Previous article Table of Contents  Next article

CASE REPORT
Year : 2013  |  Volume : 7  |  Issue : 2  |  Page : 194-196

Esophageal misplacement of a single-lumen tube after its exchange for a double-lumen tube despite the use of an airway-exchange catheter


Department of Anesthesiology and Pain Medicine, School of Medicine, Hallym University, Chuncheon, Korea

Correspondence Address:
Jae Jun Lee
Department of Anesthesiology and Pain Medicine, Chuncheon Sacred Heart Hospital, #153, Kyo-dong, Chuncheon, Gangwon do
Korea
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1658-354X.114050

Rights and Permissions
Date of Web Publication26-Jun-2013
 

  Abstract 

An airway-exchange catheter (AEC) can increase the safety of exchanges of endotracheal tubes (ETTs); however, the procedure is associated with potential risks. We describe a case of esophageal misplacement of a single-lumen ETT after switching from a double-lumen tube, despite the use of an AEC as a guidewire. To avoid this, physicians should consider the insertion depth and maintenance depth of the AEC and should verify its position before changing ETTs and should perform, if possible, with simultaneous visualization of the glottis with direct or video laryngoscopy during the exchange. Additionally, the new ETT position should be confirmed by auscultation, end-tidal carbon dioxide, and portable chest X-ray.

Keywords: Airway extubation, esophagus, intratracheal, intubation


How to cite this article:
Hwang SM, Lee JJ, Jang JS, Lee NH. Esophageal misplacement of a single-lumen tube after its exchange for a double-lumen tube despite the use of an airway-exchange catheter. Saudi J Anaesth 2013;7:194-6

How to cite this URL:
Hwang SM, Lee JJ, Jang JS, Lee NH. Esophageal misplacement of a single-lumen tube after its exchange for a double-lumen tube despite the use of an airway-exchange catheter. Saudi J Anaesth [serial online] 2013 [cited 2020 Oct 20];7:194-6. Available from: https://www.saudija.org/text.asp?2013/7/2/194/114050


  Introduction Top


Anesthesiologists are frequently required to replace an endotracheal tube (ETT) for various reasons, including a cuff leak, a tube laceration, or a tube occlusion. With this procedure, there is a significant risk of losing control of the airway. Chest surgery using a double-lumen tube (DLT) is one situation in which an AEC is useful. DLTs are routinely used to isolate the lungs for surgery, but changing from a DLT to a single-lumen tube peri or postoperatively can be difficult. [1] An airway-exchange catheter (AEC) is a long, hollow, slightly rigid catheter of small diameter which is inserted through an in situ ETT before tracheal extubation, and can be a useful tool for exchanging the ETT. [2],[3] After the ETT is withdrawn over the AEC, the AEC serves as a stylet for repeated intubation. Although changing an ETT using an AEC has been described as a simple and relatively safe procedure; [4] it can be associated with life-threatening complications. We present a case of esophageal misplacement of a single-lumen ETT after its exchange for a DLT despite the use of an AEC.


  Case Report Top


A 22-year-old male victim of a traffic accident presented with dyspnea, and was diagnosed with right hemothorax and pneumothorax. He was intubated and chest tube drainage (CTD) was performed, after which he was transferred to our emergency room (ER) for further evaluation and management. On arrival, he had decreased mental status, and his initial vital signs were as follows: Blood pressure (BP): 80/50 mmHg, heart rate (HR): 124 beats/minute, respiratory rate (RR): 28 breaths/minute, oxygen saturation: 90%, and arterial blood gas analysis (ABGA) values of pH: 7.28, PaCO 2 : 31, PaO 2 : 60 mmHg, HCO 3 : 14.6 mEq/dL, and Hb: 10.9 g/dL. The patient was placed on mechanical ventilation (continuous mandatory ventilation (CMV) mode, fraction of inspired oxygen (FiO 2): 100, tidal volume: 500 mL, respiratory rate: 15/minute, positive end-expiratory pressure (PEEP): 5 mmHg), and a central catheter and arterial catheter were inserted into the right subclavian vein and left femoral artery, respectively. Chest X-ray showed right pulmonary hemorrhage [Figure 1], and computed tomography (CT) revealed a 9 cm radiopacity in the right upper hemithorax which suggested hematoma (hemothorax) as well as minor pneumothorax.
Figure 1: Chest radiograph showing right pulmonary hemorrhage

