Oral to Nasal Tracheal Tube Exchange

A 32-year-old female (52kg, 5’4”) with multiple injuries status post four-story fall and history of difficult oral endotracheal tube (ETT) placement using an asleep fiberoptic bronchoscope (FOB) technique presented to the... [ view full abstract ]

A 32-year-old female (52kg, 5’4”) with multiple injuries status post four-story fall and history of difficult oral endotracheal tube (ETT) placement using an asleep fiberoptic bronchoscope (FOB) technique presented to the operating room for fixation of multiple facial and mandibular fractures. Surgical fixation required oral ETT removal, therefore replacement with a nasal ETT was planned. The patient was taken to the OR, placed on standard monitors, and induced. Both nares were then dilated with sequentially larger nasal airways. A 7.0mm nasal RAE tube was inserted into the right nostril. The FOB was then passed through the nasal RAE and directed into the oropharynx. Significant oropharyngeal and subglottic edema were noted. The FOB was advanced anteriorly over the in situ oral ETT and beyond the vocal cords. Attempted advancement of the nasal RAE over the FOB pass the vocal cords was unsuccessful due to limited space. Discussion was made with the surgeon whether to continue attempting a nasal tracheal tube exchange, perform a tracheostomy, or cancel the surgery to await tissue edema improvement. Nasal RAE intubation was preferred if safely achievable. A sterile tracheostomy kit was then opened and ready if required. The patient was disconnected from the ventilator and a Cook Aintree catheter was advanced into the oral ETT with connector pieces available if ventilation became necessary. Under FOB visualization the oral ETT was removed with the Aintree catheter now in the trachea. The FOB was then advanced into the trachea and the nasal RAE was threaded over the FOB while simultaneously removing the Cook Aintree catheter. Appropriate ETT positioning was confirmed and mechanical ventilation resumed. No oxygen desaturations occurred. The nasal RAE was secured and surgery proceeded without complications. The exchange of an oral to nasal tracheal tube is not a common practice, however, this method using a Cook Aintree airway exchange catheter allows continuous immediate availability of ventilation and has not previously been described in the anesthesia literature.