Airway

CASE REPORT
Year
: 2022  |  Volume : 5  |  Issue : 2  |  Page : 81--84

Redefining exchange of tracheal tube from nasal to oral in high risk sepsis patient


Rashid M Khan, Aziz Haris, Abdullah Al Jadidi, Naresh Kaul 
 Oman Medical Specialty Board and Khoula Hospital, Department of Anesthesia and ICU, Khoula Hospital, Muscat, Oman

Correspondence Address:
Dr. Naresh Kaul
Department of Anesthesia and ICU, Khoula Hospital, Muscat
Oman

Abstract

A 35-year-old male weighing 94 kg developed significant oropharyngeal and perilaryngeal oedema with sepsis in the postoperative period following mandibular advancement surgery. He needed change of an existing nasotracheal tube to the orotracheal route in the intensive care unit (ICU). The procedure had to be abandoned in the ICU for fear of losing the airway in this patient requiring high inspired oxygen concentration of 60% and positive end expiratory pressure of 8.0 cm H2O. The changeover of tube was safely achieved in the operation theatre by utilising the splinting effect of the existing nasotracheal tube that helped to keep the oedematous epiglottis lifted while an airway exchange catheter (AEC) was placed by its side under videolaryngoscopic guidance. Railroading the new orotracheal tube over the preplaced AEC after withdrawing the nasal tube while receiving oxygen at 4 litres per minute helped to accomplish the safe exchange of the tracheal tube.



How to cite this article:
Khan RM, Haris A, Al Jadidi A, Kaul N. Redefining exchange of tracheal tube from nasal to oral in high risk sepsis patient.Airway 2022;5:81-84


How to cite this URL:
Khan RM, Haris A, Al Jadidi A, Kaul N. Redefining exchange of tracheal tube from nasal to oral in high risk sepsis patient. Airway [serial online] 2022 [cited 2022 Dec 7 ];5:81-84
Available from: https://www.arwy.org/text.asp?2022/5/2/81/351375


Full Text



 Introduction



Tracheal intubation is considered a high-risk procedure in the intensive care unit (ICU). The overall complication rate can be as high as 40%. While hypotension and severe hypoxaemia occur in 10%–25% of cases, cardiac arrest may occur in 2%.[1],[2],[3],[4] This is often the result of preexisting hypoxaemia and haemodynamic instability. Tracheal intubation-related death or brain damage is significantly higher in the ICU as compared to the operating room.[5] We describe a recently operated patient of mandibular advancement surgery who had developed significant intraoral and perilaryngeal oedema with sepsis needing change of a nasotracheal tube to the orotracheal route in the ICU. The changeover of the tracheal tube was safely achieved in this patient in the operation theatre using an airway exchange catheter (AEC) in a unique manner.

 Case Report



A 35-year-old male patient weighing 94 kg belonging to the American Society of Anesthesiologists Physical Status II underwent orthognathic maxillomandibular advancement surgery for obstructive sleep apnoea. The patient had a 7.0 mm internal diameter tube placed nasotracheally. Following surgery, the patient was electively ventilated on adaptive pressure synchronised intermittent mandatory ventilation mode in a head-elevated position for a few days for the oropharyngeal oedema to subside. He was put on 8 mg dexamethasone thrice daily which was gradually tapered. The patient subsequently developed severe facial and neck oedema with redness and swelling spread over the upper chest and neck, possibly secondary to wound infection. In addition, his blood pressure dropped and he was put on noradrenaline infusion that was gradually tapered. The patient needed an inspired oxygen concentration of 70% and a PEEP of 10 cm H2O to maintain an oxygen saturation of 93%–95%. He was suspected to be in sepsis and was administered multiple antibiotics (meropenem, vancomycin and ciprofloxacin). For better ICU care, the patient was shifted to our hospital 5 days after surgery. During the course of his ICU stay, the patient had developed severe scrotal oedema and consolidation of the lower segment of the lung which could be attributed to bacteraemia secondary to abrasion of the nasal mucosa.[6] The patient continued to be ventilated via the 7.0 mm ID nasotracheal tube. Permission for tracheostomy was refused by the patient's relatives. By the 7th postoperative day, the patient still needed inspired oxygen concentration of 60% and a PEEP of 8 cm H2O to maintain an inspired oxygen saturation between 93 and 95%. Airway pressures were on the higher side. This was attributed to a diagnosis of acute respiratory distress syndrome (ARDS) and ventilation through a narrow nasotracheal tube. Unfortunately, none of the countermeasures suggested by Yamamoto et al. were adopted to avoid nasotracheal intubation-related carriage of bacteria into the trachea to avoid subsequent ARDS.[7] However, the attending anaesthesiologist did decongest the more patent nasal passage before nasotracheal intubation to avoid traumatising it.

