Page 16 - CASA Bulletin of Anesthesiology 2020 Issue 2

CASA Bulletin of Anesthesiology

We held a brief discussion amongst anesthesiologist, intensivist, pulmonologist, and surgical team. We all
agreed that we would make one more attempt with videolaryngoscopy . If we had a good view, we might be
able to pull out the existing ETT and re-intubate the patient with a smaller size/or a different type of ETT . If in
case this strategy fails, surgical airway would be the final solution.

The Glidescope gave us a good view of the vocal cord and confirmed our suspicion of a herniated pilot
balloon at the vocal cord. The ETT pilot balloon was seen riding over the vocal cord. While manipulating the
ETT, we successfully advanced it further past the curved tracheal part and the pilot balloon under the vocal
cord. The FOB confirmed that ETT tip was located above carina. At this point, the patient’s ventilation had
been maintained without problem, and we were able to pass the suction tube through without any obstructions,
following CXR confirmed tip of ETT above corina. (Fig.2.) The CT chest scan showed bilateral dependent
consolidations with near-complete collapse of both lower lobes .

During the tube exchange process, appropriate PPE were used with everyone in the room. The first and the
second PCR tests for the patient was negative for COVID-19 .

Discussion:

Anesthesiologists are often called to the ICU to help with different airway management, such as intuba-
tion, ETT exchange, or to standby for extubation for a patient with a difficult airway. Dr. Mort and Dr. Surette
described different methods, complications and recommendations toward optimizing patient’ safety in their
review article: ETT exchange in the ICU Such methods include direct laryngoscopy (DL), video-assisted
(2).
laryngoscopy (VAL), FOB with 2nd ETT (alongside the 1st ETT), and combined FOB + VAL or DL, with
or without airway exchange catheter (AEC). They found that if only an AEC was used, only 58.7 % of the
first-attempts succeeded. First-attempt success increased to 75.3 % if a combination of DL + AEC was used,
and to 91.8% if VAL + AEC was used. Furthermore, Desaturation to < 80% happened in 21.9% cases with
AEC only, but dropped to 2.1% cases when both VAL + AEC were used. Esophageal intubation occured in
8% cases with AEC only and to 0% with VAL + AEC. They also showed outcomes of non-AEC assisted ex-
changes: first-attempt success rate was 51.6 % with DL and up to 91.7% with VAL; esophageal intubation rate
was 31.3% with DL and down to 1.1% with VAL.

The main issue we faced in our patient care was that the patient’s ventilation was fine but the passing of
the suction tube was blocked, which led to the suspicion of a kinked or partially occluded ETT. We were con-
cerned about the potential of virus transmission (suspected COVID-19 pneumonia) that could be associated
with airway manipulation. Since there was no problem with the initial intubation, we did not suspect a difficult
airway. But the higher ETT tip shown on the CXR and the throat noises with every ventilation suggested that
the patient might have a partial extubation and the pilot balloon was herniating at the vocal cord . Because of
the obstruction of passing suction tube, we decided to use a FOB to perform an evaluation and may potentially
push the ETT further. To our surprise, we encountered difficulty in passing the FOB even with direct vision.
If we had used AEC blindly, we could have caused airway trauma by forcing it down blindly or could lose the
airway completely . A pulmonologist was very helpful in evaluating the airway down to carina and ruling out
luminal lesions as a concern. When we performed the final attempt with VAL, we confirmed our suspicion of
herniated pilot balloon . The force and traction of the VAL might have changed tracheal position somewhat
and the curvature was straightened a little bit . This might be the reason why we successfully pushed ETT fur-
ther beyond the curvature part and reached above the carina .

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