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It is not necessary to remove a jet stylet to determine tracheal tube location
It Is Not Necessary to Remove a Jet Stylet to Determine Tracheal Tube Location
Randall Goskowicz, MD,* Sheila Gaughan, MD,* Jonathan L. Benumof, MD,_F George T. Ozaki$ Ikprtrnent of Anesthesiology. (kmer, San Diego, (:A.
A jet stylet is u .small internal catheter
that is inserted
ofa patient
to extubution ,4fier
the truchenl
hollow
catheter
trutrucheul
removed
who may be difficult
hollow
tube prior
reintubation
thought
with u new trucheal
tube. We describe
a method for preserving
ment of the new tracheal
tube
haue to be
of the new tube to the breathing of ~ntrutrucheal
locution qf the jet stylet while corzfirming
placement
of the
the intrutracheul intrutrucheul
pluce-
tube.
*Resident :Protessor ZSpecialist
in Anesthesia
Address reprint requests to Dr. Benumol at the Department of Anesthesiology, University of.California at San Diego Medical Center, Mail Code H-77OA. 22.5 Dickinson Street, San Diego, CA 92103, USA. Received for publication March 1, 199 1; t-evised cepted for publication May 20, 199 1.
manuscript
J. Clin. Anesth. 4:42-44,
1992
42
vol. 4, .JanuaryiFebruary
Anesth.,
Keywords: Jet ventilation; jet stylet; extubation; intubation, tracheal tube; airway.
Introduction
ac-
Bedger and Chang’ described the concept and use of a jet stylet during extubation of a patient who may be difficult to ventilate and/or reintubate. A jet stylet is a small ID, semirigid hollow catheter (e.g., a commercial tube changer) that is inserted into an in situ tracheal tube. After the tracheal tube is withdrawn over the jet stylet, the hollow catheter can be used for jet ventilation [after adaptation with an appropriately sized intravenous (IV) catheter (preferred)’ or a 2 to 3 mm tracheal tube adapter] (i.e., the jet function) or as an intratracheal stylet for reintubation (i.e., the stylet function). We recently measured and confirmed the capability of a tube changer to function effectively as a jet ventilation device. When a l&gauge IV catheter is inserted into one end of a medium-size tube changer and connected to a 50-pound-per-square-inch wall oxygen (
0 1992 Butterworth-Heinemann
J. Clin.
Medical
tube.
that ufter the new truchenl
to allow connection
at San Diego
to reintubate.
ouer the jet stylet, the stylet would _
und confirmation
of CZalifornia
oxjer the jet stylet, the
cun be used ,for jet z~entilation or us un in-
It wus preuiously
circuit
(III), semirigid
tube is withdrawn
stylet for
wus inserted
diameter
into an in situ trucheul
University
IYYP
Preserving the intratrachealjet stylet during reintubation: Goskowicz et el.
rate of 30 breaths/minute, the minute ventilation is 22.8 L/min. The jet function often allows additional time to assess the need for the reintubation stylet function. In the past, clinicians believed that when they were using the reintubation stylet function, the jet stylet had to be removed after the new tracheal tube was inserted over it to allow connection of the new tube to the breathing circuit and confirmation of intratracheal placement of the tube (by capnography, breath sounds, etc.). However, removal of the jet stylet to confirm proper tracheal tube placement results in the loss of both the jet and the stylet functions. In cases where the tracheal tube is not in the trachea, a situation may be created in which the patient’s lungs cannot be ventilated or the trachea intubated. We describe a method for preserving the intratracheal location of the jet stylet while confirming intratracheal placement of the reintubation tracheal tube.