On the 11th postoperative day, it was decided to change the nasotracheal tube to a bigger size orotracheal tube in the ICU. However, the C-MAC videolaryngoscope showed significant perilaryngeal oedema. There was apprehension that removing the nasotracheal tube could cause the oedematous epiglottis to fall over the glottis, making it nonliftable (Cormack and Lehane 3B) for oral intubation.[8] A decision was taken to perform the tube exchange from nasal to oral route in the operation theatre with backup for emergent surgical tracheostomy. On the 12th postoperative day, the patient was shifted to the main operation theatre with an inspired oxygen concentration of 60% and PEEP of 8 cm H2O. He was receiving infusions of morphine 5 mg/h, propofol 40 mg/h and midazolam 12 mg/h. He had stable vitals without inotropic support. However, it was anticipated that the patient could rapidly desaturate if there would be any delay in tube exchange as he had the high requirement of oxygen and PEEP.

Plans A, B and C were discussed in the operation theatre and appropriate arrangements were made to facilitate the change of tracheal tube from nasal to oral route. Plan A was to perform videolaryngoscopy using the D-blade of the C-MAC videolaryngoscope, inspect the oropharyngolaryngeal structures and change from nasotracheal to the orotracheal tube if no difficulty was anticipated. Plan B was to place a Cook's AEC (Cook Critical Care, Bloomington, IN, USA) via the oral route into the trachea visualising the larynx using the videolaryngoscope with the nasotracheal tube still in place and its cuff deflated. At this stage, the nasotracheal tube was expected to keep the epiglottis elevated and the glottis in view. After the placement of AEC, the nasotracheal tube would be removed and an 8.0 mm ID endotracheal tube railroaded over the AEC into the trachea. Plan C was for the plastic surgeons to perform an emergency surgical tracheostomy in case of a lost airway.

After instituting monitoring with a 5-electrode electrocardiogram, noninvasive blood pressure and pulse oximeter, the patient was administered 100 μg fentanyl, 10 mg cisatracurium and 2% sevoflurane in oxygen. Following ventilation with 100% oxygen for 5 min, a gentle videolaryngoscopy was performed by the seniormost anaesthesiologist who was well versed in the management of difficult airways. It was apparent that there was the persistence of perilaryngeal oedema with the possibility of the epiglottis becoming nonliftable once the nasotracheal tube was removed because it had become oedematous, heavy and possibly noncompliant. Under these circumstances, even passage of a bougie could prove to be difficult. This would delay oral intubation and could lead to rapid desaturation in this patient who was dependent on high inspired oxygen concentration and PEEP.

It was decided to implement Plan B for achieving orotracheal intubation. To execute this, the cuff of the nasotracheal tube was deflated, a well-lubricated 14 Fr Cook's AEC was gently placed via the oral route into the trachea besides the nasal tube under videoscopic vision [Figure 1]. The nasotracheal tube was removed while a Rapi-Fit® adaptor (William Cook Europe ApS, Bjaeverskov, Denmark) was connected to the AEC and an oxygen flow of 4 L/min administered throughout the period of railroading the orotracheal tube. Following successful railroading of the tracheal tube, the AEC was removed. Correct placement of the orotracheal tube was confirmed by capnography and air entry. The patient was shifted back to the ICU for appropriate care. He was finally extubated and made an uneventful recovery for a safe discharge. Before discharge, the patient's consent was obtained for publication while ensuring anonymity.{Figure 1}

