Anesth Analg 2004;98:545-547
© 2004 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000097184.55842.C2
GENERAL ARTICLES
Rigid Bronchoscope-Assisted Endotracheal Intubation: Yet Another Use of the Gum Elastic Bougie
Vladimir Nekhendzy, MD, and
and Paul K. Simmonds, MD
Department of Anesthesia, Stanford University, California
Address correspondence and reprint requests to Vladimir Nekhendzy, MD, Stanford University Medical Center, Department of Anesthesia, Route 2, 300 Pasteur Dr., Stanford, CA 94305-5640. Address e-mail to nek{at}stanford.edu
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Abstract
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We describe a technique by which a gum elastic bougie (GEB) is used to facilitate an anticipated difficult endotracheal intubation in a patient undergoing rigid bronchoscopy. After placing the GEB through the lumen of the rigid bronchoscope, the GEB-suction catheter assembly was used to safely withdraw the bronchoscope in a manner mimicking the withdrawal of an intubating laryngeal mask airway (LMA) over the endotracheal tube using a stabilizer rod. The rationale for management and potential advantages of this approach versus use of an airway exchange catheter (including increased stability of an intubation guide) are discussed.
IMPLICATIONS: We describe a technique of using a gum elastic bougie to facilitate an endotracheal intubation in a patient undergoing rigid bronchoscopy, which can be useful in a variety of clinical situations when the rigid bronchoscope is used in patients with abnormal airway.
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Introduction
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A gum elastic bougie (GEB) is widely used as the first-line tracheal intubation aid for the management of unexpected difficult intubation (1,2). We report a novel technique of the GEB use for facilitating an anticipated difficult endotracheal intubation in a patient undergoing rigid bronchoscopy.
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Case Report
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A 39-yr-old woman (weight, 84 kg) with the medical history of systemic lupus erythematosus and the antiphospholipid-A syndrome requiring chronic anticoagulation presented with urosepsis, renal failure, and respiratory failure. She required an emergent tracheal intubation and was placed on the ventilatory support, demonstrating large PaO2–PaO2 gradient (108 mm Hg). Chest radiograph showed a near-complete atelectasis of the left lung, and flexible bronchoscopy demonstrated a tightly adhered blood clot partially obstructing a left mainstem bronchus. Attempts at suctioning, endobronchial lavage, and breaking down the clot with the forceps introduced through the flexible bronchoscope were unsuccessful, and the patient was referred to the thoracic surgeons for a rigid bronchoscopy and clot removal. Preoperative evaluation revealed moderate intraoral mucosal swelling and significantly diminished breath sounds over the left lung (preoperative arterial blood gas: pHa 7.40, PaCO2 37.5 mm Hg, and PaO2 97 mm Hg with a fraction of inspired oxygen [FIO2] of 0.5). During total IV anesthesia, the endotracheal tube (ETT) was removed and replaced with a 9.0F rigid bronchoscope. Ventilation was controlled manually with a FIO2 of 1.0 through the side-port adapter of the bronchoscope, maintaining SpO2 within the 92%–95% range. A combination of the rigid and flexible bronchoscopy was performed to remove the organized clot extending through the left mainstem bronchus to its branches in the upper and lower lobe.
At the completion of prolonged (99 min) surgical procedure, a marked increase in intraoral edema was noted, making the required reintubation after bronchoscopy very difficult. A multiple-use 15.0F GEB was passed into the trachea through the lumen of the bronchoscope until the resistance was met (the distal hold up sign) (3). The GEB was then stabilized in place and extended using a 16.0F rubber suction catheter. The resultant length of the intubation guide was sufficient to permit safe withdrawal of the rigid bronchoscope in a manner mimicking the removal of an intubating laryngeal mask airway (LMA) over the ETT using a stabilizer rod (Fig. 1–3). A new 7.0 ETT was then uneventfully passed into the patient’s trachea over the GEB, assisted by a 4.0 Macintosh laryngoscopic blade placed inside the patient’s mouth. Back-up airway management plans included direct laryngoscopy, LMA insertion, fiberoptic tracheal intubation, and cricothyrotomy. The patient’s trachea was extubated the day after, and she was discharged a week later.
