Placement of an Endotracheal Tube in the Short Tratheal Stump Daniel P. Pellegrini, MD, Samuel J. Mucci, MD, Dennis S. Durzinsky, MD, and F’rabir K. Chaudhuri, MD Department of Surgery, Medical College of Ohio, Toledo, Ohio
Placement of an endotracheal tube in the short tracheal stump, such as after a mediastinal tracheostomy, can be a difficult task. The tube may easily slide into the right main bronchus or slip out of the trachea completely. We have described a method for securing such an airway for ventilation during general anesthesia. (Ann Thoruc Surg 2992;54:578-9)
T
he presence of a mediastinal tracheostomy can result in difficulty placing an airway tube during subsequent siirgical procedures requiring general anesthesia and intubation. The endotracheal tube may slip into the right main bronchus or slip out of the stoma due to the short length of the tracheal stump. Also, immediately after construction of mediastinal tracheostomy, it is important to place and anchor the tracheostomy tube properly to prevent tube dislodgement during the period of mechanical ventilation. Proper placement of an endotracheal tube in the mediastinal stoma is considered to be the responsibility of the surgeon [ 11. In this communication, we describe a safe and easy method for placement of an endotracheal tube in a short tracheal stump that avoids the problems of repeated dislodgernent or misplacement of the tube into the main bronchi.
Material and Methods For this purpose, we used a reinforced, cuffed, Murphy eye tracheal tube of 7.5 mm or 8.0 mm internal diameter (Mallinckrodt Critical Care, Glens Falls, NY) for intubation of the patient. Before intubation, the air-cuff (which is usually 3 cm in length when inflated) is partially wrapped with thick adhesive tape to allow a balloon of only 1 cm in length (Fig 1).The tube is inserted through the stoma up to the lower edge of the adhesive tape to allow the tip of the tube to be above the carina. Thereafter, the balloon is inflated and the tube is anchored with a 1-0 silk suture placed in the skin on either side of the stoma and tied over near the lower margin of the tape-wrapped portion of the tube (Fig 2). This prevents the suture from cutting the balloon, and also anchors the tube firmly and prevents dislodgement into a bronchus or out of the stoma. When
the balloon is inflated with 5 mL of air, measured cuff pressures are 16 mm Hg, approximately equal to those measured in an unaltered balloon inflated with 10 mL of air.
Results A 61-year-old woman with a previously created mediastinal tracheostomy was intubated according to the method described above. This was done for the purpose of a median sternotomy. The patient’s tracheostomy was created approximately 4 years before the median sternotomy. Inhalation anesthetic agents were appropriately administered without complication or dislodgement of tube during procedure. The patient was extubated immediately postoperatively and had an unremarkable postoperative course.
Comment A method for secure placement of an endotracheal tube in a short tracheal stump, as in a mediastinal tracheostomy, is described. Although a laryngectomy tube (Mallinckrodt Critical Care) can be used in a short trachea, it is not flexible and still poses a problem with proper placement in stoma. Our method requires no additional instruments. Wrapping the upper portion of the endotracheal tube balloon with tape allows shortening of the balloon to fit into the short trachea properly. Also, it is safer to tie the tube over the tape at the stoma, which prevents the tie from breaking the balloon.
Accepted for publication April 21, 1992. Address reprint requests to Dr Pellegrini, Department of Surgery, Medical College of Ohio, 3000 Arlington Ave, Toledo, OH 43699.
0 1992 by The Society of Thoracic Surgeons
Fig 1 . ( A ) Reinforced, cuffed, Murphy eye tracheal tube. ( B ) Endotracheal tube with tape applied over superior portion of balloon.
0003-4975/92/$5.00
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sia [2]. It should be noted that pulse oximetry and capnography are necessary for recognizing hypoxia and a possible airway problem. Establishment of a good ventilatory airway in these patients can be difficult to achieve and sustain. This takes on further relevance when the patient is undergoing a thoracic procedure, particularly a median sternotomy, or when the airway lies in close proximity to the operative field and the endotracheal tube may be subject to inadvertent manipulation and dislodgement. Securing the tube firmly is important as the tracheal mucosa is sensitive to erosion, which can be caused by motion of the tip of the tube against the tracheal wall [3]. It should also be stressed that the endotracheal tube should be a reinforced tube [4], as it may become kinked by the weight of sterile drapes or by retractors. Finally, a Steri-drape or Ioban (3M, Saint Paul, MN) drape can be placed over the endotracheal tube and stoma to enhance sterility and protect the operative field. Securing the tube with a skin stitch should prevent accidental extubation when removing the Steri-drape at the end of the procedure.
References
Fig 2. Endotracheal tube secured in airway in mediastinal tracheostomy.
A safe means of intubating the short tracheal stump is important because respiratory problems are the most common cause of brain damage and death under anesthe-
1. Gomes MN, Kroll S, Spear SL. Mediastinal tracheostomy. Ann Thorac Surg 1987;43:53943. 2. Norton ML, Brown ACD. Evaluating the patient with a difficult airway for anesthesia. Otolaryngol Clin North Am 1990;23:771-85. 3. Streitz JM Jr, Shapshay SM. Airway injury after tracheotomy and endotracheal intubation. Surg Clin North Am 1991;71: 1211-30. 4. Colice GL. Technical standards for tracheal tubes. Clin Chest Med 1991;12:4334.
