An approach for safe conversion of an oral endotracheal tube to a nasal endotracheal tube Michael Hofkamp, MD, and Zhiying Diao
We present an approach for safe management of a patient with an oral endotracheal tube who required conversion to a nasal endotracheal tube. A 35-year-old man presented for mandibular fracture repair after multiple injuries sustained in a motor vehicle accident. The patient already had an oral endotracheal tube, and the surgical team requested a nasal endotracheal tube to facilitate surgical exposure and postoperative airway management in anticipation of a wired jaw. A nasal endotracheal tube was inserted through the naris and a video laryngoscope was used to visualize the glottis. A tracheal tube introducer was inserted through the oral endotracheal tube, and the oral endotracheal tube was then withdrawn approximately 5 cm. The nasal endotracheal tube was advanced through the vocal cords alongside the tracheal tube introducer. The nasal endotracheal tube cuff was then inflated and the tracheal tube introducer was withdrawn.
O
ccasionally, anesthesiologists are requested to convert an oral endotracheal tube to a nasal endotracheal tube. Unlike the relatively straightforward oral to oral endotracheal tube exchange that uses a modification of the Seldinger technique (1), an oral to nasal endotracheal tube conversion is complicated by head and neck anatomy. The foremost concern in performing such a tube exchange is maintaining secure control of the airway. We present a technique for converting an oral endotracheal tube to a nasal endotracheal tube while continuously maintaining reliable access to the airway. CASE DESCRIPTION A 35-year-old man sustained multiple injuries in a motor vehicle accident that necessitated emergent endotracheal intubation and admission to the intensive care unit. On hospital day 4, the patient was scheduled to undergo open repair of a mandibular fracture. A tracheostomy was considered, but the attending surgical critical care intensivist believed that the patient had a chance to be extubated within 3 to 4 days after the operation. A multidisciplinary decision was made to convert the oral endotracheal tube to a nasal endotracheal tube for surgical exposure and postoperative airway management. The patient arrived intubated with an 8.0 mm oral endotracheal tube and was anesthetized with inhaled desflurane, paralyzed with rocuronium 40 mg intravenous, and preoxy-
Proc (Bayl Univ Med Cent) 2017;30(1):83–84
Figure 1. Endotracheal tube configuration recreated with an airway mannequin, endotracheal tubes, airway exchange catheter, and video laryngoscope.
genated with 100% oxygen. The left naris was topicalized with oxymetazoline. A lubricated 8.0 mm nasal endotracheal tube (Hudson RCI Sheridan Preformed, DRE Medical, Louisville, KY) was then inserted. A video laryngoscope (C-MAC D-blade, Karl Storz Endoskope, Beirut, Lebanon) was used to visualize the glottis. A Venn Reusable Tracheal Tube Introducer (Smiths Medical, St. Paul, MN) was inserted through the oral endotracheal tube as an airway exchange catheter. Under direct visualization with the video laryngoscope, the oral endotracheal tube cuff was deflated and withdrawn approximately 5 cm, leaving the tracheal tube introducer through the vocal cords. The nasal endotracheal tube was then carefully advanced to the glottis using Magill forceps. For illustrative purposes, this configuration was recreated using an airway mannequin (AirSim, TruCorp, Belfast, N. Ireland), and a picture taken using the camera of the video laryngoscope is included in Figure 1. A simple schematic representation of our technique is included in Figure 2. From Baylor Scott & White Health, Temple, Texas (Hofkamp) and Baylor University, Waco, Texas (Diao). Corresponding author: Michael Hofkamp, MD, Baylor Scott & White Health, 2401 South 31st Street, Temple, TX 76508 (e-mail: Michael.Hofkamp@ BSWHealth.org). 83
Figure 2. Basic schematic diagram of the endotracheal tube configuration during tube exchange.
