Esophageal Perforation following Use of Esophageal Airway* David B. Pilcher, M.D., and ]ames E. DeMeules, M .D.
The esophageal airway has gained increasing acceptance in airway management during cardiopulmonary resuscitation, and its enthusiastic advocates are urging expansion of its use. A fatal case of esophageal perforation foUow-
ing the use of an esophageal airway is presented. Possible contributing factors are discussed. A modified esophageal airway which seems safer and more versatile, ellective, and economic is described.
The esophageal airway has gained increasing acceptance in this country for management of respiratory arrest by paramedical personnel in the field. Since ambulance personnel are delivering patients to emergency departments with the esophageal airway in place, physicians must be familiar with this apparatus. Endotracheal intubation is accepted as providing the most effective airway. With cuffed tubes, such intubation is the best safeguard against aspiration. The use of endotracheal intubation by ambulance personnel in the field is limited by the requisite expertise and training, by the apneic time delay incident to insertion even by anesthesiologists, and by suboptimal conditions in the field. The esophageal airway as originally described by Don Michael et aP and more recently by Farley2 and Smock3 overcomes many of these objections. It is easy to insert, necessitating less requisite training and expertise than is required for endotracheal intubation. Insertion time and, consequently, time of apnea are minimal. The currently marketed esophageal airway has been uniformly supported by those using it in the field; it has been described by others, and believed by us, to have been effective in preventing vomiting and aspiration. Farley2 has discussed such successes and some common problems, ie, removal prior to endotracheal intubation by emergency-room personnel unfamiliar with the device. She also quotes practical experience in California and Missouri. There do not appear to be any controlled studies
comparing this airway with other techniques. Tests before marketing by Gordon showed ventilation to be "equivalent to that which results from endotracheal intubation," according to Farley.2 While introducing this esophageal airway to ambulance personnel in Vermont, the staff of the emergency department utilized this apparatus for
°From the Department of Surgery, University of Vermont College of Medicine, and the Medical Center Hospital of Vermont, Burlington. Manuscript received June 16; revision accepted September 2. Reprint requests: Dr. Pilcher, Department of Surgery, University of Vermont School of Medicine, Burlington 054Ql
CHEST, 69: 3, MARCH, 1976
FIGURE 1. Meglumine-diatrizoate ( Gastrografin) swallow six hours after resuscitation with esophageal airway, demonstrating leak into right mediastinum of the seventh thoracic vertebra.
ESOPHAGEAL PERFORATION FOLLOWING USE OF ESOPHAGEAL AIRWAY 377
FIGURE 2. Meglumine-diatrizoate ( Gastrografin) swallow on 14th postoperative day, demonstrating disruption of esophageal repair.
several cardiac resuscitations undertaken in the emergency department. During one of these resuscitations, esophageal disruption occurred, . prompting reevaluation of the esophageal airway. CASE REPORT
A 63-year-old man presented to the Emergency Department of the Medical Center Hospital of Vermont, Burlington, on Sept 25, 1973, complaining of sweating and a sense of rapid heartbeat. The patient had had documented myocardial infarctions five years, four years, and nine months preceding this admission. In July 1973 the patient had survived a cardiopulmonary arrest with ventricular fibrillation occurring outside the hospital. That resuscitation was accomplished with bag-mask breathing en route to the hospital and endotracheal intubation in the emergency department. An esophageal airway was not used during the cardiac arrest in July 1973. A pacemaker was implanted in August 1973. During the present admission, while still in the emergency
department on Sept 25, 1973, the patient suffered cardiac arrest with seizure activity. Closed-chest massage was required for less than three minutes, when intravenous administration of lidocaine converted his ventricular tachycardia to a sinus tachycardia and the patient regained consciousness. The esophageal airway had been inflated with a 60-ml syringe, which had replaced the 35-ml syringe originally supplied with the esophageal airway. The same syringe was used to deflate the cuff prior to removal, and the indicator balloon was believed to be Hat. Initially the airway was removed without difficulty, but when the cuff reached the posterior pharynx, slow steady tension caused the tube to pop out of the mouth with the cuff one-third to one-half inflated. The patient was alert and talking, complaining about the use of the airway but not of any pain. One hour later after the resuscitation, while in the coronary care unit, the patient complained of neck pain aggravated by deep breathing and motion. Over the next few hours, this pain became more severe and radiated to the right posterior chest. Five hours after resuscitation, the patient experienced shaking chills. A chest x-ray film showed mediastinal air, and a meglumine-diatrizoate ( Gastrografin) swallow documented a large esophageal rupture with leakage into the right mediastinum ( Fig 1 ) . The patient was explored through a right thoracotomy incision 12 hours after his resuscitation. There was a 7 em longitudinal rent in the posterolateral esophagus starting about 2 em above the bronchial carina and extending distally. Esophageal tissues appeared pink and surprisingly healthy. A two-layer closure was accomplished and was reinforced with an intercostal-muscle pedicle Hap. The chest was drained with a thoracic catheter. On the fifth postoperative day a repeat megluminediatrizoate ( Gastrografin) swallow demonstrated a small esophageal leak, and this progressed to a complete disruption by the 14th postoperative day ( Fig 2) . Rib resection and mediastinal drainage were followed by continued esophageal leakage and intermittent sepsis. Because of the patie~t's extremely labile cardiac condition, esophageal diversion was not performed. Continuing sepsis and cardiac arrhytbmias finally led to death on the 47th postoperative day. Autopsy
~ ---~-
·- -·-
·-
.·:YL----
FIGURE 3. Currently marketed esophageal airway. Obturator end (A) enters esophagus, and balloon ( B) prevents regurgitation. Side holes (C) allow lung inflation with bag attached ( D) and mask firmly applied to face.
