Repositioning a displaced tracheostomy tube
Wolverhampton, UK
* E-mail: anilbhuvanagiri{at}hotmail.com
Editor—We found Rajendram's case report on the repositioning of a displaced tracheostomy tube with Aintree intubation catheter (AIC) mounted on a fibre-optic bronchoscope (FOB)1 to be particularly interesting, as we experienced a similar difficult situation, which did not run as smoothly as Rajendram's, although it was ultimately successful. We believe that comparison between the two patients would be useful in emphasizing the crucial aspects of management of similar situations.
A 19-yr-old, Afro-Caribbean male presented to the maxillofacial team with Ludwig's angina, an airway threatening condition caused by dental infection involving multiple tissue planes in the neck. He had emergency incision and drainage of the infection followed by tracheostomy. After inducing anaesthesia with sevoflurane, the surgical procedure was uneventful and a size 8 Shiley cuffed, fenestrated tracheostomy tube (Tyco Healthcare, Pleasanton, CA, USA) was inserted. This tube has a fenestrated outer tube and an interchangeable solid or fenestrated inner tube. The solid inner tube is used for the immediate perioperative period, and this is changed to the fenestrated inner tube as the airway becomes less at risk. The patient was initially very drowsy after reversal of the neuromuscular block, but then had violent bouts of coughing and developed massive surgical emphysema over his chest extending to the arms, neck, and face. The maxillofacial team was called back immediately. The patient was re-sedated whilst still self-ventilating with good tidal volumes. Because of the risk of increasing swelling and displacement of the tracheostomy tube, it was decided to replace the fenestrated tracheostomy tube with an adjustable flange reinforced size 8 tracheostomy tube (Mallinckrodt, Ireland). Anaesthesia was again induced with propofol 1 mg kg–1 and atracurium 0.5 mg kg–1. The plan was to exchange the tracheostomy tubes over a Cook airway exchange (CAE) catheter (William Cook, Europe, CAE-Ref 19.0-83). The inner lumen of the Shiley tube was removed, and the CAE was passed through the outer lumen of the tube, but with resistance. When the fenestrated tube was withdrawn, the CAE was noticed to have slipped through the fenestration. The maxillofacial surgeon immediately took control and replaced the adjustable tracheostomy tube under direct vision using Langenbeck's tissue retractors. The position of the tracheostomy tube was confirmed with the FOB. The whole procedure lasted less than 4 min, and the patient remained well oxygenated throughout.
By comparing and contrasting Rajendram's report and our own, we have learnt several important lessons:
- The CAE is much more rigid than the AIC, and therefore, more difficult to pass along the natural curve of the tracheostomy tube.
- The visual (FOB) method adds an extra element of certainty in securing the airway although this is less necessary when the tube is replaced under direct vision.
- The presence of the Maxillofacial/ENT team is mandatory.
- Use of the fenestrated tracheostomy tube in the early stages of managing tracheostomized patients can be hazardous if correct consideration is not given to the presence of the fenestration in the outer tube.
References
1 Rajendram R and McGuire N. (2006) Repositioning a displaced tracheostomy tube with an Aintree intubation catheter mounted on a fibre-optic bronchoscope. Br J Anaesth 97:576–9.
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