Trachlight-guided intubation with esophageal combitube in situ.

Sir,

The esophageal tracheal combitube (ETC) (Tyco Kendall Co., Mansfield, MA) is a supralaryngeal airway device recommended for difficult airway management.[1] We describe airway management in a patient with difficult airway using combitube and Trachlight™ (Laerdal Medical Inc., Armonk, NY).

A 48-year-old man presented to the emergency department with head injury following a road traffic accident. Patient was unconscious and was graded as Glasgow Coma Scale (GCS) 7. He had fracture of nasal bones with epistaxis. He was tachypneic and crepts and wheeze were heard on chest auscultation. Patient's lungs were preoxygenated with 100% oxygen, manual inline stabilization was applied, and rapid sequence induction was carried while applying cricoid pressure. Laryngoscopy revealed a grade-4 Cormack-Lehane view, which did not improved on releasing the cricoid pressure and backward, upward, and rightward pressure maneuver. After two attempts at direct laryngoscopy and bougie assistance, patient began to desaturate. A size ETC 37Fr SA was successfully placed with the distal tip in the esophagus. The lungs could be successfully ventilated via the blue pharyngeal lumen, as evident by capnography, bilateral auscultation of the chest and improvement in oxygen saturation to 97%. Computerized tomography scan of the patient's head and neck revealed bilateral multiple contusions with midline shift and fracture of right frontal bone. Cervical spine was normal. As elective ventilation was indicated, exchange of ETC to an endotracheal tube was needed. Direct laryngoscopic examination, after partial deflation of the oropharyngeal balloon, revealed Cormack-Lehane grade-4 view. Two attempts to intubate trachea using a gum elastic bougie failed. A fiberoptic bronchoscope was passed alongside the ETC after partial deflation of the cuff, but we failed to negotiate it into the glottic aperture as the vision was poor due to bleeding in the oral cavity.

It was decided to attempt light wand aided tracheal intubation. An adult light wand was threaded through the Murphy eye of size 8-mm ID endotracheal tube [Figure 1].[2] The cuff of the ETC was partially deflated and the Trachlight wand (Laerdal Medical, Armonk, NY, USA) was passed via oral cavity alongside the ETC. Gentle maneuvering of the Trachlight wand led to its entry into the trachea as evident by well-circumscribed glow in the anterior neck slightly below the thyroid prominence. The tracheal tube was advanced over the wand. A resistance was felt to the passage of the tracheal tube into the glottic aperture, which was overcome by anticlockwise rotation by 90°, which facilitated its passage into the trachea. Light wand was removed and the position was confirmed by bilateral auscultation of chest and capnography. ETC was also removed and elective ventilation continued. Patient was weaned from ventilator after 12 days with a GCS of 11.

Figure 1

Tracheal tube mounted on the Trachlight for intubation

The ETC has been used as a rescue device for emergency airway management. ETC can be exchanged for conventional endotracheal tube using various techniques including direct and video laryngoscopy, fiberoptic-assisted intubation, and surgical airway.[34] However, exchanging the ETC for definitive airway may not be straightforward.[4] Its insertion in precarious circumstances, such as after multiple attempts after failed ventilation/intubations and esophageal/tracheal distortion by the ETC rendering visualization of the glottic aperture, may make tracheal intubation difficult.[45] Leaving the ETC in place while manipulating the airway confers a safety margin to continue ventilation and oxygenation. Fiberoptic intubation after partial deflation of the oropharyngeal balloon of the ETC is feasible,[3] but this failed in our case due to obscuring of the airway by blood. Light wand intubation does not require direct viewing of the glottic aperture. Light wand guided intubation is useful in situations in which flexible endoscopy is difficult, as in cases where the airway is obscured by secretions or blood or when patient's head cannot be manipulated.[4] We found Trachlight to be very useful tool for exchanging ETC with an endotracheal tube.