We recently encountered a case that required extubation strategy for difficult airway as recommended by American Society of Anesthesiologists task force.1A 50-yr-old lady underwent segmental mandibulectomy and radical neck dissection with deltopectoral flap for carcinoma parotid gland. At the end of surgery the oral endotracheal tube was left in place and she was shifted to the intensive care unit.

In the absence of either a jet stylet2or commercially available tube changer3that is “rigid to facilitate intubation and/or hollow to facilitate ventilation,”1we thought of using a readily available tube changer. We were wary of using the previously described tube changers because of their lack of lumen to provide oxygen,4lack of stiffness,4–6or small external diameter.4,5Therefore, we decided to test these on mannequins (Ambu International, Copenhagen, Denmark). In the course of our experiments we realized that the sheath provided with Fogarty catheters (Willy Rusch AG, Kernen, Germany) is hollow and stiff and has a length of 80 cm and a varying external diameter (3–5 mm for sheaths of 6-French, 7-French, and 8-French Fogarty), making it a potentially good tube changer. We tested it on mannequins and found that it was successful in guiding the endotracheal tube every time and was adequate for both oxygen insufflation and jet ventilation.

We extubated the trachea of our patient over this tube changer (sheath of Fogarty 8-French), confirmed its correct position by end-tidal carbon dioxide monitoring before and after extubation, and kept it in place for over 2 h, giving oxygen at 4 l/min for the initial 30 min. For monitoring the end-tidal carbon dioxide we connected the sample line of the side-stream capnometer (Capnomac Ultima; Datex Ohmeda Division Instrumentarium Corporation, Helsinki, Finland) to the machine end of the Fogarty sheath (it could be easily screwed into the machine end). On the other hand, for delivering oxygen, we could slide the oxygen delivery tubing from the wall-mounted flowmeter over the machine end of the Fogarty sheath. We also tried keeping both carbon dioxide sampling tube and oxygen delivery tube together after mounting a three-way connector to the machine end of our tube changer (carbon dioxide sampling tube on the side port and oxygen delivery tube on the end port). The problem with this arrangement was that the end-tidal carbon dioxide readings became too low at oxygen flow rates greater than 1.5 l/min. The patient tolerated our tube changer well until it was removed; our patient did not require reintubation.

We feel that in the absence of a commercially available tube changer, this tube changer fulfills all the criteria of rigidity, hollowness, and length required of such a device.1Its two minor limitations are 1) its nonstreamlined tip, which is of little practical consequence if it is used correctly when it passes through an already placed endotracheal tube and remains in mid-trachea and 2) its material is probably not tested for tissue compatibility.

* Maulana Azad Medical College and Associated Hospitals, New Delhi, India. rakeshrampal@hotmail.com

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