to leave the AEC in place until it was certain that no residual anesthetic was present and the need for reintubation was unlikely.During his stay in the postanesthesia care unit, the patient was switched from facemask to oxygen through AEC; the reason for this is unclear. Unfortunately, the flow rate of oxygen insufflation at that time was not known. Approximately 1 h into his stay in the postanesthesia care unit, the patient reported pain disproportionate to his surgery. On physical examination, the patient’s abdomen was noted to be remarkably distended, associated with belching. Oxygen through the AEC was discontinued. Portable chest (fig. 1) and abdominal (fig. 2) radiographs were ordered, illustrating free air under the diaphragm and massive gastric distention. A surgical consult highlighted the need for emergent surgery for probable gastric perforation. The patient was scheduled to undergo an emergent laparoscopy. On repeat fiberoptic intubation for the subsequent surgery, the AEC was noted to be in the esophagus. Diagnostic laparoscopy revealed a small perforation on the lesser curvature of the stomach consistent with gastric overdistension, which was subsequently repaired laparoscopically. Whether the perforation was caused directly by the device or gastric distension from oxygen insufflation is unknown. The patient subsequently made a full recovery and was discharged from hospital a week later.The literature suggests four potential risks associated with the use of AECs: misplacement, bronchial or lung trauma, laryngeal trauma, and barotrauma related to jet ventilation.1,2This incident illustrates the consequence of unforeseen AEC misplacement. The key issues leading to this complication were as follows: (1) failure to confirm endotracheal placement highlighting the necessity of end-tidal carbon dioxide monitoring (end-tidal monitoring can be facilitated through the Luer lock mechanism provided with the Cook AEC kit; a lateral chest radiograph may be of some benefit to confirm placement; however, the practicality of this investigation could be debated); (2) belching as an early sign of esophageal placement; (3) the questionable benefit of oxygen insufflation through an AEC (apart from its role as a means for jet ventilation) in a patient able to saturate adequately via facemask; and (4) ensuring appropriate length of placement (in this case, the AEC was inserted too far; the literature recommends 22–25 cm for oral placement and 27–30 cm for nasal placement).1In summary, we believe that an AEC should be treated as an endotracheal tube, and its placement should never be assumed to be correct until objective data support that conclusion.*University Hospital of Michigan, Ann Arbor, Michigan. mreay@umich.edu

Contrôle novateur des voies aériennes dans un cas de phlegmon amygdalien

To describe innovative airway management in an adult with a peritonsillar abscess (quinsy) located atypically in the inferior pole of the palatine tonsil. A 25-yr-old male was admitted for surgical drainage of a left-sided, inferior pole peritonsillar abscess. Previous attempts at intraoral needle and scalpel drainage with topical anesthesia in the emergency department had failed. He had an interdental distance of 1.5 cm and computed tomography imaging showed narrowing of the airway diameter to 8 mm and lateral displacement of the epiglottis. He gargled 10 mL 0.5% lidocaine in the sitting position. We advanced a 3.1-mm pediatric fibreoptic bronchoscope (FOB) through an orally inserted nasopharyngeal airway to identify the glottis and sprayed 0.5% lidocaine onto the airway mucosa. We replaced the airway with a reinforced 6.5-mm internal diameter tracheal tube (TT), advanced the FOB through it until its tip was just above the carina, and then advanced the TT into the trachea. After iv induction of general anesthesia, the surgeon performed a tonsillectomy and drained the neck abscess. Postoperative direct laryngoscopy revealed a markedly improved airway lumen and tracheal extubation over a Cook Airway Exchange Catheter was uneventful. The patient was stable in the recovery room, and was discharged on the third postoperative day. We present an innovative technique of fibreoptic intubation in an awake patient with an inferior pole peritonsillar abscess.

Utility of airway exchange catheters in pediatric patients with a known difficult airway