-16
gauge Intravenous Jet SWkt Medium EIT Changer
Fiberoptic
Elbow Adapt
Figure 1. Schematic diagram of a method to preserve the
intratracheal location of the tracheal tube changer during confirmation of intratracheal placement of a tracheal tube. The tube changer is passed through a self-sealing diaphragm in a fiber optic elbow adapter. With this method,
Case Report
positive pressure ventilation and carbon dioxide (CO,) sampling may occur around the tracheal tube changer but within
The patient was a 62-year-old female who had undergone a neck dissection and hemilaryngectomy with subsequent laryngotracheal anastomosis for invasive thyroid carcinoma. Two days postoperatively, a tracheal tube cuff leak was detected. Air was leaking through the anastomosis site, resulting in emphysema and crepitance of the soft tissues of the neck and preventing healing of the anastomosis. Consequently, we decided to replace the tracheal tube in the operating room (OR) under general anesthesia. We modified the standard anesthesia circle system by replacing the existing elbow connector with a connector with a self-sealing diaphragm such as the type used for bronchoscopy (model 625207, Portex, Wilmington, MA). In addition, the proximal end of the lumen of a medium-size tracheal tube changer (model 5-24004, Sheridan Corp., Argyle, NY) was dilated by the hub of a 16-gauge IV catheter to allow for rapid connection of the tracheal tube changer to the IV catheter and subsequent use of jet ventilation if necessary.’ After placing standard monitoring devices, obtaining adequate IV access, and initiating preoxygenation, anesthesia was induced with thiamylal 4 mg/kg and maintained with 1% isoflurane and 99% 0,. The tracheal tube changer was inserted through the diaphragm of the elbow connector and down the existing tracheal tube until the 28 cm mark was at the upper incisors. Intermittent positive pressure ventilation was continuously maintained around the tracheal tube changer but within the tracheal tube (Figure 1). The
the tracheal tube. (ETT = endotracheal tube.)
old tracheal tube was then disconnected from the bronchoscopy elbow connector and removed over the tracheal tube changer (without the IV catheter in place in the tube changer) while countertraction was applied to the tube changer. The new tracheal tube was then passed over the tracheal tube changer without difficulty and connected to the existing anesthesia circuit by passing the tracheal tube changer retrograde through the self-sealing diaphragm of the bronchoscopy elbow connector (Figure 1). After conclusively establishing the intratracheal position and patency of the new tracheal tube by capnography and auscultation of bilateral breath sounds, the tracheal tube changer was removed by pulling it through the self-sealing diaphragm of the bronchoscopy elbow connector. The patient tolerated the procedure well.
Discussion The benefit of the jet stylet is twofold. First, it serves as a guide for the new tracheal tube. Second, it serves as a conduit for emergency jet ventilation if desaturation occurs during the exchange of the tracheal tubes or if the second tube fails to enter the trachea. The value of a reintubation method that maintains the intratracheal location of a jet stylet until tracheal location of the new tube is confirmed is that ventilation J. Clin. Anesth., vol. 4, January/February
1992
43
iit all times. 11 the jet stylet is reto allow circuit hookup and the new tracheal tube is not in the trachea, it mav not he possible to ventilate the lungs or intubate the trachea. In om patient, who had a nonhealing laryngeal anastomosis, venuse of percutaneous IV catheter tr-anstra~heal,jet tilation to rectifj ;I situation in which thr lungs could not have been ventilated by mask or the trachea could not have been intuhated probabl?; would have been contraindicated because the proxunity of’ the tip of the IV catheter to the anastomosis wo~11d have increased the hkelihood of massive neck and mediastinal emphysema [whereas the tracheal tube changer could be placed near the carina (27 to 28 cm) and reasonably far away from the anastomosis]. In addition, a tracheostomy would have been an undesirable remedy for such a situation because of‘ obvious intercan
be
m~tintaintxl
moved
Irl c-oiiclusioii, tracheal
this
niethoti
of
loc~ation of’thc
t~xheal
tube
44
J. Clin. Anesth.,
vol. 4, January/February
1992
pro\,icles
iirrr,tati cslr;l
nl;lrgin ot saft\, in c.hanging a tracheal tul)r’ 1)) llsi~lg the j~l st\let method to maintain its intratrac.heal locatioli utitil the intratracheal placement of. the nc\2’ tube is conf’irrned.
References 1. H~tl~~~~ KC:,C:hi~n~.Il.: :I jet-stylet endotracheal lOI dil‘ficult airwa\ I ‘)xi~Mj:‘ f -‘$. . L”_%
management.
~athetel
.4UP.S//W\;O/O&?
2. l’wn~mlof,]L. Sheller MS: ‘I‘he importance of transtr;lcheal jet ventilation in the management of the difficuh ,Grwa\,. ;1,~(~.\lk~~\io/o,~~ l!C+9;7 1:769-78.
L~WIPIU Rr.stwrch~.c itr .~wJ~~~P.~M cc~iArrctlgrsiu. Vol. 3 1, March-April 19.52. Rept-oduced with permission from the International Anesthesia Research Society, Clex eland, Ohio, and Wood Library-Museum of’ Anesthesiology, Park Ridge, IL.