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Figure 1. The 9F 40-cm-long rigid bronchoscope (CL Jackson Fiberoptic Bronchoscope, Pilling Inc, Fort Washington, PA), 15F 60-cm-long multiple-use gum elastic bougie (Eschmann Tracheal Tube Introducer, SIMS Portex Inc, Keene, NH), and 16F 41-cm-long rounded closed-tip suction catheter (Robi-Nel catheter, Kendall Dover, Mansfield, MA) used to facilitate an endotracheal intubation in the patient.
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Figure 2. The gum elastic bougie (GEB) introduced through the rigid bronchoscope. The resistance to the bougie advancement in a small bronchus (the distal hold up sign) usually occurs at the depth of 24–40 cm measured at the patient’s lips (4) and results in almost full embedding of the GEB inside the bronchoscope.
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Figure 3. The catheter-assisted stabilization of the gum elastic bougie (GEB) placed inside the rigid bronchoscope and the tracheobronchial tree. The GEB is tightly fit inside the funnel end of the catheter, which is appropriately stiff to hold the bougie in place. Of note, the catheter needed to be cut 2 cm at the end to fit inside the bronchoscope. When uncut, its outside diameter (12 mm) exceeds the narrowest diameter of the bronchoscope (7.8 mm).
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Discussion
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Reintubation by conventional direct laryngoscopy in this patient was anticipated to be very difficult because of a severe intraoral edema caused by repeated and prolonged upper airway instrumentation.
When choosing the intubation guide, we also considered a 14.0F Cook airway exchange catheter (CAEC) (Cook Critical Care, Bloomington, IN), which has an advantage of allowing apneic oxygen insufflation and jet ventilation. However, had the reintubation failed, the possibility of adequately and safely oxygenating this patient using the CAEC seemed unlikely because of the unresolved shunt in the left lung and the increased risk of barotrauma due to the severe upper airway edema.
We, therefore, considered an alternative use of the GEB, specifically because it may provide a better intubation guide than the CAEC. The reliability of the GEB is confirmed by multiple reports and studies (2,5,6). Only limited data are available about the CAEC performance as an intubation guide in patients with abnormal airway (7). Loudermilk et al. (7) cautioned that not all patients’ tracheas may be easily reintubated over the CAEC because of its excessive flexibility; this concern is also shared by others (5). Other types of the AEC (Sheridan Catheter Corporation, Argyle, NY; CardioMedSupplies Inc, Gormley, Ontario, Canada) may be less compliant and potentially more effective than the CAEC for reintubating the trachea, although the reliability of these devices awaits a larger experience (8,9).
We were also concerned about a potential lung perforation by a deeply placed CAEC. During the bronchoscope withdrawal, it would be impossible to monitor on the intubation guide any marks mapping out the distance to the carina, and therefore, a deep subcarinal placement of either device was required to prevent its inadvertent dislodgment from the trachea into the posterior pharynx. Subcarinal placement of the AEC is not recommended because of the recognized risk of perforation of the distal tracheobronchial tree (10–13). This complication has not been reported with the multiple-use GEB, likely because its angulated tip does not reach a distal bronchus reducing a potential for lung trauma (14,15). Lodging of the GEB in a small bronchus assured a necessary depth of the intubation guide placement and provided a required stability of the bougie-catheter assembly, allowing safe withdrawal of the rigid bronchoscope while maintaining the GEB within the trachea.
The presented technique can be used in a variety of clinical circumstances when the rigid bronchoscope is used in patients with abnormal airway, including panendoscopy procedures and "can’t intubate-can’t ventilate" situation (16). Risks and benefits of passing the GEB versus the AEC through the rigid bronchoscope must be carefully weighed depending on the clinical situation and the nature of airway compromise.
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Acknowledgments
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The authors thank Dr. John Brock-Utne (Professor of Anesthesia, Stanford University, CA) for reviewing the manuscript.
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References
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Accepted for publication September 8, 2003.
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Abstract
Introduction