Placement of an endotracheal tube in the short tracheal stump, such as after a mediastinal tracheostomy, can be a difficult task. The tube may easily slide into the right main bronchus or slip out of the trachea completely. We have described a method for securing such an airway for ventilation during general anesthesia. (Ann Thoruc Surg 2992;54:578-9)
T
he presence of a mediastinal tracheostomy can result in difficulty placing an airway tube during subsequent siirgical procedures requiring general anesthesia and intubation. The endotracheal tube may slip into the right main bronchus or slip out of the stoma due to the short length of the tracheal stump. Also, immediately after construction of mediastinal tracheostomy, it is important to place and anchor the tracheostomy tube properly to prevent tube dislodgement during the period of mechanical ventilation. Proper placement of an endotracheal tube in the mediastinal stoma is considered to be the responsibility of the surgeon [ 11. In this communication, we describe a safe and easy method for placement of an endotracheal tube in a short tracheal stump that avoids the problems of repeated dislodgernent or misplacement of the tube into the main bronchi.
Material and Methods For this purpose, we used a reinforced, cuffed, Murphy eye tracheal tube of 7.5 mm or 8.0 mm internal diameter (Mallinckrodt Critical Care, Glens Falls, NY) for intubation of the patient. Before intubation, the air-cuff (which is usually 3 cm in length when inflated) is partially wrapped with thick adhesive tape to allow a balloon of only 1 cm in length (Fig 1).The tube is inserted through the stoma up to the lower edge of the adhesive tape to allow the tip of the tube to be above the carina. Thereafter, the balloon is inflated and the tube is anchored with a 1-0 silk suture placed in the skin on either side of the stoma and tied over near the lower margin of the tape-wrapped portion of the tube (Fig 2). This prevents the suture from cutting the balloon, and also anchors the tube firmly and prevents dislodgement into a bronchus or out of the stoma. When
the balloon is inflated with 5 mL of air, measured cuff pressures are 16 mm Hg, approximately equal to those measured in an unaltered balloon inflated with 10 mL of air.
Results A 61-year-old woman with a previously created mediastinal tracheostomy was intubated according to the method described above. This was done for the purpose of a median sternotomy. The patient’s tracheostomy was created approximately 4 years before the median sternotomy. Inhalation anesthetic agents were appropriately administered without complication or dislodgement of tube during procedure. The patient was extubated immediately postoperatively and had an unremarkable postoperative course.
Comment A method for secure placement of an endotracheal tube in a short tracheal stump, as in a mediastinal tracheostomy, is described. Although a laryngectomy tube (Mallinckrodt Critical Care) can be used in a short trachea, it is not flexible and still poses a problem with proper placement in stoma. Our method requires no additional instruments. Wrapping the upper portion of the endotracheal tube balloon with tape allows shortening of the balloon to fit into the short trachea properly. Also, it is safer to tie the tube over the tape at the stoma, which prevents the tie from breaking the balloon.
Accepted for publication April 21, 1992. Address reprint requests to Dr Pellegrini, Department of Surgery, Medical College of Ohio, 3000 Arlington Ave, Toledo, OH 43699.
0 1992 by The Society of Thoracic Surgeons
Fig 1 . ( A ) Reinforced, cuffed, Murphy eye tracheal tube. ( B ) Endotracheal tube with tape applied over superior portion of balloon.
0003-4975/92/$5.00
HOW TO DO IT PELLEGRINI ET AL INTUBATING THE SHORT TRACHEA
579
sia [2]. It should be noted that pulse oximetry and capnography are necessary for recognizing hypoxia and a possible airway problem. Establishment of a good ventilatory airway in these patients can be difficult to achieve and sustain. This takes on further relevance when the patient is undergoing a thoracic procedure, particularly a median sternotomy, or when the airway lies in close proximity to the operative field and the endotracheal tube may be subject to inadvertent manipulation and dislodgement. Securing the tube firmly is important as the tracheal mucosa is sensitive to erosion, which can be caused by motion of the tip of the tube against the tracheal wall [3]. It should also be stressed that the endotracheal tube should be a reinforced tube [4], as it may become kinked by the weight of sterile drapes or by retractors. Finally, a Steri-drape or Ioban (3M, Saint Paul, MN) drape can be placed over the endotracheal tube and stoma to enhance sterility and protect the operative field. Securing the tube with a skin stitch should prevent accidental extubation when removing the Steri-drape at the end of the procedure.
References
Fig 2. Endotracheal tube secured in airway in mediastinal tracheostomy.
A safe means of intubating the short tracheal stump is important because respiratory problems are the most common cause of brain damage and death under anesthe-
1. Gomes MN, Kroll S, Spear SL. Mediastinal tracheostomy. Ann Thorac Surg 1987;43:53943. 2. Norton ML, Brown ACD. Evaluating the patient with a difficult airway for anesthesia. Otolaryngol Clin North Am 1990;23:771-85. 3. Streitz JM Jr, Shapshay SM. Airway injury after tracheotomy and endotracheal intubation. Surg Clin North Am 1991;71: 1211-30. 4. Colice GL. Technical standards for tracheal tubes. Clin Chest Med 1991;12:4334.
