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Year : 2023  |  Volume : 43  |  Issue : 4  |  Page : 195

Oral to nasal endotracheal tube exchange in patients difficult to undergo laryngoscopy

1 Department of Dentistry, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
2 Anesthesiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan

Date of Submission15-Feb-2022
Date of Acceptance22-Mar-2022
Date of Web Publication08-Apr-2022

Correspondence Address:
Chen-Hwan Cherng
Anesthesiology, Tri-Service General Hospital, National Defense Medical Center, Taipei
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmedsci.jmedsci_31_22

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How to cite this article:
Cheng CD, Cherng CH. Oral to nasal endotracheal tube exchange in patients difficult to undergo laryngoscopy. J Med Sci 2023;43:195

How to cite this URL:
Cheng CD, Cherng CH. Oral to nasal endotracheal tube exchange in patients difficult to undergo laryngoscopy. J Med Sci [serial online] 2023 [cited 2023 Sep 29];43:195. Available from: https://www.jmedscindmc.com/text.asp?2023/43/4/195/342798

Dear Editor,

Nasotracheal intubation is indicated in patients receiving oromaxillary surgery. When an already oral intubated patient with unstable cervical spine fracture will undergo oromaxillary surgery, the oral intubation should be switched to nasal intubation. Under such situation, laryngoscopy is not suitable for reintubation because of the unstable cervical spine. Here, we introduce a safe maneuver for the endotracheal tube (ETT) exchange using a double-swivel connector and an 11 Fr exchange catheter (Cook® Airway Exchange Catheter [CAEC]) as a guide to ensure the airway security [Figure 1]. Under standard monitoring and appropriate analgesia and sedation, the patient maintains spontaneous breathing, 2 ml 2% lidocaine is injected into the oral ETT for tracheal topical anesthesia, and then, the CAEC is inserted into the oral ETT via the double-swivel connector which can maintain oxygenation during tubes exchange. The CAEC's tip is positioned at 5 cm beyond the distal end of the oral ETT. A fiberscope with a loaded lubricated ETT (6.5 mm ID) is inserted via left naris into the oropharynx. When the oral ETT is visualized from the fiberscope, the oral ETT is pulled out of glottis, but the CAEC is remained in place. Then, the fiberscope will be easily introduced into trachea guided by the in situ CAEC. The nasal ETT is then railroaded into trachea with the fiberscope. The diameter of CAEC is small (4 mm). It is allowed for the simultaneous placement of the CAEC and the ETT in the trachea. After confirming the correct position of the nasal ETT by the fiberscope and end-tidal CO2, the oral ETT and CAEC can be removed.
Figure 1: View of the oral to nasal tube exchange, as with a Cook® Airway Exchange Catheter in the oral endotracheal tube through a double-swivel connector, and a fiberscope in the nasal endotracheal tube

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Handling difficult airway is a crucial task for an anesthesiologist. Converting oral to nasal intubation in a patient with unstable cervical spine poses a big challenge. Several methods have been reported to perform the tube exchange from oral to nasal.[1],[2],[3] The technique of using CAEC and double-swivel connector we describe here have several advantages, such as (1) CAEC can ensure the airway security in case of fiberscope-aided intubation failure, (2) CAEC can guide the fiberscope to find the glottis, and (3) during the process of tubes exchange, not only the double-swivel connector but also the CAEC can easily maintain patient's oxygenation. The CAEC can act as a tool for oxygen insufflation or jet ventilation.

Data availability statement

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Nakata Y, Niimi Y. Oral-to-nasal endotracheal tube exchange in patients with bleeding esophageal varices. Anesthesiology 1995;83:1380-1.  Back to cited text no. 1
Salibian H, Jain S, Gabriel D, Azocar RJ. Conversion of an oral to nasal orotracheal intubation using an endotracheal tube exchanger. Anesth Analg 2002;95:1822.  Back to cited text no. 2
Sharma R, Kumar A, Panda A. Using a central venous pressure guidewire and suction catheter to facilitate oral to nasal tracheal tube change in a child with a difficult airway. Anesth Analg 2009;108:1716-7.  Back to cited text no. 3


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