To evaluate the utility of the Cook airway exchange catheter (CAEC) for extubation/reintubation in pediatric patients with a known difficult airway. Prospective, nonrandomized. Pediatric intensive care unit; single academic institution. Twenty intubated children </=18 yrs of age with a known difficult airway requiring extubation. The CAEC was inserted into the trachea before extubation in children with a known difficult airway who were at risk for a difficult reintubation. The CAEC provided a means of a "guided" reintubation while maintaining the ability to provide supplemental oxygenation directly into the trachea. The respiratory rate, oxygen saturation, and amount of oxygen administered were measured immediately before extubation and at 5-, 15-, 30-, and 60-min intervals thereafter. In addition, the child's ability to tolerate the CAEC was noted and rated (0 = tolerable without difficulty, 1 = tolerable with difficulty, 2 = intolerable). No sedatives were administered in the presence of the CAEC. The duration of the CAEC placement was dependent on the satisfaction of the child's airway patency as determined by the unlikely need for reintubation. Five of the 20 (25%) children who had been extubated were reintubated in the intensive care unit with the assistance of the CAEC. Three of the five (60%) children were reintubated for upper airway obstruction. The ability to provide supplemental oxygen through the CAEC into the trachea during reintubation diminished the potential for hypoxia and maintained the ability to reintubate the trachea using the CAEC as a guidewire to pass an endotracheal tube. In children with a known difficult airway who are at risk for a difficult reintubation, the CAEC is a useful tool for a trial of extubation in the intensive care unit.

Use of the Cook Airway Exchange Catheter® to Facilitate Fiberoptic Intubation: Are We Trying to Solve a Problem That We Created?

American University of Beirut, Beirut, Lebanon. chakib.ayoub@aub.edu.lbIn Reply:—Thank you for referring to me the letter of Drs. El-Orbany, Klimas-Osolkowski, and Salem. We agree with Dr. El-Orbany et al. that the difference between the OD of the fiberoptic bronchoscope (FOB)(3.8 mm) and the ID of the endotracheal tube (ETT) (7.5–8 mm) contributed to the high incidence of failure in advancing the ETT over the FOB. However, in our department and in many other institutions, the 3.8 mm FOB may be the only available size. In order to solve this problem, multiple maneuvers have been suggested to facilitate the advancement of the ETT, such as 90-degree anticlockwise rotation and designing different tube tips. 1Moreover, we have designed a removable conical polyvinyl chloride sleeve to sheath the insertion cord of the FOB, which increases its size from 3.8 mm to 5.5 mm; the use of this sleeve technique increases the incidence of successful advancement from the first attempt to 96%. 2Our report shows that failure from the first attempt when using the FOB alone amounts to 32%. It is only in these failed attempts that we introduced the Cook Airway Exchange Catheter® (Cook Critical Care, Bloomington, IN), which increased the success rate up to 9 of 16 from the first attempt. Also, as mentioned in our manuscript, when the ETT tube failed to pass over the FOB to the trachea, the FOB was not withdrawn, and the tip of the ETT tube was kept in close proximity to the glottis, which facilitated the introduction of the Cook Airway Exchange Catheter® from the first attempt.In conclusion, we agree with Dr. El-Orbany et al. that the use of a proper technique is the best prophylaxis against the failure of ETT advancement over the FOB. However, we can still encounter failure to advance the tube over the FOB despite the use of a larger FOB or a smaller tube size, the application the jaw thrust maneuver, generous lubrication, and 90-degree counterclockwise rotation. It is this situation that the introduction of Cook Airway Exchange Catheter® can centralize the tube in front of the glottis and facilitate advancement.

Facilitation of passing the endotracheal tube over the flexible fiberoptic bronchoscope using a Cook airway exchange catheter.

Facilitation of passing the endotracheal tube over the flexible fiberoptic bronchoscope using a Cook airway exchange catheter.

Rapiscope™—a portable fibre optic device to establish endotracheal tube position

AbstractClinical methods to determine endotracheal tube position are unreliable. The Oesophageal Detector Device and capnometry allow a quick and reliable assessment of tube position (oesophageal vs airway), but neither can differentiate between a tracheal or bronchial tube position. The Rapiscope™ (Cook Critical Care, Bloomington, USA) is a battery powered, ultralight fibrescope designed to visualise upper airway anatomy and to confirm the endotracheal tube position. The Cook Airway Exchange Catheter™ is designed to be used with the Rapiscope™ and to protect the fibre optic.During experiments with intubated minipigs, an additional, identical tube was inserted into the oesophagus. Anaesthetists and medical students were asked to determine the position of one of the tubes (randomly chosen after disconnection of the pig from the ventilator) using the Rapiscope™ with and without the Cook Airway Exchange Catheter. The decision (tracheal or oesophageal) was then confirmed with the Oesophageal Detector Device and subsequently, whether tracheal or bronchial, was checked with a conventional endoscope. The time needed to determine the tube position was recorded.Using the Rapiscope™ either alone or with the Cook Airway Exchange Catheter it was not possible, in most cases, to determine the correct tube position. The failure in establishing tube position was caused by the ‘foggy’ optic. The visibility could not be improved by using the Cook Airway Exchange Catheter or by oxygen insufflation. Consequently, the use of the Rapiscope™ cannot be recommended at this stage.