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GENERAL ARTICLES

Fiberoptic-Guided Airway Exchange of the Esophageal-Tracheal Combitube® in Spontaneously Breathing Versus Mechanically Ventilated Patients

Luis A. Gaitini, MD^*, Sonia J. Vaida, MD^*, Mostafa Somri, MD^*, Milo Fradis, MD, and Bruce Ben-David, MD

Departments of *Anesthesiology and Otolaryngology, Bnai Zion Medical Center; and Department of Anesthesiology, Herzlia-Haifa (Horev) Medical Center, Haifa, Israel

Address correspondence and reprint requests to L. Gaitini, MD, Director, Department of Anesthesiology, Bnai-Zion Medical Center, P.O. Box 4940, 31048, Haifa, Israel. Address e-mail to gaitini @netvision.net.il.

	Abstract

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The aim of this study was to compare fiberoptic-guided airway exchange of the esophageal-tracheal Combitube® (ETC, Kendall-Sheridan Catheter Corp., Argyle, NY) with an endotracheal tube in spontaneously breathing versus mechanically ventilated patients. Forty patients with Mallampati score III and IV scheduled for elective surgery were randomly allocated into two groups (n = 20 each): nonparalyzed, spontaneously breathing or paralyzed, mechanically ventilated patients. After anesthetic induction and insertion of the ETC, a fiberoptic bronchoscope threaded into an armored endotracheal tube was passed transnasally into the larynx. Endotracheal intubation was successful in 18 spontaneously breathing patients and in 15 patients during controlled ventilation. Successful airway exchange was completed in significantly less time (P < 0.05) in spontaneously breathing patients (9 ± 3 min; mean ± SD) than in mechanically ventilated patients (13 ± 4 min). Both methods allowed for continuous airway control and maintenance of ventilation and oxygenation. The described method is a means of replacing the ETC with an endotracheal tube without interruption of airway control or ventilation. Replacing the ETC with an endotracheal tube using this method is more readily accomplished during spontaneous ventilation than during controlled ventilation.

Implications: We describe the replacement of the Combitube® by an endotracheal tube by the aid of fiberoptic bronchoscopy and without interruption of airway control or ventilation. The performance of this technique was facilitated by spontaneous ventilation compared with mechanical ventilation.

	Introduction

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The esophageal-tracheal Combitube® (ETC, Kendall-Sheridan Catheter Corp., Argyle, NY) is a twin-lumen device that allows for ventilation independent of its position either in the esophagus or the trachea (1). Blind insertion results in successful esophageal intubation in nearly all patients (2). The ASA Task Force on Management of the Difficult Airway has recommended using the ETC in addition to the laryngeal mask, jet ventilation, and surgical airway when intubation problems occur in patients with a previously unrecognized difficult airway, especially in a "cannot ventilate, cannot intubate" situation (3). The ETC also has an established role in cardiopulmonary resuscitation in both prehospital and in-hospital settings (1,4,5).

Although it is possible to maintain an airway with the ETC, endotracheal intubation is the preferred method for definitive or protracted securing of the airway. Therefore, exchange of the ETC with an endotracheal tube (ETT) may often be desirable in continued management of the airway (6,7).

Ovassapian et al. (7) describe an ETC-ETT exchange technique in paralyzed, mechanically ventilated patients (7). We designed the current study to compare the facility of fiberoptic-guided airway exchange of the ETC in nonparalyzed, spontaneously breathing patients versus paralyzed, mechanically ventilated patients.

	Methods

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After obtaining approval from the local research ethics committee and written consent from the patients, 40 adult patients (ASA physical status I and II) undergoing elective surgery under general anesthesia were entered into the study. The Samsoon and Young modification (8) of the Mallampati airway classification (9) was used to evaluate the airway preoperatively, and only patients with a score of III or IV were included in the study. Exclusion criteria included intraabdominal surgery and a history of peptic disease, hiatus hernia, hypertension, ischemic heart disease, or cervical spine problems.

All patients received a premedication of oral diazepam 10–20 mg. The usual monitoring was used. The patients were randomly allocated into two groups of 20 using a sealed envelope technique. The same anesthesiologist (LAG), with wide experience in fiberoptic bronchoscopy, performed the procedure in all patients.

In the group of spontaneously breathing patients, anesthesia was induced with fentanyl 1–2 µg/kg and propofol 2–3 mg/kg and was maintained with N₂O/O₂ and isoflurane. Ventilation was manually assisted using the reservoir bag of a semiclosed system when end-tidal CO₂ was >45 mm Hg. In the group of mechanically ventilated patients, the same induction technique was used, with the sole addition of vecuronium 0.1 mg/kg. Neuromuscular blockade was assessed using a peripheral nerve stimulator with electrodes placed over the median nerve.

In all patients, the ETC was inserted blindly into the oropharynx and advanced until the printed ring on the tube was adjacent to the patient's incisors, in accordance with the manufacturer's recommendations. The oropharyngeal balloon was inflated with 85 mL of air, and the distal cuff was inflated with 5–15 mL of air. Proper positioning of the ETC was confirmed by bilateral chest movement, bilateral chest auscultation, absence of gastric insufflation, pulse oximetry, and partial pressure of end-tidal CO_2.

