- Email: [email protected]
Airway exchange catheter and laser endotracheal tube
324
Correspondence
Airway exchange catheter and laser endotracheal tube To the Editor: Airway exchange catheters (AECs) are used mainly to facilitate the substitution of an endotracheal tube (ETT), and they are hollow to facilitate ventilation. The American Society of Anesthesiologists practice guidelines for management of the difficult airway have proposed inserting these devices before the tracheal tube is removed, when dealing with a difficult airway [1]. The caliber selection needs to be adjusted to the internal diameter (ID) of the tube to be changed, to allow for easy railroading, but without leaving too much room to catch on the laryngeal structures. Usually, each AEC is labeled on the surface with the recommended diameter to be used with it. We admitted into our Postanesthesia Care Unit an intubated patient who had undergone prolonged pharyngolaryngeal laser surgery. An expert anesthesiologist had had difficulty in intubating this patient’s trachea; thus, a difficult extubation (removal of the ETT tube) was anticipated. Because of his condition after surgery, the patient was brought to the Postanesthesia Care Unit with the laser ETT (Laser-Flex; Mallinkrodt Medical, Athlone, Ireland) still in place. This ETT was labeled as having an ID of 5.5 mm. We decided to replace it with a standard ETT with the aid of a lubricated AEC of corresponding diameter. This arrangement would, we believed, enable good suctioning of secretions and facilitate opening atelectatic areas in the left inferior lobe of the lung. However, in spite of the fact that we chose the AEC that was recommended by the manufacturer (14.0F size for replacement of ETT with ID 5 mm or larger; William Cook Europe, Bjaeverskov, Denmark), we were unable to place the AEC through the laser tube, because the conduits to the cuffs, which run inside the laser tube lumen, reduced the ID of the tube. We therefore had to search for a smaller guide, that is, an 11.0F (C-CAE-11.0-83; William Cook Europe), which would be able to fit inside the laser tube already in place (Fig. 1). Over the guide, a reinforced 7-mm ID ETT was introduced into the trachea, although it presented some difficulty when it was advanced into the larynx. Anticipating a possible bcan’t intubate-can’t ventilateQ situation, we had the means for subglottic access readily available. Five hours later, a rigid laryngoscopy was performed showing a Cormack–Lehane view grade II. The patient’s trachea was then extubated without any problem. In conclusion, because the actual diameter is less than 5.5 mm, we suggest that the manufacturer modify the design of these laser tubes so as to achieve an accurate circumferential ID (ie, by making a channel for the conduits in the tube wall). This modification would then facilitate suctioning and simplify the process of selecting the correct AEC in case the need arises to change the laser tube. Another possibility would be for the manufacturer to clearly take into
Fig. 1 View of the 5.5-mm ID laser ETT and the small AEC (11.0F), showing the position of the 2 conduits for the cuffs (cross section).
consideration the actual conduit area when measuring the lumen diameter of the tube. When a long-term postoperative mechanical ventilation is expected, one alternative to facilitate suctioning and ventilation would be to make the change to a standard tube while the patient is still in the operating room. In this case, an AEC of smaller diameter than is usually advised must be chosen. Julio Cortinas MD (Staff Anesthesiologist) Valentı´n Caruezo MD (Staff Anesthesiologist) Cristina Penide MD (Resident) Servicio de Anestesiologı´a Reanimacio´n y Tratamiento del Dolor Hospital Clı´nico Universitario de Santiago 15704 Santiago de Compostela, Spain E-mail address: [email protected] Julia´n Alvarez MD, PhD (Professor and Director) Servicio de Anestesiologı´a Reanimacio´n y Tratamiento del Dolor School of Medicine Santiago de Compostela, Spain Reference [1] Practice guidelines for management of the difficult airway An updated report by the American Society of Anesthesiologists Task Force on management of the difficult airway. Anesthesiology 2003;98:1269 - 77.