There was difficulty advancing the nasal endotracheal tube through the vocal cords, and an additional Venn Reusable Tracheal Tube Introducer (Smiths Medical, St. Paul, MN) facilitated placement of the endotracheal tube using a modified Seldinger technique (1). The balloon of the nasal endotracheal tube was inflated, breath sounds were auscultated bilaterally in the axillae, and expired end-tidal carbon dioxide was confirmed. Finally, the tracheal tube introducer associated with the oral endotracheal tube was withdrawn past the inflated cuff of the nasal endotracheal tube. DISCUSSION Oral to nasal endotracheal tube exchanges have been described using various techniques. Dutta and colleagues inserted a bronchoscope through the naris, delivered it through the mouth, and used the bronchoscope as a guide to withdraw an existing oral endotracheal tube back through the naris (2). Similarly, Hoffman and colleagues used a urethral exchange catheter wire inserted through the naris and delivered through the mouth that was subsequently taped to an oral airway exchange catheter; the connected components acted as a guide (3). Nakata and Niimi designed a proprietary commercial device to facilitate oral to nasal endotracheal tube exchange where a two-part airway exchange catheter is used; the distal portion is inserted through the oral endotracheal tube, and the oral endotracheal tube is then withdrawn, the proximal portion is inserted through the nares, and then the two parts are connected, forming an intact airway exchange catheter to facilitate passage of a nasal endotracheal tube (4). Uria and colleagues reported using downward pressure on an existing oral endotracheal tube to bring the glottis into view, and a nasally placed bougie was inserted through the vocal cords to allow passage of an endotracheal tube (5). Monclus and colleagues inserted an airway
84
exchange catheter that could be used for oxygenation during apnea through an oral endotracheal tube and then performed a nasal fiberoptic intubation, using the airway exchange catheter as a guide to the glottis (6). Nasal to oral endotracheal tube exchanges have also been described. Using a video laryngoscope, Galgon and Ketzler advanced an oral endotracheal tube over a rigid stylet to the glottis, deflated the cuff of an existing nasal endotracheal tube before withdrawing it, and then inserted the oral endotracheal tube through the glottis (7). Lee and colleagues inserted an airway exchange catheter through an existing nasal endotracheal tube, removed the endotracheal tube, and delivered the proximal end of the airway exchange catheter through the mouth, allowing an oral endotracheal tube to be placed (8). An advantage to our technique is that access to the airway is continuously maintained; we always had the ability to replace the existing oral endotracheal tube if our technique failed and the patient became hypoxemic. Additionally, we used equipment that is commonly available in operating rooms. This technique took less than 2 minutes to complete and was accomplished on the first attempt. Disadvantages of this technique are that the oropharynx can get crowded with the two endotracheal tubes, particularly with abnormal anatomy, and that an airway with copious amounts of blood or vomitus would impair the view of the video laryngoscope during the endotracheal tube exchange. We anticipated this complication and had a trauma surgeon available to perform an emergency tracheostomy if indicated. We believe that our technique is a reasonable first-line approach for the uncommon request of oral to nasal endotracheal tube exchange. 1. 2.
3.
4. 5.
6.
7.
8.
Seldinger SI. Catheter replacement of the needle in percutaneous arteriography: a new technique. Acta Radiol 1953;39(5):368–376. Dutta A, Chari P, Mohan RA, Manhas Y. Oral to nasal endotracheal tube exchange in a difficult airway: a novel method. Anesthesiology 2002;97(5): 1324–1325. Hoffman J, Matthews JM, Reese AR. Oral endotracheal tube exchange to the nasal route in a patient with facial trauma. J Clin Anesth 2011;23(4): 342. Nakata Y, Niimi Y. Oral-to-nasal endotracheal tube exchange in patients with bleeding esophageal varices. Anesthesiology 1995;83(6):1380–1381. Uria M, Kost K, Schricker T, Backman SB. Case report: nasotracheal intubation—look before leaping to assess the laryngeal view. Can J Anaesth 2008;55(5):302–305. Monclus E, Garces A, Artes D, Mabrock M. Oral to nasal tube exchange under fibroscopic view: a new technique for nasal intubation in a predicted difficult airway. Paediatr Anaesth 2008;18(7):663–666. Galgon RE, Ketzler JT. The GlideScope for videolaryngoscopy-assisted nasotracheal-to-orotracheal tube exchange in the intensive care unit in a patient with a known difficult airway. J Clin Anesth 2012;24(5):412–414. Lee SH, Kim JE, Kang JM. Alternative technique for changing from nasal to oral endotracheal tube for orthognathic and nasal surgery by using an airway exchange catheter: a case report. Korean J Anesthesiol 2014;67(1): 48–51.
