Double Intubation via an Endotracheal Tube Exchanger
Meghan Ficarotta, MD and Andrea Gabrielli, MD
Department of Anesthesiology, University of Florida, Gainesville, Florida
Endotracheal tube exchangers may effectively and safely facilitate the
exchange of an endotracheal tube (ETT) and the reintubation of patients.
These thin, flexible, hollow tubes may also be used to insufflate oxygen,
monitor end tidal CO2, and provide jet ventilation in emergency situations.
A 27 y/o, 136kg man was admitted to SICU after high speed, ejection MVA. The
patient was intubated in the emergency department, however no details were
recorded. The anticipated duration of intubation was less than one week.
On the second hospital day, the patient was noted to have a cuff leak that
prevented adequate tidal volumes for oxygenation. Due to the patient’s
morbid obesity, cervical spine immobilization, large protruding tongue, and
small mouth opening, a difficult intubation was anticipated. In an effort to
avoid tracheostomy, the decision was made to attempt replacement of the ETT.
To avoid a possible emergent surgical airway, it was planned to place a
second ETT prior to removing the initial ETT. Direct laryngoscopy with a
Macintosh #3 blade revealed a Cormack-Lehane grade IV view. With the
assistance of laryngoscopy, a fiberoptic intubation over a bronchoscope was
attempted. Due to distorted anatomy, excess soft tissue, and the limited
mouth opening, this was unsuccessful. With the continued assistance of the
laryngoscope, a tube changer was blindly manipulated through the vocal
cords, without significant resistance or trauma. The bronchoscope confirmed
the placement of the tube changer into the trachea, alongside of the ETT. A
second 7.0 ETT was then maneuvered over the tube changer. Correct
positioning was confirmed by the bronchoscope and the initial ETT was
removed. The patient was subsequently extubated on the eighth hospital day
with no complications noted to phonation.
It was not until the late 1980s that publications began to report
endotracheal catheters used for tube exchange (3). Several case reports have
reiterated success with airway exchange catheters, but have additionally
urged caution, citing serious complications and failure of tube exchange
(4,5). Some causes of a failed exchange have been due to the inability of
the ETT to pass over the exchange catheter, and the ETT getting caught on or
damaging anatomy such as the arytenoids or epiglottis. More serious but rare
complications have included endobronchial rupture and lung laceration (6,7).
In this patient, damage to the arytenoids could have occurred from the blind
placement of tube changer and ETT. Damage to the vocal cords secondary to
temporary pressure from two endotracheal tubes was also a potential risk.
Ultimately, it was felt that the risks of an ETT exchanger were outweighed
by the benefit of avoiding an emergent surgical airway and the potential
difficulties or complications from a short term, immature tracheostomy in a
morbidly obese man (8).
References:
1. Dosemici L, et al. 2004. Critical Care.8: R385-390
2. Hartmannsgruber M, et al. 1998. Anesthesiology 88: 1683
3. Rosenbaum S, et al. 1981. Anesthesiology 54: 169-170
4. Cooper, et al. 1994. Canadian J of Anesthesiology 41 (12): 1196-1199
5. Benumof J. 1997. Chest 111 (6): 1483-1486
6. Seitz P, Gravenstein N. 1989. J Clin Anesthesiology 1 (3): 214-217
7. Luiz G, et al. 1991. Anesth Anal 73: 350-351
8. Francois et al. Chest. 2003;123:151-158