doi:10.1016/j.jclinane.2004.12.011 Operating room turnover times To the Editor: In a recent editorial in Anesthesia and Analgesia, surgeon Robert Udelsman described the operating room (OR) as a bbattle zoneQ because of the conflicting goals and incentives among stakeholders. He stated, bSurgeons are
Correspondence
Airway exchange catheter and laser endotracheal tube To the Editor: Airway exchange catheters (AECs) are used mainly to facilitate the substitution of an endotracheal tube (ETT), and they are hollow to facilitate ventilation. The American Society of Anesthesiologists practice guidelines for management of the difficult airway have proposed inserting these devices before the tracheal tube is removed, when dealing with a difficult airway [1]. The caliber selection needs to be adjusted to the internal diameter (ID) of the tube to be changed, to allow for easy railroading, but without leaving too much room to catch on the laryngeal structures. Usually, each AEC is labeled on the surface with the recommended diameter to be used with it. We admitted into our Postanesthesia Care Unit an intubated patient who had undergone prolonged pharyngolaryngeal laser surgery. An expert anesthesiologist had had difficulty in intubating this patient’s trachea; thus, a difficult extubation (removal of the ETT tube) was anticipated. Because of his condition after surgery, the patient was brought to the Postanesthesia Care Unit with the laser ETT (Laser-Flex; Mallinkrodt Medical, Athlone, Ireland) still in place. This ETT was labeled as having an ID of 5.5 mm. We decided to replace it with a standard ETT with the aid of a lubricated AEC of corresponding diameter. This arrangement would, we believed, enable good suctioning of secretions and facilitate opening atelectatic areas in the left inferior lobe of the lung. However, in spite of the fact that we chose the AEC that was recommended by the manufacturer (14.0F size for replacement of ETT with ID 5 mm or larger; William Cook Europe, Bjaeverskov, Denmark), we were unable to place the AEC through the laser tube, because the conduits to the cuffs, which run inside the laser tube lumen, reduced the ID of the tube. We therefore had to search for a smaller guide, that is, an 11.0F (C-CAE-11.0-83; William Cook Europe), which would be able to fit inside the laser tube already in place (Fig. 1). Over the guide, a reinforced 7-mm ID ETT was introduced into the trachea, although it presented some difficulty when it was advanced into the larynx. Anticipating a possible bcan’t intubate-can’t ventilateQ situation, we had the means for subglottic access readily available. Five hours later, a rigid laryngoscopy was performed showing a Cormack–Lehane view grade II. The patient’s trachea was then extubated without any problem. In conclusion, because the actual diameter is less than 5.5 mm, we suggest that the manufacturer modify the design of these laser tubes so as to achieve an accurate circumferential ID (ie, by making a channel for the conduits in the tube wall). This modification would then facilitate suctioning and simplify the process of selecting the correct AEC in case the need arises to change the laser tube. Another possibility would be for the manufacturer to clearly take into
Fig. 1 View of the 5.5-mm ID laser ETT and the small AEC (11.0F), showing the position of the 2 conduits for the cuffs (cross section).
consideration the actual conduit area when measuring the lumen diameter of the tube. When a long-term postoperative mechanical ventilation is expected, one alternative to facilitate suctioning and ventilation would be to make the change to a standard tube while the patient is still in the operating room. In this case, an AEC of smaller diameter than is usually advised must be chosen. Julio Cortinas MD (Staff Anesthesiologist) Valentı´n Caruezo MD (Staff Anesthesiologist) Cristina Penide MD (Resident) Servicio de Anestesiologı´a Reanimacio´n y Tratamiento del Dolor Hospital Clı´nico Universitario de Santiago 15704 Santiago de Compostela, Spain E-mail address: [email protected] Julia´n Alvarez MD, PhD (Professor and Director) Servicio de Anestesiologı´a Reanimacio´n y Tratamiento del Dolor School of Medicine Santiago de Compostela, Spain Reference [1] Practice guidelines for management of the difficult airway An updated report by the American Society of Anesthesiologists Task Force on management of the difficult airway. Anesthesiology 2003;98:1269 - 77.
doi:10.1016/j.jclinane.2004.12.011 Operating room turnover times To the Editor: In a recent editorial in Anesthesia and Analgesia, surgeon Robert Udelsman described the operating room (OR) as a bbattle zoneQ because of the conflicting goals and incentives among stakeholders. He stated, bSurgeons are