Endotracheal Tube Exchange Research Articles

To the Editor

We thank Dr. Dongelmans and his coworkers for their interest in our study (July 2004) 1 Ferraro F Capasso A Troise E et al. Assessment of ventilation during the performance of elective endoscopic percutaneous tracheostomy: clinical evaluation of a new method. Chest. 2004; 126: 159-164 Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar and for sharing their data. We agree that the use of a small-sized scope (⊘, < 4 mm) generally may allow adequate ventilation around the bronchoscope during a percutaneous tracheostomy, but these smaller scopes also do not permit secretions to be adequately cleared from view. 2 Crockett JA Chendrasekhar A Fagerli JC et al. Assessment of ventilation during the performance of a percutaneous dilational tracheostomy: hypoventilation is not common complication. Am Surg. 1998; 64: 455-457 PubMed Google Scholar 3 Deblieux P Wadell C Mc Clarity Z et al. Facilitation of percutaneous dilational tracheostomy by use of a perforated endotracheal tube exchanger. Chest. 1995; 108: 572-574 Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar Nevertheless, a separate operator is required to maintain the withdrawn endotracheal tube with the cuff just above the vocal cords, a very proximal scope position that provides little margin for safety against extubation. 3 Deblieux P Wadell C Mc Clarity Z et al. Facilitation of percutaneous dilational tracheostomy by use of a perforated endotracheal tube exchanger. Chest. 1995; 108: 572-574 Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar 4 Mc Guire G El-Beheiry H Brown D Loss of the airway during tracheostomy: rescue oxygenation and re-enstablishent of the airway. Can J Anaesth. 2001; 48: 697-700 Crossref PubMed Scopus (20) Google Scholar We proposed our procedure because changing the endotracheal tube is safe when using a tube exchanger, even in cases of difficult airways, and ensures airway control during the whole procedure. 1 Ferraro F Capasso A Troise E et al. Assessment of ventilation during the performance of elective endoscopic percutaneous tracheostomy: clinical evaluation of a new method. Chest. 2004; 126: 159-164 Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar

Facilitation of alternative one-lung and two-lung ventilation by use of an endotracheal tube exchanger for pediatric empyema during video-assisted thoracoscopy

Video-assisted thoracoscopic surgery (VATS) has emerged as an innovative and popular procedure for the management of postpneumonic empyema in children refractory to medical response. Alternative uses of two- and one-lung ventilations have been required during VATS. This study evaluated the efficacy of alternating one- and two-lung ventilation through intraoperatively through the same single-lumen endobronchial tube using a tube exchanger during a thoracoscopic procedure for pediatric empyema. Between May 1995 and August 2001, 62 consecutive pediatric patients undergoing VATS for evacuation of the loculated empyema cavity were studied. The same single-lumen endobronchial tube was used, with an indwelling endotracheal tube exchanger in place for readjustment of the tube position to provide alternation of one- and two-lung ventilations in a thoracosopic procedure. Duration of operation, heart rate, mean arterial pressure, peak airway pressure, an partial pressure of oxygen (PaO(2)) and carbon dioxide (PaCO(2)) changes during one- and two-lung ventilations were recorded. The quality of lung deflation and inflation was rated by the surgeon using direct visualization as excellent, fair or poor. The mean operating time was 90 min (range, 50-120 min). No differences were found in heart rate, mean arterial pressure, or PaO(2) during one- and two-lung ventilations. Peak airway pressure and PaCO(2) during two-lung ventilation were significantly higher than during one-lung ventilation. The quality of lung deflation and inflation was judged excellent for all the patients. The VATS procedure can be performed safely and effectively in children using proper anesthetic technique. Retention of a tube exchanger within a single-lumen endobronchial tube an easily provide alternative one- and two-lung ventilations without inducing any significant airway flow obstruction during the operation.

