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The Parker Flex-Tip Tube Is Useful in a Bougie-Assisted Endotracheal Tube Exchange After Lung Lavage
LETTERS TO THE EDITOR
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4. Svensson LG, Labib SB, Eisenhauer AC, et al: Intimal tear without hematoma: An important variant of aortic dissection that can elude current imaging techniques. Circulation 99:1331-1336, 1999 doi:10.1053/j.jvca.2009.07.016
The Parker Flex-Tip Tube Is Useful in a Bougie-Assisted Endotracheal Tube Exchange After Lung Lavage To the Editor: In difficult intubation cases, a bougie is available for exchanging the endotracheal tube (ETT).1 When using a bougie, we have occasionally experienced difficulty in advancing the ETT, with its tip impinging on the epiglottis or vocal cords. In this situation, we inserted a Macintosch laryngoscope into the pharynx and then advanced the ETT through the laryngeal structures while viewing the epiglottis or glottis opening. The Parker Flex-Tip tube (Parker Medical, Englewood, CO) has a soft, flexible, curved, centered, distal tip.2,3 This superior, beveled tip tends to smoothly move through the laryngeal structures. We have found that the Parker Flex-Tip tube with a bougie can be smoothly advanced through the laryngeal structures into the trachea without a laryngoscope after lung lavage. A 42–year-old woman weighing 70 kg was scheduled for unilateral bronchopulmonary lavage because of pulmonary alveolar proteinosis. After the induction of anesthesia with propofol and rocuronium, a double-lumen tube (DLT) was inserted with the Pentax airway scope (Hoya, Tokyo, Japan). The bronchopulmonary lavage was smoothly performed. After completion of the 3-hour lung lavage, a change from a DLT to a single ETT was needed for postlavage ventilation. On a previous occasion, the exchange of a DLT for an ETT with an airway scope was disturbed by a flood of drained fluid. Therefore, in this case, a bougie-assisted intubation was chosen. The bougie was inserted into the left-side lumen of the DLT. Leaving the bougie in the trachea, the DLT was removed gently from the oral cavity. To avoid laryngeal trauma by reintubation of the ETT, we chose a Parker Flex-Tip tube as the single ETT. The Parker Flex-Tip tube (7.5-mm inner diameter) was mounted on the bougie and slowly advanced into the trachea. The Parker Flex-Tip tube was smoothly inserted without hitting or striking the laryngeal structures. The bougie-assisted conventional ETT was advanced through the laryngeal structures with the laryngoscopic view of the larynx, but the Parker Flex-Tip tube was smoothly advanced through the epiglottis and glottis opening without it. No postoperative sore throat or severe hoarseness was observed. The bougie-assisted Parker Flex-Tip tube facilitates smooth passage through the laryngeal structures without a laryngoscope. The Parker Flex-Tip tube is useful in exchanging the ETT with a bougie. Hirotoshi Kitagawa, MD, PhD* Yasuhiko Imashuku, MD* Toji Yamazaki, MD, PhD† *Department of Anesthesiology Shiga University of Medical Science
Shiga, Japan †Department of Anesthesiology National Hospital Organization Kinki-Chuo Chest Medical Center Osaka, Japan REFERENCES 1. Ovassapian A, Yelich SJ, Dykes MHM, et al: Fiberoptic nasotracheal intubation: Incidence and causes of failure. Anesth Analg 62:692-695, 1983 2. Kristensen MS: The Parker Flex-Tip tube versus a standard tube for fiberoptic orotracheal intubation: A randomized double-blind study. Anesthesiology 98:354-358, 2003 3. Makino H, Katoh T, Kobayashi S, et al: The effects of tracheal tube tip design and tube thickness on laryngeal pass ability during oral tube exchange with an introducer. Anesth Analg 97:285-288, 2003 doi:10.1053/j.jvca.2009.08.004
Congenital Pleuropericardial Fistula Complicating Awake Cardiac Surgery To the Editor: Conducting awake cardiac surgery using thoracic epidural anesthesia (TEA) has been reported.1 Off-pump coronary artery surgeries, on-pump cardiac surgeries, and thoracic surgeries have been conducted successfully by using TEA (without endotracheal general anesthesia) at the authors’ institute.1,2 Several other authors have reported conducting similar surgeries and have commented about the benefits of maintaining the pleural integrity during spontaneous ventilation during such surgeries.3-6 The occurrence of pneumothorax has been cited as one of the most important etiologies of failed awake surgeries. The modes of management of inadvertent pneumothorax include repairing the pleural breach, inserting intercostal drains connected to negative pressure, continuing the surgery while accepting the pneumothorax, or extending the opening in the pleura further to intentionally collapse the lung (so that the mediastinal movements do not disturb the operating surgeon) and applying fibrin glue on the pleural opening.2,7,8 The occurrence of congenital pleura pericardial fistula in a patient undergoing awake surgery may be rare, and such an anomaly may have adverse outcome during awake surgeries. We report a case causing difficulties in performing awake surgery because of pneumothorax that resulted after opening the pericardium. A 23-year-old man who had ostium secundum atrial septal defect and was scheduled for surgery opted to undergo the closure while remaining awake under TEA. As per the institutional protocol, an epidural catheter was inserted on the evening before surgery, and the epidural anesthesia was begun the next day in the operating room. The patient breathed enriched air with oxygen via a facemask. During surgery, we monitored the electrocardiogram, invasive arterial and central venous pressures, and rectal temperature. As a protocol, in all our patients, we insert a mainstream end-tidal carbon dioxide probe under the facemask. Surgery commenced via midsternotomy. Care was taken to avoid injury to the pleura. The surgery went on
