Prolonged Use of an Endotracheal Tube Changer in a Pediatric Patient With a Potentially Compromised Airway

relationships to adjacent anatomic structures. This evaluation is useful in detecting associated congenital cardiac anomalies which are present in 20 percent of cases of CAF.5 In comparison to other procedures, TEE has many practical advantages. It is noninvasive, readily available, and not limited by contrast or rhythm concerns, and TEE can be used intraoperatively to assess the surgical repair.4.a Transesophageal echocardiography is useful in the diagnosis and localization of congenital and traumatic CAF. It is comparable, and in some cases superior, to coronary angiography and other noninvasive methods. Given its diagnostic utility and practical advantages, TEE may now be the diagnostic procedure of choice for patients with suspected CAF. REFERENCES

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Reeder GS, Tajik AJ. Smith HC. Visualization of coronary artery fistula by two-dimensional echocardiography. Mayo Clin Proc 1980; 55:185-89 Shakudo M, Yoshikawa J. Yoshida K. Yamaura Y. Noninvasive diagnosis of coronary artery fistula by Doppler color flow mapping. J Am Coli Cardiol 1989; 13:1572-77 Velvis H, Schmidt KG. Silverman NH , Turley K. Diagnosis of coronary artery fistula by two-dimensional echocardiography. pulsed Doppler ultrasound and color flow imaging. J Am Coli Cardiol 1989; 14:968-76 Samdarshi TE. Mahan EF, Nanda NC, Sanyal RS . Transesophageal echocardiographic assessment of congenital coronary artery to coronary sinus fistulas in adults. Am J Cardiol 1991: 68:263-66 Kugelmass AD. Manning WJ, Piana RN, Weintraub RM, Bairn DS, Grossman W. Coronary arteriovenous fistula presenting as congestive heart failure. Cathet Cardiovasc Diagn 1992; 26:1925

6 Rubin DA, Zaki AM. Zaghlol S. Abdala S, Fahmy AR, Ziady G. Visualization of coronary artery fistula with transesophageal echocardiography. JAm Soc Echocardiogr 1992; 5:173-75 7 Sunaga Y, Taniichi Y. Okubo N, Hayashi K, Karakawa M, Sugiura T, et al. Biplane transesophageal echocardiographic study of left coronary artery to right atrium fistula. Am Heart J 1992; 123:1058-60 8 Kuo CT. Chiang CW, Fang BR. Lee CP, Hsu TS, Lee YS, et al. Coronary artery fistula: diagnosis by transesophageal twodimensional and doppler echocardiography. Am Heart J 1992; 123:218-20 9 Sandhu JS. Uretsky BF. Zerbe TR. Goldsmith AS, Reddy S, Kormos RL, et al. Coronary artery fistula in the heart transplant patient: a potential complication of endomyocardial biopsy. Circulation 1989; 79:350-56

Prolonged Use of an Endotracheal Tube Changer in a Pediatric Patient With a Potentially Compromised Airway* PaulS. Chipley. M.D.; Manuel Castresana, M.D.; M. Tn1ett Bridges. M.D.; and Timothy T. Catchings. M.D. , F.C.C.P. *From the Department of Anesthesiology, Medical College of Georgia, Augusta (Drs. Chipley and ~ridges); and Mercer University School of Medicine, Macon, Ga (Drs. Castresana and Catchings).

A 14-year-old obese male patient presented following a motor vehicle accident with multiple injuries and respiratory failure requiring endotracheal intubation and mechanical ventilation. Because of potential problems with a difficult airway, an endotracheal tube changer was used at the time of extubation and left in place for a prolonged period of time. Leaving the tube changer in place maintained access to the airway. Additionally, the manipulation of the tube changer was used to stimulate the cough reflex. (Chest 1994; 105: 961-62)

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espite well established weaning and extubation criteria, removal of an endotracheal tube may result in respiratory distress and/or airway compromise requiring emergency reintubation. In patients with known risk factors for difficult endotracheal intubation, reintubation can be a life-threatening complication. Endotracheal tube changers have been shown to be a safe and effective means of maintaining access to the airway and assisting in reintubation in patients requiring replacement of an endotracheal tube. We report the use of an endotracheal tube changer left in place for 48 h following extubation in a patient at risk for recurrent respiratory failure in whom reintubation was expected to be difficult. CASE REPORT

