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Re‐intubation over airway exchange catheters – mind the gap

2010; Wiley; Volume: 65; Issue: 8 Linguagem: Inglês

10.1111/j.1365-2044.2010.06433.x

1365-2044

A. Higgs, C. Swampillai, R. M. Dravid, V. Mitchell, Anita Patel, M. Popat,

Respiratory Support and Mechanisms

In patients who have undergone a difficult intubation, extubation can also be present significant risks [1]. In these situations many experts recommend the use of airway exchange catheters [2, 3]. These hollow polyvinyl chloride ventilating catheters can be inserted through a tracheal tube at the conclusion of surgery and left in situ when the tracheal tube is removed. Should extubation fail, these catheters provide a ready means of re-intubating the trachea. The airway exchange catheter available in the UK is made by Cook Medical (William Cook Europe, Bjaeverskov, Denmark). Most literature describes the use of smaller diameter catheters (8 and 11 Fr.) [2]. This is because they are the most easily tolerated by the conscious patient, when compared with the larger 14- and 19- Fr. catheters. Railroading appropriately sized tracheal tubes over these devices is rarely difficult but difficulty can be encountered due to the discrepancy between the external diameter of the airway exchange catheter and the internal diameter of the tracheal tube, the gap causing hold-up at the larynx [4]. In order to improve the ease of railroading when using these smaller gauge devices, the discrepancy in size between the airway exchange catheter and the tracheal tube can be bridged by passing an Aintree intubation catheter ™ (Cook Medical; external diameter 6.5 mm) over a size 11 Fr. airway exchange catheter (external diameter 3.7 mm). The tracheal tube can then be railroaded over the airway exchange catheter-Aintree combination. This is in keeping with the concept of 'the gap filler'; all other manoeuvres to facilitate railroading should also be employed [4]. An Aintree intubation catheter will accommodate 7.0-mm tracheal tubes and larger. This combination of catheters is stiffer than either device alone, which aids railroading a tracheal tube into the trachea (Fig. 1). Left: 11-Fr. Cook airway exchange catheter in a 7.0-mm tracheal tube. Right: bridging of gap between 11-Fr. Cook airway exchange catheter and 7.0-mm tracheal tube with an Aintree catheter. The airway exchange catheter is too long (83 cm) to permit passage of a fibre-optic laryngoscope to confirm tip position. However, when an Aintree intubation catheter has been passed over an airway exchange catheter, the latter can be removed, and a fibreoptic laryngoscope can then be passed through the shorter Aintree intubation catheter (length 56 cm) to view the lower airway and optimise tip position. This excercise is crucial when oxygen insufflation or jet ventilation via the catheter is being considered, as barotrauma in this circumstance is believed to be the result of a sub-carinal tip position and is consistent with the recommendation to use shorter airway exchange catheters [5]. On behalf of the Difficult Airway Society Clinical Extubation Guidelines Group.