An underappreciated risk of an airway exchange catheter
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CORRESPONDENCE
An underappreciated risk of an airway exchange catheter Julena Foglia, MD
. John Guy, MD, FRCPC
Received: 23 September 2019 / Revised: 8 October 2019 / Accepted: 8 October 2019 Ó Canadian Anesthesiologists’ Society 2019
To the Editor, The airway exchange catheter (AEC) is a valuable tool to facilitate safe endotracheal tube (ETT) exchange,1 and has been incorporated into the Difficult Airway Society algorithm for stepwise extubation of known difficult airways.2 Despite its reported successes, the potential for complications from AEC use must be understood. The most common complications reported include airway injury (including tracheal-bronchial disruption), pneumothorax, as well as the loss of airway.3–5 Failure rates for single-lumen ETT exchanges have been reported to be as high as 9.3%.4 Herein, we present a unique experience during a case for mandibular fixation with postoperative jaw wires where a failed ETT exchange with an AEC resulted in a near loss of the airway. Written consent was obtained prior to the composure of this letter. The patient was a 56 yr-old healthy adult male who obtained isolated facial injuries after a mechanical fall resulting in bilateral anterior mandible fractures and a right condylar fracture. An awake nasal flexible bronchoscopic (FB) technique was used to secure the airway with a size 8.0 Parker Flex-TipÒ (Model: H-PFHV-80, Parker Medical; Highlands Ranch, CO, USA) ETT. There was a moderate amount of dried blood and minor oropharyngeal bleeding, but visualization was adequate, and FB-assisted nasal intubation was uneventful. Approximately two minutes after the ETT
J. Foglia, MD (&) Department of Anesthesiology, Pharmacology, & Therapeutics, University of British Columbia, Vancouver, BC, Canada e-mail: [email protected]
was secured, there were difficulties with ventilation due to an air leak from a ruptured ETT cuff. To facilitate ETT exchange, an 83 cm long Cook Airway Exchange Catheter (Model: C-CAE-19.0-83, Cook Medical; Bloomington, IN, USA) was gently advanced inside the ETT until resistance was met. Immediately after, two attempts at pulling the ETT over the AEC were met with resistance preventing the ETT from being removed. Subsequently, a GlidescopeÒ (Model: Video monitor 0570-0338 with LoPro 3 blade, Verathon Medical (Canada) ULC; Burnaby, BC, Canada) was cautiously inserted to assess the supraglottic area. As seen in the Figure, the tip of the AEC had passed through the murphy eye of the ETT, and then in a retrograde manner had looped back on itself and kinked in the trachea. Seeing this tortuous path of the AEC, we attempted to pull back the AEC into the ETT. Nevertheless, significant resistance was met because of kinking of the AEC at the ETT murphy eye. Therefore, under GlidescopeÒ guidance, the kinked AEC and ETT were removed en bloc and the patient was successfully re-intubated orally. The patient was followed up postoperatively for five days, and there were no apparent sequelae. The use of AECs are frequently seen in clinically diffi
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