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University of Nebraska Medical Center; Omaha, Nebraska; teschult{at}unmc.edu
To the Editor:
Exchange catheters are often used to assist in the changing of tracheal tubes. The following case illustrates one complication of using such exchange catheters. A 73-year-old man, admitted for pneumonia and requiring tracheal intubation for respiratory failure, was transferred directly from the intensive care unit to the operating room to undergo video-assisted thorocoscopy. An 8.0 single-lumen tracheal tube was in place. After inducing anesthesia with sevoflurane, a Cook exchange catheter (Cook C-CAE-11.0–100-DLT-EF Extra Firm Exchange Obturator with Rapi Fit Adapters for Double-Lumen Endotracheal Tube, Cook Critical Care, Bloomington, IN) was placed through the 8.0 tracheal tube to the 30-cm mark. The tube was withdrawn, and the exchange catheter threaded through the blue bronchial lumen of a 41F Sheridan double-lumen endotracheal tube. The double-lumen endotracheal tube was met with mild resistance at 20 cm and then inserted to 29 cm at the patient’s lips. Severe resistance was met when attempting to pull the Cook exchange catheter out of the double-lumen endotracheal tube and the exchange catheter stretched and then snapped. The broken end of the exchange catheter was 2 cm into the double-lumen tube and could not be reached with a hemostat.
The double-lumen endotracheal tube was completely withdrawn along with the broken exchange catheter. Direct laryngoscopy was performed and a 7.5 single-lumen tracheal tube was initially placed, and then a 41F double-lumen endotracheal tube was placed with proper position of lung isolation confirmed with auscultation and fiberoptic bronchoscopy. The video-assisted thorocoscopy was then performed without complication. At the end of the case, a single-lumen 8.0 tracheal tube was placed after removal of the double-lumen tube.
An airway exchange catheter is a hollow, semirigid catheter that can be used to assist with changing tracheal tubes, provide oxygen insufflation and jet ventilation, or be left in situ for a "trial" extubation (1–3). These are not without risk because of complications including misplacement, tracheobronchial trauma or lung laceration, jet ventilation-associated barotrauma and pneumothorax, and laryngeal or vocal cord trauma from a new tracheal tube "hanging up" during the exchange (4–7). Esophageal placement has occurred leading to gastric perforation (8).
In this case, the double-lumen tube was caught at the glottic opening. When attempting to insert the double-lumen endotracheal tube further into the trachea, the double-lumen endotracheal tube kinked and bent the airway exchange device inside it as well. The double-lumen endotracheal tube was actually coiled in the hypophaynx and the kink in the tube prevented removal of the exchange catheter and pulling the catheter caused it to break.
The Cook Exchange catheters with Rapi Fit Adapters are manufactured hollowed tubes allowing ventilation to be performed. However, if the catheter is difficult to withdraw from the lumen of a tracheal tube, caution is required to prevent fracture of the catheter at the kink site.
REFERENCES
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