378 PILCHER, DE MEULES
CHEST, 69: 3, MARCH, 1976
c
FIGURE 4. Vermont modification of esophageal airway. Nasotracheal tube open at end (A) with low-pressure cuH (B) replacing obturator tube. If regurgitation occurs, vomitus egresses at point C. Side connector (D) can be used to inflate lungs with mask firmly applied to face.
revealed a 7.5 em widely patent perforation in the middle portion of the esophagus. Other autopsy findings included healed and organizing myocardial infarctions, pseudomembranous enterocolitis, and multiple pulmonary thrombi. CURRENT EsoPHAGEAL AmwAY
The esophageal airway as supplied (Fig 3) is equipped with a 35-ml syringe. Inflation with this syringe results in a cuff-balloon circumference of 3.5 em and an intracuff pressure of about 300 mm Hg. Inflation with 55 ml (as in the present case) results in a cuff circumference of 4.0 em and an intracuff pressure of 420 mm Hg.
endotracheal intubation the fortunate result. The tube should be marked such that if in the trachea, it is not inserted all the way, in order Jo avoid placement in the right main-stem bronchus. If the esophageal tube enters the esophagus, as will usually be the case, the mask can be held tightly applied to the face and respirations accomplished via the side connector (Fig 4). A further advantage results from the employment of a standard nasotracheal tube as the esophageal tube, since these tubes are readily available and
MoDIFICATION OF EsoPHAGEAL AmwAY
The esophageal airway has been modified as follows to overcome the problems described and incidentally to offer other advantages. Our modifications are shown in Figure 4. This tube has a low-pressure cuff with approximately 40 mm Hg when inflated with 35 ml of air. The cuff balloon will, therefore, conform more readily to the esophagus and not be as rigid with external cardiac compression. The tube is a standard nasotracheal tube with a longer shaft bag-mask adapter. The esophageal tube is open at the end so that if vomiting occurs, the vomitus will exit via the outlet in the mask. Distal esophageal pressures with vomiting should be low while still allowing low cuff pressure. If the esophageal tube should enter the trachea (Fig 5), this can be recognized by a quick trial oral inflation and the mask removed, with a successful CHEST, 69: 3, MARCH, 1976
FIGURE 5. Vermont modification of esophageal airway. If tube fortuitously enters trachea, lungs can be inflated through tube, as with any other endotracheal tube with mask detached. With tube in trachea-, ventilation can also be achieved by attaching bag to adapter on end of tube without removing mask.
ESOPHAGEAL PERFORAnON FOLLOWING USE OF ESOPHAGEAL AIRWAY
3~9
inexpensive for replacement and sterilization. Since the mask is durab!e and cuffed tubes are not, this should provide considerable economy. Nasotracheal tubes are available with low-pressure cuffs. Cuff pressures can easily be checked with a three-way stopcock and manometer. As suggested by Wu et al, 4 prestretching some cuffs may overcome this problem. The foam cuff (Bivona Fome), which is open to the atmosphere, should offer even less of a rigid bolus with cardiopulmonary resuscitation than low-pressure cuffs. This modified tube is currently undergoing trial by our paramedical personnel.
ume greater than recommended, removal without complete deflation, and conceivably high distal esophageal pressures secondary to vomiting and seizure activity may individually or in combination have caused the resultant esophageal perforation. In the absence of alternatives, the currently marketed esophageal airway has been used successfully and does provide an airway with protection against vomiting and aspiration. Anyone using this airway must be aware of the dangers of overinHation and the necessity of complete deflation prior to removal. We believe that the suggested modifications should result in greater safety, effectiveness, and economy.