Before the induction of anesthesia, cotton-tipped applicators soaked in 5% cocaine were inserted into one nostril to provide local anesthesia and vasoconstriction of the nasal mucosa. After placement of the ETC, a lubricated fiberoptic bronchoscope threaded into a 7.5- or 8-mm inner diameter spiral reinforced ETT was advanced through the nostril and into the nasopharynx. Partial deflation of the oropharyngeal balloon of the ETC facilitated passage of the fiberoptic bronchoscope. The deflation was performed progressively, under direct vision, until the nasopharyngeal structures were identified. The fiberoptic bronchoscope was then advanced until visualization of the pharyngeal section of the ETC positioned superiolateral to the larynx was possible. Gentle manipulation of the fiberoptic bronchoscope was used to visualize the epiglottis and the vocal cords. Once the fiberscope was positioned in the trachea below the cords, the armored ETT was advanced into the trachea and the fiberoptic bronchoscope was removed. The ETT was then connected to the breathing circuit, and the ETC was removed.

In the spontaneous ventilation group, 3 mL of lidocaine 1% was injected via the bronchoscope on direct visualization of the vocal cords, and another 4 mL was injected into the trachea once the bronchoscope had passed below the level of the vocal cords.

SpO₂ and end-tidal CO₂ were recorded every minute in both groups with inflated and partially deflated pharyngeal balloons. The time required to complete the procedure was recorded as the time from the nasal introduction of the fiberoptic bronchoscope until the insertion of the ETT. The procedure was considered unsuccessful and abandoned after 15 min of trial in both groups. Cases of failed intubation were excluded from the calculation of average time required to successfully perform the procedure.

Student's paired t-test was used to compare the average time needed for the airway exchange procedure. A value of P < 0.05 was considered statistically significant.

	Results

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Patient demographic data are shown in Table 1. In all patients, the ETC was correctly positioned in the esophagus on the first attempt. Advancement of the fiberoptic bronchoscope was possible in nine patients (four in the spontaneous ventilation group and five in the mechanical ventilation group) only when the ETC was withdrawn 1 cm. In spontaneously breathing patients, the procedure was unsuccessful in two patients (Table 2). In these two patients, the ETC was left in place, and spontaneous ventilation was maintained throughout the surgery. The oropharyngeal balloon was deflated every 20 min to avoid excessive pressure on the tracheal mucosa and tongue swelling. In mechanically ventilated patients, the exchange procedure was unsuccessful in five patients (Table 2). In these five patients, the ETC was also left in place until the end of the surgical procedure.

No airway trauma was noted during the procedure, although five patients complained of sore throat 24 h after surgery. These patients required no special treatment and recovered without incident.

	Discussion

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This study compared the facility of fiberoptic-guided airway exchange of an ETC with a nasal ETT in nonparalyzed, spontaneously breathing patients versus paralyzed, mechanically ventilated patients. ECT-ETT exchange was successful in 90% of the spontaneous ventilation group and in 75% of the controlled ventilation group. ETC-ETT exchange times were significantly shorter in the spontaneous ventilation group, despite the additional time required to perform local anesthesia.

Two techniques of ETC-ETT exchange under fiberoptic vision have been described (6,7). These two techniques differ fundamentally in that passage of the fiberscope is either inside or outside the Combitube®. Kraft et al. (6) redesigned the ETC by replacing its two proximal perforations with a larger hole, allowing the passage of a fiberoptic bronchoscope through the ETC. In this technique, a guidewire is then passed through the scope into the trachea, the ETC and scope are removed, and an ETT is passed over the guidewire that has been left in place. Ovassapian et al. (7) inserted the fiberoptic bronchoscope orally alongside the ETC while the patients were paralyzed and ventilated, with a 85% success rate. An important difference between the two techniques is that Kraft et al.'s (6) technique requires brief abdication of the airway after withdrawal of the fiberscope and ETC and until passage of an ETT over the guidewire. Our technique, based on that of Ovassapian et al. (7), eliminates that problem and provides for continuous airway control, ventilation, and oxygenation. Therefore, although the airway exchange may be time-consuming, one has the luxury of a safe, unhurried fiberoptic bronchoscopy.

The limitations of this technique are primarily those of the ETC itself: the inability of assuring a patent airway in patients with glottic or subglottic problems and the risk of aspiration in the face of a full stomach or oropharyngeal bleeding. Oropharyngeal bleeding would also disturb vision under fiberoptic bronchoscopy, further prolonging the time required to perform the procedure.

No study has yet assessed the effect of spontaneous ventilation during airway exchange. We recently described a case (10) of unexpected difficult ventilation successfully managed with the technique presented in this article. Our results indicate that maintaining spontaneous ventilation during an "outside" ETC-ETT exchange significantly improved the effectiveness of the technique. With spontaneous breathing, the retention of pharyngeal muscle tone and spontaneous movement of the epiglottis and vocal cords with ventilation seems to make identification and exposure of the epiglottis and larynx easier. Additional maneuvers that could improve the success rate of the exchange procedure are jaw thrust, as well as continuous positive airway pressure (11,12). Applying jaw thrust keeps the oropharyngeal space open (11), whereas continuous positive airway pressure can facilitate visualization of anatomical landmarks (12) by passively distending soft tissue, such as the epiglottis.