Cover,
niaintainirig
Randall Goskowicz, MD,* Sheila Gaughan, MD,* Jonathan L. Benumof, MD,_F George T. Ozaki$ Ikprtrnent of Anesthesiology. (kmer, San Diego, (:A.
A jet stylet is u .small internal catheter
that is inserted
ofa patient
to extubution ,4fier
the truchenl
hollow
catheter
trutrucheul
removed
who may be difficult
hollow
tube prior
reintubation
thought
with u new trucheal
tube. We describe
a method for preserving
ment of the new tracheal
tube
haue to be
of the new tube to the breathing of ~ntrutrucheal
locution qf the jet stylet while corzfirming
placement
of the
the intrutracheul intrutrucheul
pluce-
tube.
*Resident :Protessor ZSpecialist
in Anesthesia
Address reprint requests to Dr. Benumol at the Department of Anesthesiology, University of.California at San Diego Medical Center, Mail Code H-77OA. 22.5 Dickinson Street, San Diego, CA 92103, USA. Received for publication March 1, 199 1; t-evised cepted for publication May 20, 199 1.
manuscript
J. Clin. Anesth. 4:42-44,
1992
42
vol. 4, .JanuaryiFebruary
Anesth.,
Keywords: Jet ventilation; jet stylet; extubation; intubation, tracheal tube; airway.
Introduction
ac-
Bedger and Chang’ described the concept and use of a jet stylet during extubation of a patient who may be difficult to ventilate and/or reintubate. A jet stylet is a small ID, semirigid hollow catheter (e.g., a commercial tube changer) that is inserted into an in situ tracheal tube. After the tracheal tube is withdrawn over the jet stylet, the hollow catheter can be used for jet ventilation [after adaptation with an appropriately sized intravenous (IV) catheter (preferred)’ or a 2 to 3 mm tracheal tube adapter] (i.e., the jet function) or as an intratracheal stylet for reintubation (i.e., the stylet function). We recently measured and confirmed the capability of a tube changer to function effectively as a jet ventilation device. When a l&gauge IV catheter is inserted into one end of a medium-size tube changer and connected to a 50-pound-per-square-inch wall oxygen (
0 1992 Butterworth-Heinemann
J. Clin.
Medical
tube.
that ufter the new truchenl
to allow connection
at San Diego
to reintubate.
ouer the jet stylet, the stylet would _
und confirmation
of CZalifornia
oxjer the jet stylet, the
cun be used ,for jet z~entilation or us un in-
It wus preuiously
circuit
(III), semirigid
tube is withdrawn
stylet for
wus inserted
diameter
into an in situ trucheul
University
IYYP
Preserving the intratrachealjet stylet during reintubation: Goskowicz et el.
rate of 30 breaths/minute, the minute ventilation is 22.8 L/min. The jet function often allows additional time to assess the need for the reintubation stylet function. In the past, clinicians believed that when they were using the reintubation stylet function, the jet stylet had to be removed after the new tracheal tube was inserted over it to allow connection of the new tube to the breathing circuit and confirmation of intratracheal placement of the tube (by capnography, breath sounds, etc.). However, removal of the jet stylet to confirm proper tracheal tube placement results in the loss of both the jet and the stylet functions. In cases where the tracheal tube is not in the trachea, a situation may be created in which the patient’s lungs cannot be ventilated or the trachea intubated. We describe a method for preserving the intratracheal location of the jet stylet while confirming intratracheal placement of the reintubation tracheal tube.