DISCUSSION
The original description by Don Michael et al1 showed an esophageal cuff inflated by pressure rather than volume. The intracuff pressure of the currently marketed esophageal airway with recommended inflation volume is so high that it must be essentially a rigid object in an esophagus and subject to considerable pressure when used in association with closed-chest massage. In the case described herein, inflation with a vol-
REFERENCES 1 Don Michael TA, Lambert EH, Mehran A: Mouth-to-lung airway for cardiac resuscitation. Lancet 2:1329, 1968 2 Farley M: The esophageal obturator airway. Respir Ther 3:95-99, 1973 3 Smock SN: Esophageal obturator airway: Preferred CPR technique. JAm Coli Emer Phys 4:232-233, 1975 4 Wu W, Lim I, Simpson FA, et al: Pressure dynamics of endotracheal and tracheostomy cuHs. Crit Care Med 1: 197202, 1973
Vincenzo Bellini (1801-1835) Bellini was born in Catania, the beautiful Sicilian city lying under the devastating shadow of Mount Etna. His student works met with such success and enthusiasm that he was commissioned to write an opera for the San Carlo theater at Naples. One success followed another. The famous impresario Domenico Barbaja invited Bellini to Milan. Here in six months he completed Il Pirata, which was acclaimed at La Scala. The pastel enchantment of Lake Como-and the love of Giuditta Turinainspired Bellini in 1831. During this year the fully mature melodramatic masterpieces, La Somnambula and Norma were composed. Richard Wagner, who struggled violently against Italian melodrama in his efforts to
380 PILCHER, DE MEULES
create a German national opera, singled out Norma to open the 1837 opera season at Riga. "Bellini is one of my predilections," he declared. "His music is all heart, intimately connected with the words." Bellini and Chopin became friendly to a degree where they exchanged and compared compositions. Bellini was buried at Pere Lachaise, but in 1876 his remains were conveyed to his native Catania-into the Cathedral where his small fingers had played the organ. Berges, R: The Backgrounds and Traditions of Opera, South Brunswick and New York, A. S. Barnes, 1970
CHEST, 69: 3, MARCH, 1976
The esophageal airway has gained increasing acceptance in airway management during cardiopulmonary resuscitation, and its enthusiastic advocates are urging expansion of its use. A fatal case of esophageal perforation foUow-
ing the use of an esophageal airway is presented. Possible contributing factors are discussed. A modified esophageal airway which seems safer and more versatile, ellective, and economic is described.
The esophageal airway has gained increasing acceptance in this country for management of respiratory arrest by paramedical personnel in the field. Since ambulance personnel are delivering patients to emergency departments with the esophageal airway in place, physicians must be familiar with this apparatus. Endotracheal intubation is accepted as providing the most effective airway. With cuffed tubes, such intubation is the best safeguard against aspiration. The use of endotracheal intubation by ambulance personnel in the field is limited by the requisite expertise and training, by the apneic time delay incident to insertion even by anesthesiologists, and by suboptimal conditions in the field. The esophageal airway as originally described by Don Michael et aP and more recently by Farley2 and Smock3 overcomes many of these objections. It is easy to insert, necessitating less requisite training and expertise than is required for endotracheal intubation. Insertion time and, consequently, time of apnea are minimal. The currently marketed esophageal airway has been uniformly supported by those using it in the field; it has been described by others, and believed by us, to have been effective in preventing vomiting and aspiration. Farley2 has discussed such successes and some common problems, ie, removal prior to endotracheal intubation by emergency-room personnel unfamiliar with the device. She also quotes practical experience in California and Missouri. There do not appear to be any controlled studies
comparing this airway with other techniques. Tests before marketing by Gordon showed ventilation to be "equivalent to that which results from endotracheal intubation," according to Farley.2 While introducing this esophageal airway to ambulance personnel in Vermont, the staff of the emergency department utilized this apparatus for
°From the Department of Surgery, University of Vermont College of Medicine, and the Medical Center Hospital of Vermont, Burlington. Manuscript received June 16; revision accepted September 2. Reprint requests: Dr. Pilcher, Department of Surgery, University of Vermont School of Medicine, Burlington 054Ql
CHEST, 69: 3, MARCH, 1976
FIGURE 1. Meglumine-diatrizoate ( Gastrografin) swallow six hours after resuscitation with esophageal airway, demonstrating leak into right mediastinum of the seventh thoracic vertebra.