Baylor University Medical Center Proceedings
Volume 30, Number 1
We present an approach for safe management of a patient with an oral endotracheal tube who required conversion to a nasal endotracheal tube. A 35-year-old man presented for mandibular fracture repair after multiple injuries sustained in a motor vehicle accident. The patient already had an oral endotracheal tube, and the surgical team requested a nasal endotracheal tube to facilitate surgical exposure and postoperative airway management in anticipation of a wired jaw. A nasal endotracheal tube was inserted through the naris and a video laryngoscope was used to visualize the glottis. A tracheal tube introducer was inserted through the oral endotracheal tube, and the oral endotracheal tube was then withdrawn approximately 5 cm. The nasal endotracheal tube was advanced through the vocal cords alongside the tracheal tube introducer. The nasal endotracheal tube cuff was then inflated and the tracheal tube introducer was withdrawn.
O
ccasionally, anesthesiologists are requested to convert an oral endotracheal tube to a nasal endotracheal tube. Unlike the relatively straightforward oral to oral endotracheal tube exchange that uses a modification of the Seldinger technique (1), an oral to nasal endotracheal tube conversion is complicated by head and neck anatomy. The foremost concern in performing such a tube exchange is maintaining secure control of the airway. We present a technique for converting an oral endotracheal tube to a nasal endotracheal tube while continuously maintaining reliable access to the airway. CASE DESCRIPTION A 35-year-old man sustained multiple injuries in a motor vehicle accident that necessitated emergent endotracheal intubation and admission to the intensive care unit. On hospital day 4, the patient was scheduled to undergo open repair of a mandibular fracture. A tracheostomy was considered, but the attending surgical critical care intensivist believed that the patient had a chance to be extubated within 3 to 4 days after the operation. A multidisciplinary decision was made to convert the oral endotracheal tube to a nasal endotracheal tube for surgical exposure and postoperative airway management. The patient arrived intubated with an 8.0 mm oral endotracheal tube and was anesthetized with inhaled desflurane, paralyzed with rocuronium 40 mg intravenous, and preoxy-
Proc (Bayl Univ Med Cent) 2017;30(1):83–84
Figure 1. Endotracheal tube configuration recreated with an airway mannequin, endotracheal tubes, airway exchange catheter, and video laryngoscope.
genated with 100% oxygen. The left naris was topicalized with oxymetazoline. A lubricated 8.0 mm nasal endotracheal tube (Hudson RCI Sheridan Preformed, DRE Medical, Louisville, KY) was then inserted. A video laryngoscope (C-MAC D-blade, Karl Storz Endoskope, Beirut, Lebanon) was used to visualize the glottis. A Venn Reusable Tracheal Tube Introducer (Smiths Medical, St. Paul, MN) was inserted through the oral endotracheal tube as an airway exchange catheter. Under direct visualization with the video laryngoscope, the oral endotracheal tube cuff was deflated and withdrawn approximately 5 cm, leaving the tracheal tube introducer through the vocal cords. The nasal endotracheal tube was then carefully advanced to the glottis using Magill forceps. For illustrative purposes, this configuration was recreated using an airway mannequin (AirSim, TruCorp, Belfast, N. Ireland), and a picture taken using the camera of the video laryngoscope is included in Figure 1. A simple schematic representation of our technique is included in Figure 2. From Baylor Scott & White Health, Temple, Texas (Hofkamp) and Baylor University, Waco, Texas (Diao). Corresponding author: Michael Hofkamp, MD, Baylor Scott & White Health, 2401 South 31st Street, Temple, TX 76508 (e-mail: Michael.Hofkamp@ BSWHealth.org). 83
Figure 2. Basic schematic diagram of the endotracheal tube configuration during tube exchange.
