2010 OPEN FORUM Abstracts
TRACHEAL TRAUMA FROM AN AIRWAY EXCHANGE CATHETER.
Mark Grzeskowiak, Steve Leven, Steve Reiland; Respiratory Care, Long Beach Memorial, Long Beach, CA
Introduction Airway exchange catheters (AEC) are flexible, hollow stylets that are frequently used as a guide when replacing artificial airways. AECs are reported to have very little risk and great benefits to the patient. We report a case where the use of an AEC produced airway trauma and a nearly catastrophic outcome. Case Summary A 37 year-old female with a history of limb-girdle muscular dystrophy was admitted with complaints of weakness, congestion and insomnia. She was able to speak in 3-4 word sentences. Her vital signs were HR 122 RR 25 BP 157/99. Admitting ABG showed pH 7.36 PC02 87 P02 30 HC03 49 BE 17. Initial treatment included non-invasive ventilation and supplemental 02. The patient was very resistant to this, verbalizing repeatedly that she could not tolerate it despite changes in settings and interface type. The patient later agreed to intubation. Her admitting diagnosis was pneumonia and respiratory failure. Her pneumonia resolved but she was unable to be weaned from the ventilator. After 10 days her endotracheal tube developed a leak. Using an AEC, an anesthesiologist exchanged the 7.0 tube for another tube of the same size. Immediately after the new tube was placed, massive hemoptysis was observed. Oxygen saturations and heart rate fell to 60% and 30 respectively. The patient was successfully resuscitated. Emergent fiberoptic bronchoscopy failed to identify any tumor or gross lesions. Days later, the decision was made for the patient to undergo bedside percutaneous tracheotomy. As the intensivist was inserting his bronchoscope, he observed an 8 cm tear along the long axis of the posterior tracheal wall. The procedure was stopped and further medical consultation was obtained. Seven days later the tracheotomy was completed without incident and the patient was transferred to a skilled nursing facility. Discussion Available literature shows that AEC is a widely-used device with a low incidence of sequelae. One source opined that AEC-associated trauma is under-reported. Factors which contribute to trauma are insertion technique and catheter composition. The rigidity of the AEC keeps it from being compressed while in the airway but this predisposes the patient to injury or worse if inserted without regard to the potential for trauma. A soft tip version of AEC is now available for use on all our difficult airway carts. A safe insertion depth for the AEC is determined prior to it being inserted into the patient. Sponsored Research - None