To the Editor:--Several devices have been described for use when an orotracheal tube is changed for a nasotracheal tube in a patient with a compromised airway. Most of these devices rely on direct visualization of the vocal cords. One of the authors (Niimi) has designed, in collaboration with Cook, Inc., an endotracheal tube exchanger (Patil Two-Part Intubation Catheter, Cook, Bloomington, IN) that does not require direct visualization. We describe a case of a patient with actively bleeding esophageal varices in which this newly designed endotracheal tube exchanger was used.
A 66-yr-old woman with liver cirrhosis presented with massive bleeding from esophageal varices. The trachea was orally intubated in the emergency room. The endotracheal tube developed a cuff leak, and we were asked to reintubate the trachea nasally to facilitate a hemostasis manipulation. Because the blood in the oropharynx was expected to make direct visualization difficult, we decided to use the endotracheal tube exchanger.
This endotracheal tube exchanger consists of two parts, a tracheal part and an extension part, which can be firmly connected end-to-end. They contain a hollow lumen, which allows jet ventilation.
To use this endotracheal tube exchanger, the patient's left naris was prepared by the application of topical anesthesia and vasoconstrictor. The extension component of an endotracheal tube exchanger was passed through the left naris into the nasopharynx, and its end withdrawn from the mouth with Magill forceps. A tracheal component was placed through the original orotracheal tube (Figure 1). The 25-cm marking of the tube exchanger was kept at the lips during the endotracheal tube exchange. The original orotracheal tube was removed, and the tracheal part was connected to the extension part (Figure 2), thereby forming a loop at the mouth. The end of the extension part was connected to a jet ventilation source, and jet ventilation was resumed immediately. The nasal end of the extension part was withdrawn slowly from the left naris to straighten the tube exchanger until the loop disappeared. A new endotracheal tube was threaded into the trachea over the whole endotracheal tube exchanger.
Many techniques of oral-to-nasal endotracheal tube exchange have been used in patients with bleeding esophageal varices. Direct laryngoscopy and fiberoptic bronchoscopy are the most popular and reliable methods of tracheal intubation, but they rely on direct visualization, which was severely compromised in this case. Moreover, both techniques disrupt ventilation until a new endotracheal tube is placed properly. Although the combination of a fiberoptic bronchoscope and an endotracheal tube exchanger is a well established method of exchanging endotracheal tubes and allows continuous ventilation, it is not ideal in this case, because it is difficult to introduce the fiberoptic bronchoscope into a trachea in the presence of blood.
We found four major advantages to using the newly designed endotracheal tube exchanger. First, it does not rely on direct visualization. Second, it minimizes the disruption of ventilation during the endotracheal tube exchange. Third, it is easier to perform than laryngoscopy and fiberoptic bronchoscopy. Last, and most important is the security afforded by introducing the endotracheal tube exchanger through the original endotracheal tube to minimize the chances of losing control of the airway.
One disadvantage of this technique is, if a new endotracheal tube does not go into the trachea for any reason, the airway must be secured immediately by laryngoscopy, cricothyroidotomy, et cetera. Therefore, we suggest that only well trained anesthesiologists or intensivists familiar with and experienced in emergency airway management attempt to use this technique.
Yoshinori Nakata, M.D., Clinical Fellow, Department of Emergency Medicine, Yale New Haven Hospital, 20 York Street, New Haven, Connecticut 06504.
Yoshinari Niimi, M.D., Ph.D., Associate Professor, Department of Anesthesiology, Teikyo University School of Medicine Ichihara Hospital, 3426–3 Anesaki, Ichihara, Chiba 299–01, Japan.