Chapter 88: Intubation and Tube Exchange Adjuncts

INTRODUCTION

Several devices have been developed that are commercially available to assist with endotracheal intubation and/or tube exchanges.

INTUBATING STYLET

Made of malleable metal wire, this frequently used adjunct is inserted into an endotracheal tube (ETT) prior to intubation and manually shaped to allow the ETT to conform to the upper airway anatomy of the patient. Many anesthesiologists use this stylet to form an ETT into a “hockey stick” shape that allows easier intubation of an anteriorly placed larynx. A variation of this stylet is the Verathon Stylet or “Glidescope Stylet,” which is rigid and designed to conform an ETT to the 60 degree angle of an Indirect Video Laryngoscope (Glidescope) blade.

ESCHMANN TRACHEAL TUBE INTRODUCER

This device is commonly referred to as a “gum elastic bougie” and is a 60 cm long, 15 French diameter flexible stylet with an angulated tip that can be used to facilitate a blind endotracheal intubation when the larynx cannot be visualized with direct laryngoscopy. After a direct laryngoscope is inserted into the mouth in the usual manner, the anesthesiologist keeps the laryngoscope midline and estimates the likely location of the larynx behind the epiglottis. The introducer is then passed blindly behind the epiglottis, between the vocal cords, and into the trachea. A tactile sensation of “clicking” as the introducer passes over the cartilaginous tracheal rings is often detected during a successful placement. While keeping the laryngoscope in place, an ETT is then threaded over the introducer and is guided through the larynx by the introducer. A 90° counterclockwise rotation of the ETT may assist during passage through the vocal cords.

This technique cannot be used when the epiglottis cannot be elevated away from the posterior wall of the pharynx with the direct laryngoscope. Despite its wide availability, many experts have questioned the role of this blind technique in modern anesthesia practice due to its potential to cause obstruction of the airway if the initial cause of the difficult intubation was a friable lesion that can be dislodged unintentionally. Widely available instruments such as Glidescopes and flexible fiberoptic laryngoscopes allow for indirect visualization of the larynx while minimizing these risks.

TRACHEAL TUBE EXCHANGER

These flexible catheters are similar to other introducers and are used when an ETT needs to be replaced in an intubated patient. Length ranges from 56 to 81 cm. The exchanger is inserted through the ETT and held stable as the patient is extubated. Another ETT is then threaded over the exchanger and passed through the larynx. A version of a tracheal tube exchanger called a Cook Airway Exchange Catheter (CAEC) has a central lumen that can be used to administer oxygen to the patient during an ETT exchange ensuring good oxygenation.

OPTICAL STYLET

This stylet incorporates a ...