ETT impingement during railroading over the FOB

Editor—Jackson and colleagues1 again highlight a problem well recognized amongst regular practitioners of fibreoptic intubation; that of the endotracheal tube (ETT) impinging on upper airway structures during railroading over the fibreoptic bronchoscope (FOB). The potential complications of airway trauma, desaturation and failed intubation are serious during what is essentially the only blind part of the procedure. Their reported 93% incidence of impingement with a standard tube confirms earlier studies on this topic, and emphasizes the need for an improved technique or tool for this procedure. Jackson has recognized that the problem lies in the gap between the tip of the bevelled tube and the fibreoptic scope, and by using a paediatric tube they have reduced this gap. This decreased the impingement rate to 18%.

However, the benefits of the soft tapered tip tube supplied with the intubating laryngeal mask airway (ILMA, Intavent), and available to buy separately, supersede the technique described. Lucas and Yentis,2 for the orotracheal route and Barker and colleagues3 for the nasotracheal route both showed the ILMA tube had a impingement rate of 0%, and Barker's trial was blinded to the assessor. Though some concerns may be raised concerning the high-pressure cuff of the ILMA tube, the benefits of easy first-time placement of the ETT in awake fibreoptic intubation cannot be underestimated.

D. Macnair and K. Barker

Inverness, UK


 
Editor—I would like to thank Drs Macnair and Barker for their letter. I agree that the tracheal tube of the ILMA ETT is effective in reducing impingement. The ILMA ETT and the double setup ETT have not been compared in a randomized, controlled trial, so it is uncertain which is more effective in reducing impingement. However, the ILMA ETT does appear to have two advantages: it is simple to prepare and it can be used for nasal intubations. The double setup ETT requires knowledge of which uncuffed ETT fits inside which cuffed ETT, and what length to cut the cuffed ETT. This may be a deterrent to its use, especially for occasional practitioners of fibreoptic intubation. Also, the double setup ETT is too short for nasal intubations. In contrast, the double setup ETT may be preferred for long-term intubation because of its low-pressure cuff. As noted in Drs Macnair and Barker's letter, the ILMA ETT has a high-pressure cuff.

A. Jackson

Sydney, Australia

References

1 Jackson AH, Wong P, Orr B. Randomized controlled trial of the double setup tracheal tube during fibreoptic orotracheal intubation under general anaesthesia. Br J Anaesth 2004; 92: 536–40[Abstract/Free Full Text]

2 Lucas DN, Yentis S. A comparison of the intubating laryngeal mask tracheal tube with a standard tracheal tube for fibreoptic intubation. Anaesthesia 2000; 55: 358–61[CrossRef][ISI][Medline]

3 Barker KF, Bolton P, Cole S, Coe PA. Ease of laryngeal passage during fibreoptic intubation: a comparison of three endotracheal tubes. Acta Anaesthesiol Scand 2001; 45: 624–6[CrossRef][ISI][Medline]





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