2005 OPEN FORUM Abstracts
THE UTILIZATION OF DIGITAL MANIPULATION IN AN ACUTE DISLODGED ENDOTRACHEAL TUBE
Kenneth Miller, MEd, RRT, Laura Williams, RRT, Stephen Matchett, M.D. Lehigh Valley Hospital, Allentown, PA 18105-1556
Introduction: A dislodged endotracheal tube can be a medical emergency. This is more evident when utilizing alternative modes of ventilation. Quick action and intervention is paramount in achieving a successful outcome. When traditional airway management techniques can not be employed an unconventional method must be instituted.
Case study: A forty-one year old female was transferred and admitted to our institution with respiratory failure secondary to H. influenza. On transport, she developed a left tension pneumothorax which was treated with needle and tube decompression. She was diagnosed with acute lung injury secondary to appropriate clinical criteria. She was placed on the ARDSnet ventilatory strategy and maintained on a tidal volume of 6cc/kg. Thirty-six hours post admission she developed several periods of oxygen desaturations despite increasing FiO2 and PEEP per the ARDSnet ventilatory algorithm. Airway Pressure Release Ventilation was attempt with minimal improvement in gas exchange. A second and third pneumothorax developed which was treated with additional chest tube decompression. The decision was made to place the patient on High Frequency Percussive Ventilation (HFPV) via the VDR-4. Clinical end-points were achieved utilizing a PIP of 50 cm/H2O and a PEEP of 20 cm/H2O. Over the course of the next few days, attempts to reduce the PIP/PEEP were unsuccessful. On the seventh day post admission, gas exchange deteriorated and there was evidence of airway obstruction via the end-tidal CO2 waveform. An attempt to perform bronchoscopy was unsuccessful and revealed the tip of the endotracheal tube was located in the lower portion of the oral-pharynx. Gas exchange deteriorated to the point of having an SpO2 < 80% and PaCO2 > 100 torr. Attempts to re-position the tube via bronchoscope were unsuccessful. The ability to perform manual hand-bag ventilation was difficult and evidence of increasing sub-cutaneous emphysema was noticeable. At this point the decision was made to digitally manipulate the tube externally to align the tube with the airway. SpO2 was maintained greater than 90% and the patient was emergently transported to the operating room for an emergent tracheostomy.
Conclusion: A dislodged artificial airway can be a medical emergency. Quick recognition and intervention is essential for achieving an optimal outcome. By manually manipulating the endotracheal tube over the glottis we were able to achieve a successful outcome. Creative intervention or solutions may be required in unusual situations.