 Discussion



Losing the airway in a high-risk patient with subsequent repeated attempts at tracheal intubation following the removal of an existing nasotracheal tube is very risky. Hence, three alternative plans of airway management were discussed amongst the team members before its execution in the operation theatre as outlined above. There was some apprehension about the possibility of barotrauma secondary to oxygenation via the AEC while the new tracheal tube was being railroaded past the oedematous larynx into the trachea. It was therefore decided to use a 14 Fr AEC that would allow enough space between it and the 8.0 mm ID endotracheal tube during the process of railroading, thereby preventing any build-up of pressure with resultant barotrauma.

The oral intubation technique adopted in this patient offered several advantages. First, the nasotracheal tube kept the oedematous epiglottis lifted while the AEC was being placed by its side under videoscopic guidance. Second, the danger of losing the airway was avoided by prior placement of an AEC. Finally, this patient with high dependency on oxygen continued to receive oxygen at 4 litres per minute during the exchange procedure, thereby preventing rapid desaturation as advocated by the All India Difficult Airway Association and the American Society of Anesthesiologists in their latest difficult airway guidelines where the emphasis has been placed on optimisation of oxygenation throughout the procedure.[9],[10]

In the past, the duration of nasotracheal intubation has varied from 2 days to 3 months,[11] but it is no longer advocated. Delay in changing over from nasotracheal to orotracheal route occurred in our patient possibly because of fear of losing the airway and the reluctance on the part of the relatives for tracheostomy.

We conclude that a situation-based innovation in airway management is crucial to avoid any harm to the patient. Prior planning and discussion amongst team members are essential in patients with anticipated difficult airway for a successful outcome.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Simpson GD, Ross MJ, McKeown DW, Ray DC. Tracheal intubation in the critically ill: A multi-centre national study of practice and complications. Br J Anaesth 2012;108:792-9.
2Jaber S, Jung B, Corne P, Sebbane M, Muller L, Chanques G, et al. An intervention to decrease complications related to endotracheal intubation in the Intensive Care Unit: A prospective, multiple-center study. Intensive Care Med 2010;36:248-55.
3Jaber S, Amraoui J, Lefrant JY, Arich C, Cohendy R, Landreau L, et al. Clinical practice and risk factors for immediate complications of endotracheal intubation in the Intensive Care Unit: A prospective, multiple-center study. Crit Care Med 2006;34:2355-61.
4Nolan JP, Kelly FE. Airway challenges in critical care. Anaesthesia 2011;66 Suppl 2:81-92.
5Cook TM, Woodall N, Harper J, Benger J, Fourth National Audit Project. Major complications of airway management in the UK: Results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: Intensive care and emergency departments. Br J Anaesth 2011;106:632-42.
6Valdés C, Tomás I, Alvarez M, Limeres J, Medina J, Diz P. The incidence of bacteraemia associated with tracheal intubation. Anaesthesia 2008;63:588-92.
7Yamamoto T, Flenner M, Schindler E. Complications associated with nasotracheal intubation and proposal of simple countermeasure. Anaesthesiol Intensive Ther 2019;51:72-3.
8Cook TM. A new practical classification of laryngeal view. Anaesthesia 2000;55:274-9.
9Myatra SN, Shah A, Kundra P, Patwa A, Ramkumar V, Divatia JV, et al. All India Difficult Airway Association 2016 guidelines for the management of unanticipated difficult tracheal intubation in adults. Indian J Anaesth 2016;60:885-98.
10Apfelbaum JL, Hagberg CA, Connis RT, Abdelmalak BB, Agarkar M, Dutton RP, et al. 2022 American Society of Anesthesiologists practice guidelines for management of the difficult airway. Anesthesiology 2022;136:31-81.
11Rees GJ, Owen-Thomas JB. A technique of pulmonary ventilation with a nasotracheal tube. Br J Anaesth 1966;38:901-6.