-16
gauge Intravenous Jet SWkt Medium EIT Changer
Fiberoptic
Elbow Adapt
Figure 1. Schematic diagram of a method to preserve the
intratracheal location of the tracheal tube changer during confirmation of intratracheal placement of a tracheal tube. The tube changer is passed through a self-sealing diaphragm in a fiber optic elbow adapter. With this method,
Case Report
positive pressure ventilation and carbon dioxide (CO,) sampling may occur around the tracheal tube changer but within
The patient was a 62-year-old female who had undergone a neck dissection and hemilaryngectomy with subsequent laryngotracheal anastomosis for invasive thyroid carcinoma. Two days postoperatively, a tracheal tube cuff leak was detected. Air was leaking through the anastomosis site, resulting in emphysema and crepitance of the soft tissues of the neck and preventing healing of the anastomosis. Consequently, we decided to replace the tracheal tube in the operating room (OR) under general anesthesia. We modified the standard anesthesia circle system by replacing the existing elbow connector with a connector with a self-sealing diaphragm such as the type used for bronchoscopy (model 625207, Portex, Wilmington, MA). In addition, the proximal end of the lumen of a medium-size tracheal tube changer (model 5-24004, Sheridan Corp., Argyle, NY) was dilated by the hub of a 16-gauge IV catheter to allow for rapid connection of the tracheal tube changer to the IV catheter and subsequent use of jet ventilation if necessary.’ After placing standard monitoring devices, obtaining adequate IV access, and initiating preoxygenation, anesthesia was induced with thiamylal 4 mg/kg and maintained with 1% isoflurane and 99% 0,. The tracheal tube changer was inserted through the diaphragm of the elbow connector and down the existing tracheal tube until the 28 cm mark was at the upper incisors. Intermittent positive pressure ventilation was continuously maintained around the tracheal tube changer but within the tracheal tube (Figure 1). The
the tracheal tube. (ETT = endotracheal tube.)
old tracheal tube was then disconnected from the bronchoscopy elbow connector and removed over the tracheal tube changer (without the IV catheter in place in the tube changer) while countertraction was applied to the tube changer. The new tracheal tube was then passed over the tracheal tube changer without difficulty and connected to the existing anesthesia circuit by passing the tracheal tube changer retrograde through the self-sealing diaphragm of the bronchoscopy elbow connector (Figure 1). After conclusively establishing the intratracheal position and patency of the new tracheal tube by capnography and auscultation of bilateral breath sounds, the tracheal tube changer was removed by pulling it through the self-sealing diaphragm of the bronchoscopy elbow connector. The patient tolerated the procedure well.
Discussion The benefit of the jet stylet is twofold. First, it serves as a guide for the new tracheal tube. Second, it serves as a conduit for emergency jet ventilation if desaturation occurs during the exchange of the tracheal tubes or if the second tube fails to enter the trachea. The value of a reintubation method that maintains the intratracheal location of a jet stylet until tracheal location of the new tube is confirmed is that ventilation J. Clin. Anesth., vol. 4, January/February
1992
43
iit all times. 11 the jet stylet is reto allow circuit hookup and the new tracheal tube is not in the trachea, it mav not he possible to ventilate the lungs or intubate the trachea. In om patient, who had a nonhealing laryngeal anastomosis, venuse of percutaneous IV catheter tr-anstra~heal,jet tilation to rectifj ;I situation in which thr lungs could not have been ventilated by mask or the trachea could not have been intuhated probabl?; would have been contraindicated because the proxunity of’ the tip of the IV catheter to the anastomosis wo~11d have increased the hkelihood of massive neck and mediastinal emphysema [whereas the tracheal tube changer could be placed near the carina (27 to 28 cm) and reasonably far away from the anastomosis]. In addition, a tracheostomy would have been an undesirable remedy for such a situation because of‘ obvious intercan
be
m~tintaintxl
moved
Irl c-oiiclusioii, tracheal
this
niethoti
of
loc~ation of’thc
t~xheal
tube
44
J. Clin. Anesth.,
vol. 4, January/February
1992
pro\,icles
iirrr,tati cslr;l
nl;lrgin ot saft\, in c.hanging a tracheal tul)r’ 1)) llsi~lg the j~l st\let method to maintain its intratrac.heal locatioli utitil the intratracheal placement of. the nc\2’ tube is conf’irrned.
References 1. H~tl~~~~ KC:,C:hi~n~.Il.: :I jet-stylet endotracheal lOI dil‘ficult airwa\ I ‘)xi~Mj:‘ f -‘$. . L”_%
management.
~athetel
.4UP.S//W\;O/O&?
2. l’wn~mlof,]L. Sheller MS: ‘I‘he importance of transtr;lcheal jet ventilation in the management of the difficuh ,Grwa\,. ;1,~(~.\lk~~\io/o,~~ l!C+9;7 1:769-78.
L~WIPIU Rr.stwrch~.c itr .~wJ~~~P.~M cc~iArrctlgrsiu. Vol. 3 1, March-April 19.52. Rept-oduced with permission from the International Anesthesia Research Society, Clex eland, Ohio, and Wood Library-Museum of’ Anesthesiology, Park Ridge, IL.
Cover,
niaintainirig