Click here to view


Soon after undergoing CT, the patient stopped responding to mechanical ventilation. At that time, ABGA showed pH: 7.03, PaCO 2 : 42, PaO 2 : 43 mmHg, HCO 3 : 10.8 mEq/dL, oxygen saturation: 58%, and Hb: 7 g/dL. The patient was transferred to the angiography room for extracorporeal membrane oxygenation (ECMO), where a 21 Fr venous cannula (DLP® , Medtronic Inc., Minneapolis, MN, USA) was inserted into the right atrium, and a 24 Fr venous cannula (RMI® , Edward's Life Science LLC, Irvine, CA, USA) was inserted into the inferior vena cava via both femoral veins using the Seldinger technique, and venous ECMO was begun at 4 L/minute.

Next, the patient was transferred to the operating room, where general anesthesia was induced with a bolus of rocuronium 50 mg for muscle relaxation. Then, a 37 Fr left DLT was inserted following removal of the single-lumen tube, and the correct position of the DLT was confirmed by fiberoptic bronchoscopy, both before and after positioning in the lateral decubitus position. A right anterolateral thoracotomy via the fifth intercostal space was performed, which revealed 3 L of blood in the extrapleural space as well as a blood clot due to a right subclavian artery injury. The blood and blood clot were removed and the damaged subclavian artery was repaired. During the surgery, which lasted approximately two hours, five pints of packed red cells were transfused. At the end of the operation, the DLT needed to be exchanged for a single-lumen tube. Using the AEC as a guidewire, a 12 F, 80 cm AEC with a flexible tip (METTI, VBM, Germany) was inserted 25 cm from the lip through the DLT, which we then tried to remove over the AEC. The DLT was removed stiffly, and the AEC remained in situ 25 cm from the lip following its removal. Subsequent intubation was performed through the AEC using a 7.5 Fr single-lumen tube. The tube was inserted smoothly, and fixed at 22 cm. We assumed that the ETT had been placed correctly into the trachea, although its position was not confirmed by auscultation or end-tidal carbon dioxide. Then, the patient was transferred to the intensive care unit (ICU) with Ambu bagging under ECMO. Immediately after arrival in the ICU, portable chest X-ray revealed esophageal misplacement of the ETT [Figure 2]. The patient was successfully reintubated using laryngoscopy, then extubated a week later. The ECMO was stopped 10 days later.
Figure 2: Chest radiograph showing the trachea (arrow A), an endotracheal tube in the esophagus (arrow B), a 21 Fr venous cannula inserted into the right atrium (arrow C), a 24 Fr venous cannula inserted into the inferior vena cava (arrow D), and a Levin tube in the stomach (arrow D)

Click here to view



  Discussion Top


AEC can be used as a stylet when exchanging an ETT and allows jet ventilation as well as monitoring of end-tidal carbon dioxide during the exchange. [3],[5] Although the procedure is known to be safe and relatively easy to perform without advanced training, it has the potential for life-threatening complications. Reported complications include an inability to secure the airway, tracheal or bronchial mucosal tears, or pnuemothorax. In one case, a 2 cm tear of the membranous trachea developed after changing from a single-lumen tube to a DLT using an AEC. [6] In another case report, a patient developed pneumothorax after the use of an AEC to exchange a malfunctioning ETT, even though jet ventilation was not used. [7] The authors postulated that the pneumothorax could have been related to the manipulation of the AEC to a more distal position. Many of the complications associated with the AEC result from excessively deep placement of these catheters. [5] Leeson [8] recommends the use of a marker (such as a Sharpie® ) to color a segment of the AEC 20 to 25 cm from the tip to prevent overly deep placement. When the marked zone is at the lip, the AEC is 20 to 25 cm from the lip.

In the present case, a single-lumen ETT was misplaced into the esophagus after exchange with a DLT despite the use of an AEC. The AEC was likely pulled out above the vocal cord along with the DLT during removal of the DLT over the AEC, and at this point, the AEC was pushed into the esophagus. Intubation was then performed through the AEC, and as a result, the single-lumen tube was placed in the esophagus. This case demonstrated that the appropriate depth of the AEC should be completely maintained during ETT exchange, especially when a tube with small internal diameter, such as that used in children or a DLT for single-lung ventilation, is exchanged using an AEC. The marking technique can facilitate maintenance of the position of the AEC when changing from a DLT to a single-lumen tube. [8] Additionally, another important point of this case report is that a tube exchange with an AEC should be performed, if possible, with simultaneous visualization of the glottis with direct or video laryngoscopy. This would have avoided this complication.

