Anesth Analg 2006;103:1629-1630
© 2006 International Anesthesia Research Society
doi: 10.1213/01.ane.0000247190.19850.48
LETTER TO THE EDITOR
Editor-in-Chief Steven L. Shafer
Tube Exchanger for Laryngeal Mask-Based Percutaneous Tracheostomy in the Intensive Care Unit
Federico Bilotta, MD, PhD,
Federico Giovannini, MD,
Federico Conforto, MD,
Raffaella Pinto, MD, and
Giovanni Rosa, MD
Departments of Anesthesiology, Critical Care, and Pain Medicine (Bilotta)
Departments of Anesthesiology, Critical Care, and Pain Medicine; University of Rome "La Sapienza"; bilotta{at}tiscali.it (Giovannini)
Department of Anesthesiology; Ospedale S. Giovanni (Conforto)
Department of Anesthesiology; University of the "Sacred Heart" (Pinto)
Departments of Anesthesiology, Critical Care, and Pain Medicine; University of Rome "La Sapienza"; Rome, Italy (Rosa)
To the Editor:
During percutaneous dilatational tracheostomy with the PercuTwist technique, the endotracheal tube is typically withdrawn until the cuff lies at the level of the vocal cords (1). The risks of endotracheal tube or cuff puncture or displacement can be avoided by using a laryngeal mask airway (LMA) (2). However, the LMA may be difficult to place, or may not provide adequate ventilation (3,4). In 5% of cases, fiberoptic examination through the LMA fails to visualize the trachea (4). This can be addressed by using a tube exchanger to guide LMA insertion, and subsequently guide the fiberoptic bronchoscope. This approach is consistent with the recommendations for using a tube exchanger to provide a "safe extubation strategy" for difficult intubation (5). The guidelines are given in the table and accompanying Figure 1.
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Table 1. Work-Up for Safe Airway Management with the Use of an Endotracheal Tube Exchanger During LMA-Based Fiberoptic-Guided Percutaneous Tracheostomy in Patients Receiving Postoperative Intensive Care
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Figure 1. A. The tube exchanger is advanced into the trachea through the endotracheal tube. B. The endotracheal tube is withdrawn leaving the tube exchanger in place. C. The LMA is advanced, guided by the tube exchanger. D. After checking adequate ventilation through the LMA, the fiberoptic bronchoscope is inserted alongside the tube exchanger.
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REFERENCES
- Westphal K, Maeser D, Scheifler G, et al. PercuTwist: a new single-dilator technique for percutaneous tracheostomy. Anesth Analg 2003;96:229–32.[Abstract/Free Full Text]
- Dosemeci L, Yilmaz M, Gurpinar F, Ramazanoglu A. The use of laryngeal mask airway as an alternative to the endotracheal tube during percutaneous dilatational tracheostomy. Intensive Care Med 2002;28:63–7.[Web of Science][Medline]
- Reilly PM, Anderson HL, Sing RF, et al. Occult hypercarbia. An unrecognized phenomenon during percutaneous endoscopic tracheostomy. Chest 1995;107:1760–3.
- Crockett JA, Chendrasekhar A. Assessment of ventilation during the performance of a percutaneous dilatation tracheostomy. Am Surg 1998;64:455–8.[Web of Science][Medline]
- ASA task force on management of the difficult airway. Practice guidelines for management of the difficult airway. Anesthesiology 2003;98:1269–77.[Web of Science][Medline]
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