The role of the ETC in difficult airway management is well established (3). The ease of blinded insertion ensures rapid airway control. It has been shown to have an efficiency comparable to the ETT for oxygenation and alveolar ventilation in elective surgical patients (13).

Although the ETC provides for adequate oxygenation and ventilation, its replacement by an ETT is required in situations demanding definitive airway control (e.g., specific surgical procedures), when prolonged mechanical ventilation is needed (11), and for suctioning of the trachea (6). Furthermore, there is a potential risk of impaired venous blood flow and swelling of the tongue because of the excessive pressure exerted by the oropharyngeal balloon of the ETC (7).

When the ETC is properly positioned, the oropharyngeal balloon must rest between the root of the tongue and the soft palate to seal the mouth and nasal cavities (14). Consequently, the soft palate is pushed backward, so that partial deflation of the oropharyngeal balloon is required to allow naso-oral passage of the fiberoptic bronchoscope. In addition, we observed that, in most cases, the pharyngeal balloon becomes visible behind the soft palate, impeding advancement of the fiberoptic bronchoscope. Passage of the fiberoptic bronchoscope is also easier when using a smaller 37F ETC. In this study, the fiberoptic bronchoscope was inserted nasally because, in our experience, oral insertion is more difficult, even when using an Ovassapian fiberoptic-intubating airway.

The exact incidence of complications associated with the use of ETC is unknown. In addition to minor upper airway trauma (15), major complications, including subcutaneous emphysema, pneumomediastinum, and pneumoperitoneum, have been reported (16). We observed a 25% incidence of sore throat after surgery, which was probably much higher than that expected from the use of an ETC alone and which likely resulted from the manipulations of the fiberoptic bronchoscope, as well as of the ETC, plus passage of an ETT over the bronchoscope. None of our patients suffered a serious complication of the procedure, and none required treatment.

In the present study, we demonstrated that spontaneous ventilation facilitates fiberoptic-aided ETC exchange with an ETT. Although this technique is still time-consuming, patient airway, oxygenation, and ventilation are maintained during the procedure. This airway exchange method can be of value in situations in which a patent airway cannot be established by standard methods.

	References

Top Abstract Introduction Methods Results Discussion References

 

1. Frass M, Frenzer R, Zdrahal F, et al. The esophageal tracheal combitube preliminary results with a new airway for CPR. Ann Emerg Med 1987;16:768–72.[Web of Science][Medline]
2. Wafai Y, Salem MR, Baraka A, et al. Effectiveness of a self-inflating bulb for verification of proper placement of the Esophageal Tracheal Combitube®. Anesth Analg 1995;80:122–6.[Abstract]
3. American Society of Anesthesiologists Task Force on Management of the Difficult Airway.Practice guidelines for management of the difficult airway. Anesthesiology 1993;78:597–602.[Web of Science][Medline]
4. Frass M, Frenzer R, Rauscha A, et al. Ventilation with the esophageal tracheal combitube in cardiopulmonary resuscitation promptness and effectiveness. Chest 1988;93:781–4.[Abstract]
5. Emergency Cardiac Care Committee and Subcommittees, American Heart Association.Guidelines for cardiopulmonary resuscitation and emergency cardiac care. Part III. Adult advanced cardiac life support. JAMA 1992;268:2199–235.[Abstract/Free Full Text]
6. Kraft P, Röggla M, Fridrich P, et al. Bronchoscopy via a redesigned combitube in the esophageal position a clinical evaluation. Anesthesiology 1997;86:1041–5.[Web of Science][Medline]
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10. Gaitini L, Vaida S, Fradis M, et al. Replacing the combitube by an endotracheal tube using a fiberoptic bronchoscope during spontaneous ventilation. J Otolaryngol. In press.
11. Ovassapian A, Wheeler M. Fiberoptic endoscopy-aided techniques. In: Benumof JL, ed. Airway management: principles and practice. St. Louis:Mosby-Year Book, 1996:282–319.
12. Rothfleisch R, Davis LL, Ruebel DA, deBoisblanc BP. Facilitation of fiberoptic nasotracheal intubation in a morbidly obese patient by simultaneous use of nasal CPAP. Chest 1994;106:287–8.[Abstract/Free Full Text]
13. Frass M, Frenzer R, Mayer G, et al. Mechanical ventilation with the esophageal tracheal combitube (ETC) in the intensive care unit. Arch Emerg Med 1987;4:219–25.[Web of Science][Medline]
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This Article Abstract Full Text (PDF) En Espanol Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via ISI Web of Science (16) Citing Articles via Google Scholar Google Scholar Articles by Gaitini, L. A. Articles by Ben-David, B. Search for Related Content PubMed PubMed Citation Articles by Gaitini, L. A. Articles by Ben-David, B.

Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999