Misplacement of an AEC in the esophagus can have catastrophic results. Fetterman et al. [9] reported a case of gastric perforation secondary to inadvertent esophageal placement of an AEC. They recommended that an AEC be treated as an ETT, and its placement should never be assumed to be correct until objective findings support that conclusion. Unfortunately, the physicians in the case we report here assumed that the AEC was correctly placed, and neither auscultation not end-tidal carbon dioxide were checked; thus esophageal misplacement of ETT was revealed only by a chest X-ray in the ICU. The consequences for our patient could have been gastric perforation secondary to an inadvertent esophageal intubation if an L-tube had not been used, or he could have developed hypoxia and desaturation if ECMO were not applied.

One study reported that a Cook® AEC and a bronchoscope adapter could verify the position of an AEC as well as an ETT by monitoring end-tidal carbon dioxide. [10] Of course, it is important that placement of the AEC be confirmed before subsequent intubation; however, many hospitals do not possess such helpful tools. Thus, verification of ETT position by auscultation, end-tidal carbon dioxide, and portable chest X-ray is essential; moreover, the position of the AEC must be checked prior to subsequent intubation.


  Conclusion Top


An AEC can be used to increase the safety of ETT exchange, but the potential risks include tracheal or bronchial injury, pneumothorax, and esophageal misplacement of the AEC or ETT. To avoid these, physicians should consider the insertion and maintenance depths of the AEC and should verify its position before exchange, and should perform, if possible, with simultaneous visualization of the glottis with direct or video laryngoscopy during the exchange. Additionally, the placement of the second ETT should be confirmed by basic methods such as auscultation, end-tidal carbon dioxide, and portable chest X-ray, after exchange.

 
  References Top

1.Wilson WC, Benumof JL. Anesthesia for thoracic surgery. In: Miller RD, editor. Anesthesia. Philadelphia: Elsevier Churchill Livingstone; 2005. p. 1847-939.  Back to cited text no. 1
    
2.Benumof JL. Management of the difficult adult airway. With special emphasis on awake tracheal intubation. Anesthesiology 1991;75:1087-110.  Back to cited text no. 2
    
3.Bedger RC Jr, Chang JL. A jet-stylet endotracheal catheter for difficult airway management. Anesthesiology 1987;66:221-3.  Back to cited text no. 3
    
4.Drolet P, Girard M, Poiries J, Grenier Y. Facilitating submental endotracheal intubation with an endotracheal tube exchanger. Anesth Analg 2000;90:222-3.  Back to cited text no. 4
    
5.Benumof JL. Airway exchange catheters: Simple concept, potentially great danger. Anesthesiology 1999;91:342-4.  Back to cited text no. 5
    
6.Thomas V, Neustein SM. Tracheal laceration after the use of an airway exchange catheter for double-lumen tube placement. J Cardiothorac Vasc Anesth 2007;21:718-9.  Back to cited text no. 6
    
7.Harris K, Chalhoub M, Maroun R, Elsayegh D. Endotracheal tube exchangers: Should we look for safer alternatives? Heart Lung 2012;41:67-9.  Back to cited text no. 7
    
8.Leeson S. The highlight technique: Airway exchange catheters with a colored marking may improve safety of airway management. Anesth Analg 2011;112:481.  Back to cited text no. 8
    
9.Fetterman D, Dubovoy A, Reay M. Unforeseen esophageal misplacement of airway exchange catheter leading to gastric perforation. Anesthesiology 2006;104:1111-2.  Back to cited text no. 9
    
10.Karthik S, Subramanian B. A method of avoiding loss of airway control during tracheal tube change using an airway exchange catheter. Anesth Analg 2007;105:1173-4.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]


This article has been cited by
1 Conventional Versus Video Laryngoscopy for Tracheal Tube Exchange
Thomas C. Mort,Barbara H. Braffett
Anesthesia & Analgesia. 2015; 121(2): 440
[Pubmed] | [DOI]



 

Top
 
Previous article    Next article
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  IN THIS Article
   Abstract
  Introduction
  Case Report
  Discussion
  Conclusion
   References
   Article Figures

 Article Access Statistics
    Viewed2157    
    Printed58    
    Emailed0    
    PDF Downloaded77    
    Comments [Add]    
    Cited by others 1    

Recommend this journal