To the Editor:- We read with great interest the description by Dr. Cooper of his conversion of a nasal to an orotracheal intubation using an endotracheal tube changer via manipulation of a flexible endotracheal ventilation tube exchanger from the nasal passage into the oropharynx with two Magill forceps (Anesthesiology 1997; 87:717–8). The technique seems rather cumbersome, traumatic, and perhaps a bit risky. Although it is easy to thread a flexible tube exchanger through an endotracheal tube, it lacks the rigidity needed to thread the replacement tube over the catheter. In addition with the pulling by the Magill forceps, one would have to be concerned about the possibility of the catheter being inadvertently pulled out of the trachea and of losing control of the airway in a patient in whom the glottis could not be directly visualized. A similar situation occurred at our institution during which a conversion of a nasal to an orotracheal intubation became necessary.
Briefly, the patient was an unhelmeted 28-yr-old man who presented to the trauma emergency department after a motorcycle accident. He was unconscious and unresponsive at the scene. A hard cervical collar was placed. Orotracheal intubation was difficult. He was then nasally intubated at the accident site with a 7.0-mm cuffed endotracheal tube. He presented to the emergency department with a Glasgow Coma Scale (GCS) score of 6. A head computed tomography scan without contrast revealed a left zygoma fracture, fracture at the tip of the C5 spinous process, and a mid-internal capsular bleed on the right side. On hospital day six he developed sinusitis on the right side. The decision was made to convert to an orotracheal intubation. We elected to intubate the trachea fiberoptically. The patient was given intravenous glycopyrrolate, 0.2 mg. Amnesia was afforded by intravenous midazolam, 2 + 2 mg. Finally, skeletal relaxation was attained with rocuronium, 50 mg (0.6 mg/kg). The fiberoptic scope was passed through an 8.0-mm cuffed endotracheal tube. The tip of the scope was then guided through an Ovassapian airway, and the existent nasotracheal tube was followed into the trachea. The nasotracheal tube was then withdrawn by an assistant. The tracheal rings and carina were reidentified, and the new tube was passed over the fiberoptic scope into the trachea. The entire procedure from setup to completion required 15 min, and the actual conversion took less than 1 min. The patient was extubated 5 days later without complications.
Raymond U. Tapnio, M.D.
Oscar J. Viegas, M.D.
Associate Professor; Department of Anesthesia; Indiana University/Wishard Memorial Hospital; Indianapolis, Indiana