ESOPHAGEAL PERFORATION FOLLOWING USE OF ESOPHAGEAL AIRWAY 377
FIGURE 2. Meglumine-diatrizoate ( Gastrografin) swallow on 14th postoperative day, demonstrating disruption of esophageal repair.
several cardiac resuscitations undertaken in the emergency department. During one of these resuscitations, esophageal disruption occurred, . prompting reevaluation of the esophageal airway. CASE REPORT
A 63-year-old man presented to the Emergency Department of the Medical Center Hospital of Vermont, Burlington, on Sept 25, 1973, complaining of sweating and a sense of rapid heartbeat. The patient had had documented myocardial infarctions five years, four years, and nine months preceding this admission. In July 1973 the patient had survived a cardiopulmonary arrest with ventricular fibrillation occurring outside the hospital. That resuscitation was accomplished with bag-mask breathing en route to the hospital and endotracheal intubation in the emergency department. An esophageal airway was not used during the cardiac arrest in July 1973. A pacemaker was implanted in August 1973. During the present admission, while still in the emergency
department on Sept 25, 1973, the patient suffered cardiac arrest with seizure activity. Closed-chest massage was required for less than three minutes, when intravenous administration of lidocaine converted his ventricular tachycardia to a sinus tachycardia and the patient regained consciousness. The esophageal airway had been inflated with a 60-ml syringe, which had replaced the 35-ml syringe originally supplied with the esophageal airway. The same syringe was used to deflate the cuff prior to removal, and the indicator balloon was believed to be Hat. Initially the airway was removed without difficulty, but when the cuff reached the posterior pharynx, slow steady tension caused the tube to pop out of the mouth with the cuff one-third to one-half inflated. The patient was alert and talking, complaining about the use of the airway but not of any pain. One hour later after the resuscitation, while in the coronary care unit, the patient complained of neck pain aggravated by deep breathing and motion. Over the next few hours, this pain became more severe and radiated to the right posterior chest. Five hours after resuscitation, the patient experienced shaking chills. A chest x-ray film showed mediastinal air, and a meglumine-diatrizoate ( Gastrografin) swallow documented a large esophageal rupture with leakage into the right mediastinum ( Fig 1 ) . The patient was explored through a right thoracotomy incision 12 hours after his resuscitation. There was a 7 em longitudinal rent in the posterolateral esophagus starting about 2 em above the bronchial carina and extending distally. Esophageal tissues appeared pink and surprisingly healthy. A two-layer closure was accomplished and was reinforced with an intercostal-muscle pedicle Hap. The chest was drained with a thoracic catheter. On the fifth postoperative day a repeat megluminediatrizoate ( Gastrografin) swallow demonstrated a small esophageal leak, and this progressed to a complete disruption by the 14th postoperative day ( Fig 2) . Rib resection and mediastinal drainage were followed by continued esophageal leakage and intermittent sepsis. Because of the patie~t's extremely labile cardiac condition, esophageal diversion was not performed. Continuing sepsis and cardiac arrhytbmias finally led to death on the 47th postoperative day. Autopsy
~ ---~-
·- -·-
·-
.·:YL----
FIGURE 3. Currently marketed esophageal airway. Obturator end (A) enters esophagus, and balloon ( B) prevents regurgitation. Side holes (C) allow lung inflation with bag attached ( D) and mask firmly applied to face.
378 PILCHER, DE MEULES
CHEST, 69: 3, MARCH, 1976
c
FIGURE 4. Vermont modification of esophageal airway. Nasotracheal tube open at end (A) with low-pressure cuH (B) replacing obturator tube. If regurgitation occurs, vomitus egresses at point C. Side connector (D) can be used to inflate lungs with mask firmly applied to face.
revealed a 7.5 em widely patent perforation in the middle portion of the esophagus. Other autopsy findings included healed and organizing myocardial infarctions, pseudomembranous enterocolitis, and multiple pulmonary thrombi. CURRENT EsoPHAGEAL AmwAY
The esophageal airway as supplied (Fig 3) is equipped with a 35-ml syringe. Inflation with this syringe results in a cuff-balloon circumference of 3.5 em and an intracuff pressure of about 300 mm Hg. Inflation with 55 ml (as in the present case) results in a cuff circumference of 4.0 em and an intracuff pressure of 420 mm Hg.