A 14-year-old morbidly obese male patient (100.8 kg, 151 em) was transferred to the Pediatric Intensive Care Unit of the Medical Center of Central Georgia for treatment of multiple injuries following a motor vehicle accident. Significant injuries included a fractured left clavicle, multiple left-sided rib fractures with a hemopneumothorax and pulmonary contusion, and a fracture of the left condylus occipital is at the foramen magnum without evidence of spinal cord injury. Respiratory compromise prompted endotracheal intubation prior to transfer, and positive pressure ventilation was instituted upon admission. The fracture of the condylus occipitalis was considered unstable and was treated with cervical immobilization with a hard cervical collar. Following 8 days of mechanical ventilation and parenteral alimentation, the patient's pulmonary function had markedly improved and he was considered a candidate for extubation. Concerns over potential upper airway compromise in a difficult or failed reintubation due to body habitus along with a basilar skuU fracture resulted in a novel approach to the patient's extubation management. Pre-extubation treatment included manual ventilation with 100 percent oxygen, endotracheal tube suctioning, and endotracheal administration of 3 ml of 2 percent lidocaine hydrochloride. A lubricated Cook Mizus Endotracheal Tube Replacement Obturator (Mettro, Inc, Bloomington, Ind) was advanced through the endotracheal tube into the trachea. The tube changer was positioned by aligning the single black mark on the tube changer with the proximal end of the endotracheal tube. The endotracheal tube was removed, taking care not to alter the position of the tube changer by maintaining a constant distance between a mark on the changer and the patient's mouth. The tube changer was left in place and securely taped. Apostextubation chest radiograph showed it to be in position above the level of the carina tracheae (Fig 1). The patient's oxygen saturation and respiratory efforts remained adequate though the patient had poor cough efforts. The tube changer was remarkably weD tolerated by the patient and was gently manipulated at intervals to induce coughing to assist in pulmonary toilet. After 48 h, the tube changer was removed. The patient recovered and was discharged 17· days following injury. There were no complications noted from the prolonged use of the endotracheal tube changer. CHEST I 105 I 3 I MARCH, 1994

961

patient was helie,·ed to he suffkieuth- imprm·ed. Second. there was tht' unexpected ben('fit of the ahilit~· to stimulate cough and thereby dear SP<:retious. This henefit may han· expedited the recovery process in this tmcooperatin: pediatric patient by reducing the risks of iufection or atelectasis. or both , as well as an1iding tht' trauma of repetitin· nasotracheal suctiouing fi1r pulllt0lta0· toilet. REFEHE:\CES

FJ<:nn: l. Hadio).:raph showing position of tnhe changer ahm·e len'! of the carina tracheae Iarrow ). DJS
\1am· bctors han· been identified that can make tracheal intubation potentially dilncult and rt'
962

I lfpffner J E. \I;UHI).:ing difficult intnhations in criticalk ill patients. Hespiratorv \lanagPment W~H: IH:.'iJ-.')6 2 dt>Lima LGH. Bishop \I J. Lung !act' ration aftpr tracht•al intubation OH'r a plastic tuhP chan,ger. Anesth :\nalg I H!J I: 7:3::350-.') I :3 HouiJPnoff H. Hm·ick \\'j. Pnetunothonl\ dnP to nasogastrit· feeding tuhPs. Arch lntPrn \IPtl IH~9, 1-!H:l~:3-~~ -! Sdlt'llinger HR. Tlw length oftlw airwav to thP bifmeation of till' tradtt'a. AnPstllt'sioloj.,1\ 196-!: 25: 16H-72 5 Owen HL. Clwnt'\' F\\ '. Endobrondtial intubation: a prt'H' ntable t·omplication. :\n e sthPsiolo~ IH~7: 76:2.'}.'}-.')7 6 Dorsch JA. Dorsch SE. UndPrstantling anpstllt'sia Prnning DC. Hazards of tracheal intubation. In: Orkin FK. Cooperman Lll. eds. Complications in anesthesiolo~·. Philadelphia: JB Lippincott. J9.~2: 16.'}-72

An lnterleukin-6 Secreting Myxoma in a Hypertrophic Left Ventricle* Tsttl!,iljasu Ka11da . .\1./J .. Tadashi .\'akajir11a . .\1/J: Hiro11osuke Sakamoto ..\1. /J.: Tadaslri Su:.uki ..\1./J.: a/Ill Ka:.uhiko .\lurata ..\1./J.

We describe a patient who had both a left ventricular myxoma and left ventricular hypertrophy; the myxoma was subsequently excised and revealed to produce interleukin-6. The combination of left ventricular myxoma and ventricular hypertrophy is uncommon. lnterleukin-6 secreted from the myxoma may be an important factor in the pathogenesis of ventricular hypertrophy in this patient. (Chest 1994; 105: 962-63)

I IL-6 =interleukin-6

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ardiac myxoma produces interleukin-6 (I L-6 ).' which increases proteiu synthesis. Tlte gent'sis of hypertrophic cardiomyopathy is uot clear. The comhinatin of left ,·entricular m~-xoma and n ' ntricular h~1wrtrophy is tmcommon . \\'e present herein an unusual case of left ,·entricular myxoma pedunculated from h~1wrtrophied left ,·entricle. C.-\SE REPOI\T

A 71-year-old man prPsPntPd to thP Gunma Uui,·prsitY hospital eomplaining of nocturnal dtt•st pain in IH~7. I lis pain. diagnosed as angina. was relie,·e d by tht• administration of anl\'l nitritt' anti a calcium channPI blockPr. Four \'Pars lalt'r hP complained of nocturnal dtPst pain of 1- of 2-m in duration. and pn·sPuted to tht• same hospital. liP had no historY of h\']Wrlt'nsion. Fantih- history rP\'PaiPd neither sudde n death nor endoeri11P dist·ast'. l'h\'Sical Pxamination dPmonstralt'd a blood prPssnrP of l :30/61> mm II g. and a pulse ratt' of 61> bPats per minute. Chest t'Xamination rt'YealPd *From the SPeond DPpartmPnt of lntt'rnal \(ptlicine. Gunnta Unh·ersity School of \ledicinP . \laebashi. Japan. Myxoma in Hypertrophic Left Ventricle (Kanda et at)