The Case
Our transport team was called to 24-year-old male with no significant past medical history. He presented to the referring Emergency Department (ED) by ambulance following an episode of polymorphic ventricular tachycardia resulting in cardiac arrest in setting of status epilepticus. His significant other reported that he was smoking marijuana. He stated that he was not feeling well and then collapsed, experiencing a convulsive seizure. Successful cardiac resuscitation occurred in the field and the patient was promptly transported to the referring ED.
In the ED, the patient remained unresponsive with seizure-like activity and decerebrate posturing. This was treated with multiple doses of lorazepam. He was also loaded with levetiracetam (keppra) and fosphenytoin (cerebyx). He was orally intubated. This was reportedly a difficult intubation, requiring 6 attempts due to a large tongue size and significant bloody output from his oropharynx. An initial chest x ray showed that the endotracheal tube was in good placement.
The initial EKG per the referring hospital notes demonstrated sinus rhythm HR of 80, normal QTc, incomplete right bundle branch block (RBBB), evidence of left ventricular hypertrophy (LVH) and no significant ST or T wave changes. A basic metabolic panel demonstrated hypokalemia, hypomagnesemia and an arterial blood gas (ABG) showing significant metabolic acidosis (pH 7.15). A transesophageal echocardiogram demonstrated an ejection fraction (EF) of 40-45% with global hypokinesis, a normal right ventricle (RV) size and no significant valvular abnormalities.
While awaiting the transport team, central and arterial line access was placed. A norepinephrine infusion was started for refractory hypotension. Diprivan and fentanyl infusions were also running for sedation and analgesia, respectively. A “post-line placement” chest x-ray was obtained to verify placement. It was this x-ray that created frantic anxiety from the referring staff as the transport team walked into the resuscitation bay.
Survival Flight Arrival and Case Progression
Upon arrival, the resident physician reported that per radiology, the chest x-ray indicated that the tip of the endotracheal tube (ETT) appeared to be in the oropharynx. Clinically, the patient did not appear to be decompensating. His oxygen saturations were 90-93 %. The ventilator returned adequate tidal volumes with normal airway pressures. A treatment plan was then established with the bedside team. The endotracheal tube needed to be exchanged. Equipment was prepared and induction medications were administered to maximize success.
The team initially discussed accessing and visualizing the oropharynx, deflating the balloon, and simply advancing the ETT. As this was reported as a difficult airway, the team decided to first place a tracheal tube introducer (“bougie”) before deflating the balloon to ensure they always had access to the glottic opening and below (this turned out to be a life-saving decision as you will see in the video below). The oropharynx was visualized with a video laryngoscope (STORZ C-Mac PM®) and it showed that the ETT balloon was significantly obscuring the view of the oropharynx as it was just above the glottic opening.
Once the ETT was disconnected from the ventilator to insert the bougie, both the ETT and oropharynx were filled with blood/pulmonary edema. The ETT was firmly held in place while the bougie was now blindly placed through it. Simultaneously, the ETT and oropharynx were vigorously suctioned by a second team member. The ETT was removed and a new one was placed over the bougie after a clear view of the oropharynx was obtained. The patient was aggressively preoxygenated prior to the procedure and his oxygen saturation never fell below 93%.
Discussion
ETT change over a bougie is well documented procedure for damaged balloons or difficult extubation. Cooper and Khan (2013) reported that the use of a bougie, compared to an ETT and stylet resulted in significantly higher first-attempt intubation success among patients undergoing emergency endotracheal intubation. They also reference a case of esophageal misplacement of a single-lumen ETT after switching from a double-lumen tube, despite the use of an airway exchange catheter (AEC) as a guidewire. To avoid this, clinicians should consider the insertion depth and maintenance depth of the bougie and should perform, if possible, with simultaneous visualization of the glottis with direct or video-assisted direct laryngoscopy during the exchange. Additionally, the new ETT position should be confirmed by auscultation, end-tidal carbon dioxide, and portable chest X-ray.
Take Home Points
- Never enter an airway without a clear plan of action, backup plan and adjuncts available for disaster situations.
- When deflating an ETT balloon for any reason consider the placement of a bougie prior to deflating or moving the ETT as a safety mechanism.
- Always verify ETT depth on initial survey and monitor throughout the transport.
- For any procedure involving the manipulation of a difficult airway, be prepared to access the cricothyroid membrane.
References
Cooper, R. M., & Khan, S. (2013). Extubation and reintubation of the difficult airway. Benumof and Hagberg’s airway management, 1018. Access at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7158180/pdf/main.pdf
Driver BE, Prekker ME, Klein LR, et al. Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial. JAMA. 2018;319(21):2179-2189. doi:10.1001/jama.2018.6496
Hwang SM, Lee JJ, Jang JS, Lee NH. Esophageal misplacement of a single-lumen tube after its exchange for a double-lumen tube despite the use of an airway-exchange catheter. Saudi J Anaesth. 2013;7(2):194-196. doi:10.4103/1658-354X.114050
Reardon, R. F., & Carleton, S. C. (2018). The walls manual of emergency airway management. In The Walls manual of emergency airway management (5th ed., pp. 232-237). Philadelphia: Wolters Kluwer.