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Simultaneous oral and nasal tracheal intubation utilizing a fiberoptic scope in a patient with facial trauma
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Simultaneous Oral and Nasal Tracheal Intubation Utilizing a Fiberoptic Scope in a Patient with Facial Trauma Stephen K. Patteson, MD,* Jerry L. Epps, MD,? Jeff Hall, MDT Department of Anesthesiology, ville, Tennessee
We report a case of an oral intubation in a facial trauma patient that required exchanging the oral tube to a nasal endotracheal tube. This was accomplished @ utilizing the fiberoptic bronchoscope to introduce a nasal tracheal tube beside the oral tube pior to removal of the oral tube from the trachea. This allowed continuation of oxygenation and ventilation until the airway was subsequently secured with the nasal tracheal tube. This approach may help avoid the loss of the airway and subsequent intervention with a surgical airway under poor conditions. Keywords: oral.
Facial trauma, fiberoptic,
intubation,
nasal,
Introduction Obtaining an airway in the facial trauma patient provides the anesthesiologist with a challenge. Changing an oral endotracheal to nasal endotracheal tube may be difficult under the best of circumstances. While the fiberoptic bronchoscope has been previously utilized and endorsed to change endotracheal tubes, to date no one has described a method that allows continued ventilation and oxygenation during this exchange.l-JWe present a case of facial trauma that required exchanging an oral to nasal endotracheal tube for facial surgery. This approach allows
*Associate Professor tAssistant Professor $Resident Received for publication February 17, 1995; revised manuscript accepted for publication June 13, 1995. Journal of Clinical Anesthesia 83258-259, 1996 0 1996 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
University
of Tennessee
Medical
Center,
Knox-
continued maintenance of the initial airway until the second endotracheal tube is secured. The need for a surgical airway may be avoided in some cases.
Case Report A 34year-old white male (195 cm, 115 kg) presented to the emergency department after falling approximately 50 to 60 feet from a “cherry picker.” Injuries consisted of soft tissue trauma and a 25 cm complex submandibular laceration of the cervical region of the neck, anterior maxillary fractures with hard palate fractures, bilateral maxillary ridge fractures with left posterior maxillary sinus involvement, and a comminuted fracture of the left mandible. Computed tomography (CT) of the head demonstrated LeFort I midface fractures. There were multiple upper extremity injuries. Lower extremity and spinal injuries included Ll-5 fractures with resultant paraplegia secondary to 60% spinal stenosis at Ll, and fractures of the right foot and left tibia. Radiographic dye studies of the carotid arteries and aortic arch revealed that they were free of injury. The cervical spine sustained no injuries. The patient was intubated orally (7.5 mm ID tube) in the emergency department with relative ease. He presented to the operating room (OR) 11 hours later after extensive diagnostic studies. The patient was scheduled for multiple upper and lower extremity repairs and open reduction and fixation of facial fractures. The oral facial surgeon requested a nasal endotracheal tube for completion of the facial surgery. Central venous access and arterial catheterization was accomplished in the critical care unit prior to transportation to the OR. Under general anesthesia with neuromuscular relaxation, oral direct laryngoscopy allowed epiglottis and oral tracheal tube visualization. A substantial amount of epi-
0952.8180/96/$15.00 PII SO952-8180(96)00022-0
glottic and posterior pharyngeal edema was present. An attempt to place a right nasal tube resulted in a submucosal dissection of the posterior pharynx. A left nasal tube was introduced into the oral cavity without difficulty. Direct laryngoscopy allowed visualization of the epiglottis, oral tracheal tube, and the nasal tube in the far right piriform fossa. The oral tracheal tube was removed under direct visualization. An attempt at introducing the nasal tube into the trachea was unsuccessful due to soft tissue encroachment that made direct passage of the nasal tube impossible. With difficulty the patient was reintubated orally with a 7.0 mm tube (Mallinckrodt, St. Louis, MO). Multiple attempts at manipulating the nasal tube into adequate position in the posterior pharynx were unsuccessful. A fiberoptic scope (Olympus LF-1, Olympus Corp, Lake Success, NY) with a previously loaded 7.0 mm endotracheal tube was introduced into the pharynx via the left naris. Under direct visualization, the fiberoptic scope was elevated with Magi11 forceps and directed anteriorly between the oral endotracheal tube and the epiglottis. The fiberoptic scope passed into the trachea easily after the cuff of the oral tracheal tube was deflated. The nasal tube was then passed over the fiberoptic scope and into the trachea beside the oral tube without undue force. The fiberoptic scope was removed, the oral tube occluded and end tidal carbon dioxide (ETCO,) was verified from the nasal tracheal tube with the cuff inflated. The fiberoptic scope was reintroduced through the nasal tube to the level of the carina and the oral tracheal tube was withdrawn. The fiberoptic scope was again withdrawn and ETCO, and bilateral breathsounds were verified. Due to the anticipated need for prolonged mechanical ventilation and documented sinus infection with fever, the patient received a tracheostomy on the ninth postoperative day. The patient was discharged from the hospital on the fortieth day able to speak using a fenestrated tracheostomy.