There was difficulty advancing the nasal endotracheal tube through the vocal cords, and an additional Venn Reusable Tracheal Tube Introducer (Smiths Medical, St. Paul, MN) facilitated placement of the endotracheal tube using a modified Seldinger technique (1). The balloon of the nasal endotracheal tube was inflated, breath sounds were auscultated bilaterally in the axillae, and expired end-tidal carbon dioxide was confirmed. Finally, the tracheal tube introducer associated with the oral endotracheal tube was withdrawn past the inflated cuff of the nasal endotracheal tube. DISCUSSION Oral to nasal endotracheal tube exchanges have been described using various techniques. Dutta and colleagues inserted a bronchoscope through the naris, delivered it through the mouth, and used the bronchoscope as a guide to withdraw an existing oral endotracheal tube back through the naris (2). Similarly, Hoffman and colleagues used a urethral exchange catheter wire inserted through the naris and delivered through the mouth that was subsequently taped to an oral airway exchange catheter; the connected components acted as a guide (3). Nakata and Niimi designed a proprietary commercial device to facilitate oral to nasal endotracheal tube exchange where a two-part airway exchange catheter is used; the distal portion is inserted through the oral endotracheal tube, and the oral endotracheal tube is then withdrawn, the proximal portion is inserted through the nares, and then the two parts are connected, forming an intact airway exchange catheter to facilitate passage of a nasal endotracheal tube (4). Uria and colleagues reported using downward pressure on an existing oral endotracheal tube to bring the glottis into view, and a nasally placed bougie was inserted through the vocal cords to allow passage of an endotracheal tube (5). Monclus and colleagues inserted an airway
84
exchange catheter that could be used for oxygenation during apnea through an oral endotracheal tube and then performed a nasal fiberoptic intubation, using the airway exchange catheter as a guide to the glottis (6). Nasal to oral endotracheal tube exchanges have also been described. Using a video laryngoscope, Galgon and Ketzler advanced an oral endotracheal tube over a rigid stylet to the glottis, deflated the cuff of an existing nasal endotracheal tube before withdrawing it, and then inserted the oral endotracheal tube through the glottis (7). Lee and colleagues inserted an airway exchange catheter through an existing nasal endotracheal tube, removed the endotracheal tube, and delivered the proximal end of the airway exchange catheter through the mouth, allowing an oral endotracheal tube to be placed (8). An advantage to our technique is that access to the airway is continuously maintained; we always had the ability to replace the existing oral endotracheal tube if our technique failed and the patient became hypoxemic. Additionally, we used equipment that is commonly available in operating rooms. This technique took less than 2 minutes to complete and was accomplished on the first attempt. Disadvantages of this technique are that the oropharynx can get crowded with the two endotracheal tubes, particularly with abnormal anatomy, and that an airway with copious amounts of blood or vomitus would impair the view of the video laryngoscope during the endotracheal tube exchange. We anticipated this complication and had a trauma surgeon available to perform an emergency tracheostomy if indicated. We believe that our technique is a reasonable first-line approach for the uncommon request of oral to nasal endotracheal tube exchange. 1. 2.
3.
4. 5.
6.
7.
8.
Seldinger SI. Catheter replacement of the needle in percutaneous arteriography: a new technique. Acta Radiol 1953;39(5):368–376. Dutta A, Chari P, Mohan RA, Manhas Y. Oral to nasal endotracheal tube exchange in a difficult airway: a novel method. Anesthesiology 2002;97(5): 1324–1325. Hoffman J, Matthews JM, Reese AR. Oral endotracheal tube exchange to the nasal route in a patient with facial trauma. J Clin Anesth 2011;23(4): 342. Nakata Y, Niimi Y. Oral-to-nasal endotracheal tube exchange in patients with bleeding esophageal varices. Anesthesiology 1995;83(6):1380–1381. Uria M, Kost K, Schricker T, Backman SB. Case report: nasotracheal intubation—look before leaping to assess the laryngeal view. Can J Anaesth 2008;55(5):302–305. Monclus E, Garces A, Artes D, Mabrock M. Oral to nasal tube exchange under fibroscopic view: a new technique for nasal intubation in a predicted difficult airway. Paediatr Anaesth 2008;18(7):663–666. Galgon RE, Ketzler JT. The GlideScope for videolaryngoscopy-assisted nasotracheal-to-orotracheal tube exchange in the intensive care unit in a patient with a known difficult airway. J Clin Anesth 2012;24(5):412–414. Lee SH, Kim JE, Kang JM. Alternative technique for changing from nasal to oral endotracheal tube for orthognathic and nasal surgery by using an airway exchange catheter: a case report. Korean J Anesthesiol 2014;67(1): 48–51.
Baylor University Medical Center Proceedings
Volume 30, Number 1