A High-Risk Endotracheal Tube Exchanger

A High-Risk Endotracheal Tube Exchanger

Extubating the Difficult Airway-An Unusual Role for a Fogarty Catheter

Assistant Professor of Anesthesiology; Boston University Medical Center; Boston, MassachusettsTo the Editor:-The American Society of Anesthesiologists Task Force on Management of the Difficult Airway have made recommendations for an extubation strategy after difficult endotracheal intubation. [1]One of the components of this strategy involves the “short-term use of a device that can serve as a guide for expedited reintubation.” Jet stylets, tube exchangers, and even fiberoptic bronchoscopes have all been used for this purpose. [2,3]These instruments, however, are not always available, may be somewhat cumbersome to use, and may not be easily tolerated by the awakening patient.I would like to describe a technique that has given me increased confidence with extubation of the difficult airway. Before extubation, I pass a modified 6-French, 80-cm Fogarty arterial embolectomy catheter down the endotracheal tube. I then remove the endotracheal tube over the catheter, leaving the catheter in place (Figure 1). The Fogarty catheter is modified by cutting off the Luer-lock syringe connector. The catheter is extremely well tolerated, both orally and nasally, and may be left in place for some considerable time. (I have used the device on four occasions and no patient to date has even remarked on its presence.) If rapid reintubation proves to be necessary, the catheter is rigid enough to act as a stent for an endotracheal tube or tube exchanger. This technique is not a panacea for all situations of this type, and there is no reason to believe that it is immune to problems any more than all the others. However, with selective use, I believe it to be a valuable aid to extubation of the difficult airway.Glynne D. Stanley, M.D., F.R.C.A.Assistant Professor of Anesthesiology; Boston University Medical Center; Boston, Massachusetts(Accepted for publication September 17, 1998.)

Use of Plastic Rod/Sleeve Combination to Facilitate Double- to Single-Lumen. Tracheal Tube Exchange in Patients with Difficult Glottic Visualization

To the Editor: For some time, we have used an 80-cm length of 3.2-mm (1/8-in.) diameter nylon rod as an inexpensive double-lumen tracheal tube exchanger. Because sliding a large-diameter tube through the glottic orifice over a narrow guide can be difficult, however, we now use a longer (110 cm) segment of 3.2-mm (1/8-in.) diameter nylon rod (Cadillac Plastic Co., Metairie, LA) in combination with a sleeve consisting of a 72.5-cm length of 4.3-mm inner diameter, 6.4-mm outer diameter high-density polyethylene tubing (e.g., a JEM 400 Endotracheal Tube Exchange Catheter; Instrumentation Industries, Bethel Park, PA) to facilitate double- to single-lumen tube exchange. The rod is cut to length and its ends are smoothed with fine sand paper. Depth of insertion rings are drawn 25 cm from either end of the rod and sleeve using a black marking pen (Figure 1). The rod and sleeve are washed, permitted to dry, packaged together, and gas sterilized.Figure 1: Top, A 110-cm length of 3.2-mm (1/8-in.) diameter nylon rod; middle, a 70-cm high-density polyethylene endotracheal tube exchange catheter; bottom, a 35F double-lumen tracheal tube.After assuring maximal patient oxygenation and neuromuscular blockade, a laryngoscopist inserts a laryngoscope to open the airway and to achieve the best obtainable view of relevant anatomic structures. An assistant then 1) disconnects the double-lumen tube from the breathing circuit, 2) inserts the nylon rod until the first black ring reaches the incisors, 3) withdraws the double-lumen tracheal tube, 4) slides the sleeve over the rod to align the (inserted end) black rings of both at the teeth, 5) removes the rod, and 6) slides the single-lumen tube over the sleeve to the appropriate depth. During the exchange, the laryngoscopist uses a free hand to consecutively stabilize the double-lumen tube, rod, sleeve, and single-lumen tube. Correct position of the single-lumen tube is then verified using accepted methods. The technique should be practiced on a mannequin before it is used in a patient. P. Renae Griffin, MD*[dagger] Mark R. Mitchell, MD* Susheela Viswanathan, MD*[dagger] James M. Riopelle, MD*[dagger] Carol E. Campbell, MD*[dagger] Daniel J. Karpan, RN[double dagger] *Department of Anesthesiology; Louisiana State University Medical Center-New Orleans [dagger]Anesthesia Department; Charity Hospital of New Orleans [double dagger]Charity-Xavier School of Nurse Anesthesiology; New Orleans, LA 70112

Tracheal Injury

Tracheal Injury

Facilitation of Percutaneous Dilational Tracheostomy by Use of a Perforated Endotracheal Tube Exchanger-To the Editor