Discussion This case was complicated by several factors. The lengthy preoperative diagnostic work-up allowed time for increased tissue edema of the epiglottis and pharynx, making a previous uneventful intubation difficult or impossible. The hard palate fracture distorted the anatomy of the intraoral cavity, making subsequent identification and placement of the nasal tube extremely difficult. The lacerations and soft tissue injury over the anterior larynx combined with this patient’s short, thick neck would have made an attempt at tracheostomy extremely difficult or impossible.
The placement of the fiberoptic scope required two anesthetists working concurrently. Forceps were used gently to aid placement of the tip of the scope between the existing oral tube and the epiglottis while it was guided into the trachea by the assistant. Directing the fiberoptic scope anteriorly between the existing oral endotracheal tube and the epiglottis facilitates placement of the fiberoptic scope into the trachea. This seems to allow the scope to track along the existing tube and slide underneath the epiglottis into the trachea. The nasal tube then follows and displaces the oral tube downward. Nasal intubation with midface fractures is somewhat controversial; however, visualization with the fiberoptic scope prior to nasal tube insertion into a naris may decrease this risk. Concern about the ability to advance a second endotracheal tube through the vocal cords is justified. Failure of this approach could occur if the airway were not of sufficient diameter to accommodate two endotracheal tubes. Two 7.0 ID tubes (Mallinckrodt, St. Louis, MO) present a total outside diameter of 20 mm. However, a typical double lumen endotracheal tube 41 Fr. (Broncho-Cath, Mallinckrodt, St. Louis, MO) presents an outside diameter of 16 mm at the vocal cord level. Therefore, two single lumen endotracheal tubes are only slightl) larger than a standard double lumen tube. This method of securing nasotracheal intubation provides the advantage of dual tracheal airways without the period of time required to remove the original endotracheal tube and subsequently advance another endotracheal tube as previously described.‘-‘3 Alternatives such as insufflation via cannula, jet ventilation through the fiberoptic suction port or jet stylet, may allow oxygenation while attempting to secure the airway via other modalities. Our approach however offers the added advantage of proven subsequent endotracheal intubation (ETCO,, breath sounds, chest rise) prior to removing the initial endotracheal tube. Our approach for changing from oral to nasal intubation may be useful when loss of the airwa) cannot be tolerated even for short periods of time such as severe adult respiratory distress syndrome (ARDS) or when previous oral intubation has proven difficult.
References 1. Watson CB, Prough DS, Balestieri FJ: Bronchoscope tube change in critically ill patients. Cti’t &re Mrd 1980;8:246. 2. Rosenbaum SH, Rosembaum LM, Cole RP, &kanaziJ, Hyman AI: Use of the flexible fiberoptic bronchoscope to change endotracheal tubes in critically ill patients. Anethesiolog? 1981;54:169-70. 3. U’atson CB: Use of fiberoptic bronchoscope to change endotracht=al tube endorsed [Letter]. Anesthesioloa 1981;55:47&7.
