To the Editor:—
We read with interest the case report by Dr. Baraka 1and Dr. Benumof’s accompanying editorial 2regarding difficulties associated with the use of an airway exchange catheter. The following case shows a potential pitfall of using the catheter to exchange tracheostomy tubes, a previously unreported use of the device.
A 67-yr-old man who had a fresh tracheostomy for prolonged ventilatory support required fiberoptic bronchoscopy for evaluation of hemoptysis. Because of concerns that bronchoscopy would be difficult via the tracheostomy tube (Shiley-6; Mallinckrodt Inc., Critical Care Division, St. Louis, MO), a plan was formulated to change to the next larger sized (Shiley-8) tube using an airway exchange catheter (JEM Instrumentation Industries, Bethel Park, PA). The catheter was inserted, and the old Shiley-6 tube was removed easily. However, difficulties occurred when attempting to position the new Shiley-8 tube, which was fenestrated. With its inner cannula in place, the tracheostomy tube would not slide over the airway exchange catheter, even with liberal lubrication. With the inner cannula removed, the catheter tended to protrude through the fenestration instead of traversing the curvature of the tracheostomy (fig. 1). After several unsuccessful attempts of guiding the exchange catheter through the tracheostomy tube channel, we abandoned the technique and subsequently secured the airway with conventional laryngoscopy and intubation. When the bronchoscopy was completed, we reinserted a tracheostomy tube under fiberoptic guidance. Afterward, we learned via an ex vivo trial that the airway exchange catheter would bypass the fenestration and pass through the tracheostomy tube if the end of the catheter first were bent into a curve, mimicking the curvature of the tracheostomy tube.
Tracheostomy tubes, frequently placed surgically in critically ill patients who require prolonged airway access and ventilatory management, 3occasionally need to be changed. Attempting to change a fresh tracheostomy tube before maturation of the tracheal cutaneous tract (typically 5–7 days) 3may result in dissection between tissue planes, creating a false passage and loss of the airway.
The airway exchange catheter may be of benefit when a tracheostomy tube must be changed before maturation of the tracheal cutaneous tract. Use of the airway exchange catheter for tracheostomy tube exchange, although intuitive, has not been described previously. The preceding case was presented to highlight that potential difficulties may not be apparent readily when using an airway exchange catheter for an unconventional application, such as changing a tracheostomy tube.
Obviously, we could have avoided this problem had we used a nonfenestrated tracheostomy tube, or even rehearsed the exchange maneuver ex vivo . However, we proceeded with the equipment we had at hand and did not anticipate any difficulty because of our previous experience with airway exchange catheters. Clearly, such experience was insufficient to predict that the lack of flexibility of the tracheostomy tube would limit the excursion of the airway exchange catheter.
In conclusion, although use of an airway exchange catheter may be intuitive in exchanging tracheostomy tubes, we strongly encourage ex vivo rehearsal with the catheter and tracheostomy tube before performing the exchange to ensure a smooth, efficient procedure.
*The Cleveland Clinic, Cleveland, Ohio. email@example.com