We have read Dr. Cooper's letter with great interest and are anxious to enhance dialogue concerning percutaneous dilational tracheostomy. In reviewing the article by Cooper et al (Can J Anaesth 1993; 40A71), their endotracheal tube exchanger not only offers security from insufficient extubation, but also provides a mode of mechanical ventilation. We did not utilize the endotracheal tube exchanger as a mode of ventilation, but rather as a safety and security measure (CHEST 1995; 108:572-74). Facilitation of Percutaneous Dilational Tracheostomy by Use of a Perforated Endotracheal Tube Exchanger-To the EditorCHESTVol. 109Issue 4PreviewWe read with interest the report of Deblieux and colleagues (CHEST 1995; 108:572-74) in which they described a modification of the percutaneous dilational tracheostomy procedure using a commercial tube exchanger. They concluded that such a technique enhances the safety of the procedure, having developed this modification as a result of the premature endotracheal extubation, which occurred in two of their initial eight patients. Full-Text PDF

Facilitation of Percutaneous Dilational Tracheostomy by Use of a Perforated Endotracheal Tube Exchanger

Endoscopic guidance during percutaneous dilational tracheostomy reduces the risk of paratracheal insertion of the tracheostomy tube but may impair ventilation and does not eliminate the possibility of premature endotracheal extubation. Use of a small-caliber, hollow endotracheal tube exchanger during stomal dilation in lieu of a fiberoptic bronchoscope allows for better ventilation and more secure airway control.

The effect of endotracheal tube exchange with tube exchanger device on arterial oxygen saturation and heart rate

There are several situations where the indications for changing an endotracheal tube is absolute and relative in ICU. Intubation times of 7 days or less have a low but significant incidence of serious sequelae in the modern ICU settings. In general, three techniques (Direct laryngoscopy, Tube exchangers, Fiberoptic bronchoscopy) are available for changing endotracheal tube. Each techniques is examined in terms of its advantages and disadvantages, along with its potential complication. The majority of anesthesiologists are familiar with direct laryngoscopy, however, the technique has some serious potential disadvantages. Direct laryngoscopy involves a significant stress on the cardiovascular system. Either this stress or the sedation that may be given to blunt it may be deleterious in a marginal patients. Use of tube exchangers have become popular because of their relative simplicity, widespread availability, and their potential for providing oxygenation, minimal need for sedatives and little hemodynamic insult, atraumatic teehniques. Ineluded in the study were 43 patients scheduled for changing of endotracheal tube admitted at ICU. The purpose of the present study is to compare with time, pulse rate, SaO2 between direct laryngoscopy and tube exchangers so as to endotracheal reintubation. The results were as follows. 1) Use of 19F sized tube exchanger, 21 cases were succeeded among 21 cases, but 3 cases were succeeded among 8 cases using 11F sized tube exchangers. 2) In the tube exchanger group, 28 cases among 29 cases were succeeded without use of sedatives or muscle relaxant. In laryngoscopy group, 10 cases among 14 cases were succeeded use of sedatives, 4 cases among 14 cases were succeeded use of muscle relaxants. 3) SaO2 was significantly lower in direct laryngoscopy group than tube exchanger group after tube exchange.

Severe laryngotracheobronchitis complicating measles.

To determine the incidence of severe measles-related laryngotracheobronchitis in patients hospitalized during a recent measles epidemic and to evaluate factors associated with severity of airway injury and its management. Clinical description of patient series. Children's hospital and county general hospital, Houston, Tex. One hundred twenty-four children (aged 1 month to 19 years) admitted with a diagnosis of measles. None. Twenty-seven patients had significant laryngotracheobronchitis, including 10 who had not received appropriate immunization. Six patients required endotracheal intubation for relief of upper airway obstruction. The median age of patients requiring intubation was 12 months (range, 4 to 24 months). Two patients died of complications of superinfection. Two patients survived but required prolonged intubation. Two patients underwent early diagnostic laryngoscopy and bronchoscopy and required shorter artificial airway maintenance. Severe laryngotracheobronchitis frequently occurs in patients younger than 2 years hospitalized with measles and may be related to bacterial or viral super-infection. Early diagnostic laryngoscopy and bronchoscopy for injury assessment and possible endotracheal tube exchange are recommended and, in some severe cases, tracheostomy should be considered to shorten artificial airway maintenance and decrease the incidence of airway complications.

Endobronchial rupture from endotracheal reintubation with an endotracheal tube guide

Endotracheal tube guides are often used to facilitate endotracheal tube exchange in patients whose airways are difficult to intubate. The absence of reported complications with this technique suggests it is a safe technique; however, we report a case of endobronchial rupture associated with such a guide. Diagnosis and management of tracheobronchial tears and alternative approaches to difficult reintubation are described.