,J. Clin. Anesth., vol. 8, May 1996
259
Simultaneous Oral and Nasal Tracheal Intubation Utilizing a Fiberoptic Scope in a Patient with Facial Trauma Stephen K. Patteson, MD,* Jerry L. Epps, MD,? Jeff Hall, MDT Department of Anesthesiology, ville, Tennessee
We report a case of an oral intubation in a facial trauma patient that required exchanging the oral tube to a nasal endotracheal tube. This was accomplished @ utilizing the fiberoptic bronchoscope to introduce a nasal tracheal tube beside the oral tube pior to removal of the oral tube from the trachea. This allowed continuation of oxygenation and ventilation until the airway was subsequently secured with the nasal tracheal tube. This approach may help avoid the loss of the airway and subsequent intervention with a surgical airway under poor conditions. Keywords: oral.
Facial trauma, fiberoptic,
intubation,
nasal,
Introduction Obtaining an airway in the facial trauma patient provides the anesthesiologist with a challenge. Changing an oral endotracheal to nasal endotracheal tube may be difficult under the best of circumstances. While the fiberoptic bronchoscope has been previously utilized and endorsed to change endotracheal tubes, to date no one has described a method that allows continued ventilation and oxygenation during this exchange.l-JWe present a case of facial trauma that required exchanging an oral to nasal endotracheal tube for facial surgery. This approach allows
*Associate Professor tAssistant Professor $Resident Received for publication February 17, 1995; revised manuscript accepted for publication June 13, 1995. Journal of Clinical Anesthesia 83258-259, 1996 0 1996 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
University
of Tennessee
Medical
Center,
Knox-
continued maintenance of the initial airway until the second endotracheal tube is secured. The need for a surgical airway may be avoided in some cases.
Case Report A 34year-old white male (195 cm, 115 kg) presented to the emergency department after falling approximately 50 to 60 feet from a “cherry picker.” Injuries consisted of soft tissue trauma and a 25 cm complex submandibular laceration of the cervical region of the neck, anterior maxillary fractures with hard palate fractures, bilateral maxillary ridge fractures with left posterior maxillary sinus involvement, and a comminuted fracture of the left mandible. Computed tomography (CT) of the head demonstrated LeFort I midface fractures. There were multiple upper extremity injuries. Lower extremity and spinal injuries included Ll-5 fractures with resultant paraplegia secondary to 60% spinal stenosis at Ll, and fractures of the right foot and left tibia. Radiographic dye studies of the carotid arteries and aortic arch revealed that they were free of injury. The cervical spine sustained no injuries. The patient was intubated orally (7.5 mm ID tube) in the emergency department with relative ease. He presented to the operating room (OR) 11 hours later after extensive diagnostic studies. The patient was scheduled for multiple upper and lower extremity repairs and open reduction and fixation of facial fractures. The oral facial surgeon requested a nasal endotracheal tube for completion of the facial surgery. Central venous access and arterial catheterization was accomplished in the critical care unit prior to transportation to the OR. Under general anesthesia with neuromuscular relaxation, oral direct laryngoscopy allowed epiglottis and oral tracheal tube visualization. A substantial amount of epi-
0952.8180/96/$15.00 PII SO952-8180(96)00022-0
glottic and posterior pharyngeal edema was present. An attempt to place a right nasal tube resulted in a submucosal dissection of the posterior pharynx. A left nasal tube was introduced into the oral cavity without difficulty. Direct laryngoscopy allowed visualization of the epiglottis, oral tracheal tube, and the nasal tube in the far right piriform fossa. The oral tracheal tube was removed under direct visualization. An attempt at introducing the nasal tube into the trachea was unsuccessful due to soft tissue encroachment that made direct passage of the nasal tube impossible. With difficulty the patient was reintubated orally with a 7.0 mm tube (Mallinckrodt, St. Louis, MO). Multiple attempts at manipulating the nasal tube into adequate position in the posterior pharynx were unsuccessful. A fiberoptic scope (Olympus LF-1, Olympus Corp, Lake Success, NY) with a previously loaded 7.0 mm endotracheal tube was introduced into the pharynx via the left naris. Under direct visualization, the fiberoptic scope was elevated with Magi11 forceps and directed anteriorly between the oral endotracheal tube and the epiglottis. The fiberoptic scope passed into the trachea easily after the cuff of the oral tracheal tube was deflated. The nasal tube was then passed over the fiberoptic scope and into the trachea beside the oral tube without undue force. The fiberoptic scope was removed, the oral tube occluded and end tidal carbon dioxide (ETCO,) was verified from the nasal tracheal tube with the cuff inflated. The fiberoptic scope was reintroduced through the nasal tube to the level of the carina and the oral tracheal tube was withdrawn. The fiberoptic scope was again withdrawn and ETCO, and bilateral breathsounds were verified. Due to the anticipated need for prolonged mechanical ventilation and documented sinus infection with fever, the patient received a tracheostomy on the ninth postoperative day. The patient was discharged from the hospital on the fortieth day able to speak using a fenestrated tracheostomy.
