To the Editor:—

Occasionally, it is necessary to change a nasally placed endotracheal tube to an orally placed one. 1There is significant risk of losing control of the airway during this procedure, especially in the case of a difficult intubation. A 19-yr-old man who sustained a C5 fracture that resulted in quadriplegia was nasotracheally intubated. When pneumonia developed, the patient required mechanical ventilation. We were asked to change the nasal endotracheal tube to an orotracheal tube. This intervention was complicated by the fact that a halo was used on the patient, causing initial difficulty in intubation.

We decided to maintain the position of the endotracheal tube and convert from nasal to oral. The patient’s airway was treated with topical local anesthetic, and he was sedated using intravenous propofol. Laryngoscopy was performed using a Macintosh 3 blade. The endotracheal tube was visualized and grasped with a Kelly clamp as high behind the uvula as possible. An assistant cut the tube at the 28-cm mark. The Kelly clamp was used to move the tube deeper into the trachea. The laryngoscope was removed, and a finger was placed in the mouth behind the endotracheal tube. The tube was brought out through the mouth, the adapter was reattached, and the ventilator circuit was connected. A carbon dioxide sensor was used to ensure that the tube was still endotracheal, breath sounds were checked, and the tube was retaped.

The equipment necessary for difficult intubation was available in case the tube was inadvertently removed from the trachea. This technique is an easy, atraumatic alternative to changing a nasal to an oral endotracheal tube.

Seiden AM: Sinusitis in the critical care patient. New Horiz 1993; 1: 261–70