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Sequential Extubation in a Patient with Difficult Intubation
Sona Dave*, Raghu S Thota**, RD Patel*, SK Kamath***
Abstract
Endotracheal tube exchangers (ETTE) or airway exchange catheters (AEC) have been reported to be easy and safe to use.1,2 ETTE or AEC are thin, long, rigid, hollow tubes that can be left in place as a safety device to be used as a guide for reintubation when inserted through an endotracheal tube (ETT) before its removal. Alternatively, AEC can be used to insufflate oxygen, monitor end tidal CO2, or jet ventilation.3,4 Planned sequential extubation should be performed in a patient with difficult intubation as re-intubation becomes very difficult in such patients.1,3
A 23 yr old male patient presented with haematemesis for emergency distal splenorenal shunt. The patient had micrognathia and severely restricted mouth opening. We successfully intubated the patient with awake nasotracheal technique using Fibreoptic bronchoscope and successfully extubated sequentially using endotracheal tube exchangers (ETTE) and a nasopharyngeal airway on the next day of surgery.
Sequential Extubation in a Patient with Difficult Intubation
Sona Dave*, Raghu S Thota**, RD Patel*, SK Kamath***
Abstract
Endotracheal tube exchangers (ETTE) or airway exchange catheters (AEC) have been reported to be easy and safe to use.1,2 ETTE or AEC are thin, long, rigid, hollow tubes that can be left in place as a safety device to be used as a guide for reintubation when inserted through an endotracheal tube (ETT) before its removal. Alternatively, AEC can be used to insufflate oxygen, monitor end tidal CO2, or jet ventilation.3,4 Planned sequential extubation should be performed in a patient with difficult intubation as re-intubation becomes very difficult in such patients.1,3
A 23 yr old male patient presented with haematemesis for emergency distal splenorenal shunt. The patient had micrognathia and severely restricted mouth opening. We successfully intubated the patient with awake nasotracheal technique using Fibreoptic bronchoscope and successfully extubated sequentially using endotracheal tube exchangers (ETTE) and a nasopharyngeal airway on the next day of surgery.
Case Report
A 23 year old male patient weighing 40 kg presenting with haematemesis was scheduled for emergency distal splenorenal shunt. Patient had severe congenital micrognathia, retrognathia and mouth opening of only 0.5 cm (Fig. 1). There was no history suggestive of respiratory distress in supine position. Patient was unable to eat solid foods. Coagulation profile was within normal limits.
The Sengstaken Blakemore tube, which was passed through the right nostril, was removed preoperatively. Anticipating difficult intubation Fibreoptic intubation was planned after explaining the procedure to the patient. After adequate preparation of the patient for fibreoptic bronchoscope, Teheran endotracheal was put nasally by using fibreoptic intubation technique.
An ENT surgeon remained washed up for emergency tracheostomy. Patient was monitored continuously for the pulse, BP and O2 saturation.
Thoracic epidural catheter was inserted before induction of anaesthesia for postoperative analgesia. After complete reversal of the muscle relaxant patient was shifted to Anaesthesia Intensive Care Unit with the same tube in situ. The patient was breathing spontaneously oxygen-enriched air. All vital parameters were monitored.
Extubation
Patient was taken to operation theatre next morning for sequential extubation. Thorough endotracheal and oral suction was done. A 5Fr endotracheal tube exchanger (2.5-3.5 mm, 50 cm long) was passed through the Teheran tube (which is 30 cm long) leaving proximal 1 cm of the endotracheal tube exchanger outside the endotracheal tube (Fig. 2: I and II). The Teheran tube was then removed leaving the endotracheal tube exchanger (Fig. 2: III) in situ and fixed to the nostril at 30 cm mark. A 34 F Bordeaux nasopharyngeal airway (Fig. 2: IV) was then threaded over it to prevent the tongue from falling back. The patient was observed for 2 hrs with the ETTE and nasopharyngeal airway in situ. The nasopharyngeal airway was then removed and the ETTE (Fig. 2: V) kept for another 2 hrs so that in case of respiratory obstruction a nasopharyngeal airway or endotracheal tube could be re-inserted. All vital parameters were maintained and the bougie then removed. The patient was then observed for few more hours before shifting to ward.
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Fig. 1 : Lateral profile of the patient showing micrognathia. |
Fig. 2 : Sequential extubation protocol.
L – Larynx, N – Nostril; 1. Teheran tube; 2. Teheran tube with endotracheal tube exchanger; 3. Only endotracheal tube exchanger in situ; 4. Endotracheal tube exchanger with nasopharyngeal airway; 5. Only endotracheal tube exchanger, nasopharyngeal airway removed. |
Discussion
Management of airway during intubation and extubation is always a great challenge to anaesthetist in a patient with severe trismus more so when the patient is for surgery other than correction of trismus.5 Moreover, extubation should be planned sequentially in a step wise manner using ETTE, as reintubation in such patients is extremely difficult.1-3 Patient’s poor general condition, coagulation abnormalities and portal hypertension further aggravate the severity of the problem. Thus proper planning of the technique during intubation and extubation is very much essential. Intubation can be safely done with Fibreoptic bronchoscope after the upper airway has been adequately anaesthetized. ETT exchange is a simple procedure, and it does not seem to require a special training. Airway exchange catheters1,2 (AEC) or bougie6 can also be used for planned sequential extubation. There is very little medical literature on a planned extubation for a case of difficult intubation.1-3 No parenteral sedative-analgesics were given postoperatively in order to ensure a completely awake patient at the time of extubation. Tongue stitch though essential was impossible to be taken in such a case. Thus, extubation was performed sequentially and using endotracheal tube exchangers (ETTE)1,2 and a nasopharyngeal airway7 observing the patient for a sufficient length of time at each step.
Reference
1. Topf A, Eclavea A. Extubation of the difficult airway. Anesthesiology 1996; 85 (5) : 1213-4.
2. Cooper RM. The use of an endotracheal ventilation catheter in the management of difficult extubations. Can J Anaesth 1996; 43 (1) : 90-3.
3. Benumof J. Airway exchange catheters for safe extubation: The clinical and scientific details that make the concept work. Chest 1997; 111 (6) : 1483-6.
4. Atlas GM, Mort TC. Extubation of the difficult airway over an airway exchange catheter: Relationship of catheter size and patient tolerance. Crit Care Med 1999; 27 (12) S: A57.
5. Martin L. Norton, Brown CD. Fibreoptic intubation, Atlas of the difficult airway. Pg. 16.
6. Martin L. Norton, Brown CD. Bougie (intubation guide), Atlas for the difficult airway. Pg. 22.
7. Jerry A. Dorsch, Susan E Dorsch. Nasopharyngeal airway. Understanding Anaesthesia Equipment, Construction, Care and Complications. 2nd edition, Pg.333.
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