Discussion This case was complicated by several factors. The lengthy preoperative diagnostic work-up allowed time for increased tissue edema of the epiglottis and pharynx, making a previous uneventful intubation difficult or impossible. The hard palate fracture distorted the anatomy of the intraoral cavity, making subsequent identification and placement of the nasal tube extremely difficult. The lacerations and soft tissue injury over the anterior larynx combined with this patient’s short, thick neck would have made an attempt at tracheostomy extremely difficult or impossible.
The placement of the fiberoptic scope required two anesthetists working concurrently. Forceps were used gently to aid placement of the tip of the scope between the existing oral tube and the epiglottis while it was guided into the trachea by the assistant. Directing the fiberoptic scope anteriorly between the existing oral endotracheal tube and the epiglottis facilitates placement of the fiberoptic scope into the trachea. This seems to allow the scope to track along the existing tube and slide underneath the epiglottis into the trachea. The nasal tube then follows and displaces the oral tube downward. Nasal intubation with midface fractures is somewhat controversial; however, visualization with the fiberoptic scope prior to nasal tube insertion into a naris may decrease this risk. Concern about the ability to advance a second endotracheal tube through the vocal cords is justified. Failure of this approach could occur if the airway were not of sufficient diameter to accommodate two endotracheal tubes. Two 7.0 ID tubes (Mallinckrodt, St. Louis, MO) present a total outside diameter of 20 mm. However, a typical double lumen endotracheal tube 41 Fr. (Broncho-Cath, Mallinckrodt, St. Louis, MO) presents an outside diameter of 16 mm at the vocal cord level. Therefore, two single lumen endotracheal tubes are only slightl) larger than a standard double lumen tube. This method of securing nasotracheal intubation provides the advantage of dual tracheal airways without the period of time required to remove the original endotracheal tube and subsequently advance another endotracheal tube as previously described.‘-‘3 Alternatives such as insufflation via cannula, jet ventilation through the fiberoptic suction port or jet stylet, may allow oxygenation while attempting to secure the airway via other modalities. Our approach however offers the added advantage of proven subsequent endotracheal intubation (ETCO,, breath sounds, chest rise) prior to removing the initial endotracheal tube. Our approach for changing from oral to nasal intubation may be useful when loss of the airwa) cannot be tolerated even for short periods of time such as severe adult respiratory distress syndrome (ARDS) or when previous oral intubation has proven difficult.
References 1. Watson CB, Prough DS, Balestieri FJ: Bronchoscope tube change in critically ill patients. Cti’t &re Mrd 1980;8:246. 2. Rosenbaum SH, Rosembaum LM, Cole RP, &kanaziJ, Hyman AI: Use of the flexible fiberoptic bronchoscope to change endotracheal tubes in critically ill patients. Anethesiolog? 1981;54:169-70. 3. U’atson CB: Use of fiberoptic bronchoscope to change endotracht=al tube endorsed [Letter]. Anesthesioloa 1981;55:47&7.
,J. Clin. Anesth., vol. 8, May 1996
259