endotracheal intubation the fortunate result. The tube should be marked such that if in the trachea, it is not inserted all the way, in order Jo avoid placement in the right main-stem bronchus. If the esophageal tube enters the esophagus, as will usually be the case, the mask can be held tightly applied to the face and respirations accomplished via the side connector (Fig 4). A further advantage results from the employment of a standard nasotracheal tube as the esophageal tube, since these tubes are readily available and
MoDIFICATION OF EsoPHAGEAL AmwAY
The esophageal airway has been modified as follows to overcome the problems described and incidentally to offer other advantages. Our modifications are shown in Figure 4. This tube has a low-pressure cuff with approximately 40 mm Hg when inflated with 35 ml of air. The cuff balloon will, therefore, conform more readily to the esophagus and not be as rigid with external cardiac compression. The tube is a standard nasotracheal tube with a longer shaft bag-mask adapter. The esophageal tube is open at the end so that if vomiting occurs, the vomitus will exit via the outlet in the mask. Distal esophageal pressures with vomiting should be low while still allowing low cuff pressure. If the esophageal tube should enter the trachea (Fig 5), this can be recognized by a quick trial oral inflation and the mask removed, with a successful CHEST, 69: 3, MARCH, 1976
FIGURE 5. Vermont modification of esophageal airway. If tube fortuitously enters trachea, lungs can be inflated through tube, as with any other endotracheal tube with mask detached. With tube in trachea-, ventilation can also be achieved by attaching bag to adapter on end of tube without removing mask.
ESOPHAGEAL PERFORAnON FOLLOWING USE OF ESOPHAGEAL AIRWAY
3~9
inexpensive for replacement and sterilization. Since the mask is durab!e and cuffed tubes are not, this should provide considerable economy. Nasotracheal tubes are available with low-pressure cuffs. Cuff pressures can easily be checked with a three-way stopcock and manometer. As suggested by Wu et al, 4 prestretching some cuffs may overcome this problem. The foam cuff (Bivona Fome), which is open to the atmosphere, should offer even less of a rigid bolus with cardiopulmonary resuscitation than low-pressure cuffs. This modified tube is currently undergoing trial by our paramedical personnel.
ume greater than recommended, removal without complete deflation, and conceivably high distal esophageal pressures secondary to vomiting and seizure activity may individually or in combination have caused the resultant esophageal perforation. In the absence of alternatives, the currently marketed esophageal airway has been used successfully and does provide an airway with protection against vomiting and aspiration. Anyone using this airway must be aware of the dangers of overinHation and the necessity of complete deflation prior to removal. We believe that the suggested modifications should result in greater safety, effectiveness, and economy.
DISCUSSION
The original description by Don Michael et al1 showed an esophageal cuff inflated by pressure rather than volume. The intracuff pressure of the currently marketed esophageal airway with recommended inflation volume is so high that it must be essentially a rigid object in an esophagus and subject to considerable pressure when used in association with closed-chest massage. In the case described herein, inflation with a vol-
REFERENCES 1 Don Michael TA, Lambert EH, Mehran A: Mouth-to-lung airway for cardiac resuscitation. Lancet 2:1329, 1968 2 Farley M: The esophageal obturator airway. Respir Ther 3:95-99, 1973 3 Smock SN: Esophageal obturator airway: Preferred CPR technique. JAm Coli Emer Phys 4:232-233, 1975 4 Wu W, Lim I, Simpson FA, et al: Pressure dynamics of endotracheal and tracheostomy cuHs. Crit Care Med 1: 197202, 1973
Vincenzo Bellini (1801-1835) Bellini was born in Catania, the beautiful Sicilian city lying under the devastating shadow of Mount Etna. His student works met with such success and enthusiasm that he was commissioned to write an opera for the San Carlo theater at Naples. One success followed another. The famous impresario Domenico Barbaja invited Bellini to Milan. Here in six months he completed Il Pirata, which was acclaimed at La Scala. The pastel enchantment of Lake Como-and the love of Giuditta Turinainspired Bellini in 1831. During this year the fully mature melodramatic masterpieces, La Somnambula and Norma were composed. Richard Wagner, who struggled violently against Italian melodrama in his efforts to
380 PILCHER, DE MEULES
create a German national opera, singled out Norma to open the 1837 opera season at Riga. "Bellini is one of my predilections," he declared. "His music is all heart, intimately connected with the words." Bellini and Chopin became friendly to a degree where they exchanged and compared compositions. Bellini was buried at Pere Lachaise, but in 1876 his remains were conveyed to his native Catania-into the Cathedral where his small fingers had played the organ. Berges, R: The Backgrounds and Traditions of Opera, South Brunswick and New York, A. S. Barnes, 1970
CHEST, 69: 3, MARCH, 1976