901
4. Svensson LG, Labib SB, Eisenhauer AC, et al: Intimal tear without hematoma: An important variant of aortic dissection that can elude current imaging techniques. Circulation 99:1331-1336, 1999 doi:10.1053/j.jvca.2009.07.016
The Parker Flex-Tip Tube Is Useful in a Bougie-Assisted Endotracheal Tube Exchange After Lung Lavage To the Editor: In difficult intubation cases, a bougie is available for exchanging the endotracheal tube (ETT).1 When using a bougie, we have occasionally experienced difficulty in advancing the ETT, with its tip impinging on the epiglottis or vocal cords. In this situation, we inserted a Macintosch laryngoscope into the pharynx and then advanced the ETT through the laryngeal structures while viewing the epiglottis or glottis opening. The Parker Flex-Tip tube (Parker Medical, Englewood, CO) has a soft, flexible, curved, centered, distal tip.2,3 This superior, beveled tip tends to smoothly move through the laryngeal structures. We have found that the Parker Flex-Tip tube with a bougie can be smoothly advanced through the laryngeal structures into the trachea without a laryngoscope after lung lavage. A 42–year-old woman weighing 70 kg was scheduled for unilateral bronchopulmonary lavage because of pulmonary alveolar proteinosis. After the induction of anesthesia with propofol and rocuronium, a double-lumen tube (DLT) was inserted with the Pentax airway scope (Hoya, Tokyo, Japan). The bronchopulmonary lavage was smoothly performed. After completion of the 3-hour lung lavage, a change from a DLT to a single ETT was needed for postlavage ventilation. On a previous occasion, the exchange of a DLT for an ETT with an airway scope was disturbed by a flood of drained fluid. Therefore, in this case, a bougie-assisted intubation was chosen. The bougie was inserted into the left-side lumen of the DLT. Leaving the bougie in the trachea, the DLT was removed gently from the oral cavity. To avoid laryngeal trauma by reintubation of the ETT, we chose a Parker Flex-Tip tube as the single ETT. The Parker Flex-Tip tube (7.5-mm inner diameter) was mounted on the bougie and slowly advanced into the trachea. The Parker Flex-Tip tube was smoothly inserted without hitting or striking the laryngeal structures. The bougie-assisted conventional ETT was advanced through the laryngeal structures with the laryngoscopic view of the larynx, but the Parker Flex-Tip tube was smoothly advanced through the epiglottis and glottis opening without it. No postoperative sore throat or severe hoarseness was observed. The bougie-assisted Parker Flex-Tip tube facilitates smooth passage through the laryngeal structures without a laryngoscope. The Parker Flex-Tip tube is useful in exchanging the ETT with a bougie. Hirotoshi Kitagawa, MD, PhD* Yasuhiko Imashuku, MD* Toji Yamazaki, MD, PhD† *Department of Anesthesiology Shiga University of Medical Science
Shiga, Japan †Department of Anesthesiology National Hospital Organization Kinki-Chuo Chest Medical Center Osaka, Japan REFERENCES 1. Ovassapian A, Yelich SJ, Dykes MHM, et al: Fiberoptic nasotracheal intubation: Incidence and causes of failure. Anesth Analg 62:692-695, 1983 2. Kristensen MS: The Parker Flex-Tip tube versus a standard tube for fiberoptic orotracheal intubation: A randomized double-blind study. Anesthesiology 98:354-358, 2003 3. Makino H, Katoh T, Kobayashi S, et al: The effects of tracheal tube tip design and tube thickness on laryngeal pass ability during oral tube exchange with an introducer. Anesth Analg 97:285-288, 2003 doi:10.1053/j.jvca.2009.08.004
Congenital Pleuropericardial Fistula Complicating Awake Cardiac Surgery To the Editor: Conducting awake cardiac surgery using thoracic epidural anesthesia (TEA) has been reported.1 Off-pump coronary artery surgeries, on-pump cardiac surgeries, and thoracic surgeries have been conducted successfully by using TEA (without endotracheal general anesthesia) at the authors’ institute.1,2 Several other authors have reported conducting similar surgeries and have commented about the benefits of maintaining the pleural integrity during spontaneous ventilation during such surgeries.3-6 The occurrence of pneumothorax has been cited as one of the most important etiologies of failed awake surgeries. The modes of management of inadvertent pneumothorax include repairing the pleural breach, inserting intercostal drains connected to negative pressure, continuing the surgery while accepting the pneumothorax, or extending the opening in the pleura further to intentionally collapse the lung (so that the mediastinal movements do not disturb the operating surgeon) and applying fibrin glue on the pleural opening.2,7,8 The occurrence of congenital pleura pericardial fistula in a patient undergoing awake surgery may be rare, and such an anomaly may have adverse outcome during awake surgeries. We report a case causing difficulties in performing awake surgery because of pneumothorax that resulted after opening the pericardium. A 23-year-old man who had ostium secundum atrial septal defect and was scheduled for surgery opted to undergo the closure while remaining awake under TEA. As per the institutional protocol, an epidural catheter was inserted on the evening before surgery, and the epidural anesthesia was begun the next day in the operating room. The patient breathed enriched air with oxygen via a facemask. During surgery, we monitored the electrocardiogram, invasive arterial and central venous pressures, and rectal temperature. As a protocol, in all our patients, we insert a mainstream end-tidal carbon dioxide probe under the facemask. Surgery commenced via midsternotomy. Care was taken to avoid injury to the pleura. The surgery went on