British Journal of Anaesthesia, 2004, Vol. 92, No. 4 601-602
© 2004 The Board of Management and Trustees of the British Journal of Anaesthesia
Correspondence |
Endobronchial intubation
1 Osaka, Japan 2 London, UK
Editor—We read with interest the case report on inadvertent endobronchial intubation by Drs Mackenzie and MacLeod.1 Unintentional endobronchial intubation may occur commonly, particularly in obese women undergoing laparoscopy in the head-down position, as they reported. However, we have not encountered this complication when using the manoeuvres of deliberate unilateral endobronchial intubation, chest auscultation, and cuff ballottement in the suprasternal notch.2 The course of the tracheal tube must be confirmed after the patient has been put into the position in which surgery is to be performed. Until extubation, we remain vigilant about the postion of the tracheal tube, instead of waiting for warning alarms to sound.
K. Mizutani
C. Nakamura
Osaka, Japan
Editor—We thank you for the opportunity to respond to the letter from Drs Mizutani and Nakamura. They make an important point that was omitted from our case report, that the correct tube position must be confirmed under the conditions in which the operation will proceed. The method chosen by us was simple chest auscultation. This, however, is not a perfect test, as bilateral breath sounds may be heard in as many as 60% of endobronchial intubations,3 possibly from gas leakage around the tracheal tube cuff. Breath sounds were heard bilaterally after positioning our patient in a head down position, but we do admit that bilateral breath sounds were not confirmed after insufflation of the peritoneum. Our suspicion of endobronchial intubation was aroused when the airway pressure increased and steps were taken immediately to confirm correct position of the tube. We wholeheartedly agree with Drs Mizutani and Nakamura in their implication that there is no place in anaesthesia for complacency and that proactive steps must be taken to avoid critical incidents. However, the airway pressure alarm in this instance would have been the first indication that a problem was developing, even had bilateral breath sounds been confirmed after peritoneal insufflation. Furthermore, the correspondence referenced by Drs Mizutani and Nakamura indicates that endobronchial intubation can be prevented not only by the measures they refer to, but also by chest roentgenographic studies. This was a measure that we took to confirm tube position, and was also the main point of our discussion. We are interested to know how widespread the use of intentional endobronchial intubation and cuff ballottement in the suprasternal notch is in confirming tube position, as from our experience locally, these techniques are not used commonly.
M. Mackenzie
K. MacLeod
London, UK
References
1 Mackenzie M, MacLeod K. Repeated inadvertent endobronchial intubation during laparoscopy. Br J Anaesth 2003; 91: 297–8
2 Kubota Y, Toyoda Y, Kubota H, Yamasaki Y. Confirmation of endotracheal tube positioning. Chest 1990; 98: 1306[Medline]
3 Brunel W, Coleman DL, Schwartz DE, et al. Assessment of routine chest roentgenograms and the physical examination to confirm endotracheal tube position. Chest 1989; 96: 1043–5
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