Endo tracheal tube exchange in a COVID positive patient.

Dear Editor,

As the novel coronavirus becomes ever present in hospital wards and ICUs, improved techniques are being developed. Sars-COV2 (Covid-19) is virulent and easily disseminated by airborne or droplet spread. Patients with severe disease frequently require endotracheal intubation as part of their treatment. It is important for practitioners coming into contact with these patients to take adequate precautions to minimize aerosolization of viral particles. It is of equal importance to consider appropriate endotracheal tube size based on factors such as patient size and expected duration of intubation without compromising adequate oxygenation and ventilation. It is also essential to note that patients with severe Covid-19 disease are prone to significant desaturation and so first pass success should be prioritized in any airway instrumentation procedure and must be performed by an experienced anesthesia provider [1], [2]. Informed consent was obtained from HCP for this publication.

We present the case of a 72-year-old male (180 CMS, BMI 21.6) with past medical history of cerebrovascular accident in 2007 without residual deficits and Covid-19 exposure from seniors at an assisted living facility. He presented with productive cough, shortness of breath and acute hypoxic respiratory failure requiring oxygen supplementation. He was saturating 80% on room air when found by EMS and placed on 5 L O2 by nasal cannula. Upon hospitalization he tested positive for Covid-19. During his hospital course, his oxygen requirements increased and needed respiratory support. On hospital day two he required BiPAP and hence was admitted to the step-down unit; he was subsequently intubated on hospital day 8 by a special COVID airway team and transferred to an intensive care unit.

On day 9, the patient was noted to have high peak and plateau pressures and was asynchronous with the ventilator. On reviewing the chest x-ray, the ETT tip was barely visible though originally confirmed to be in the right position after endotracheal intubation.

Evaluation with a glidescope (Verathon Inc., WA) showed that the cuff was visible above the vocal cords and that the patient had been intubated with a 7.0 endotracheal tube, instead of an 8.0 as documented.

A decision was made to exchange the 7.0 tube with an 8.0 endotracheal tube as the endotracheal tube was at the level of 29 cm at patient's lips after advancing the endotracheal tube under visualization. In preparation for tube exchange, all required materials were gathered and placed close at hand and readily available. Two other experienced practitioners were also available to facilitate the exchange smoothly in order to minimize the desaturation time. All participating practitioners were fully donned in appropriate personal protective equipment. The patient was already sedated and now was paralyzed with 50 mg of rocuronium. The patient was placed on 100% Oxygen for 5 min and then disconnected from the ventilator. The ventilator was placed on standby to prevent aerosolization from the circuit disconnection. Under glidescope visualization an 11 French Cook airway exchange catheter (Cook Critical Care, Bloomington, IN) was passed through the 7.0 tube in situ. The 7.0 tube was removed by one practitioner while the other held the exchanger in place. The 8.0 endotracheal tube was then passed over the exchanger and its position was confirmed under glidescope visualization and with end-tidal CO2 detection. The patient was then reconnected to the ventilator, and mechanical ventilation re-initiated on 100% oxygen and HME filter placed at the Y piece. With the larger endotracheal tube in place, we were able to achieve more favorable ventilatory dynamics (Figs. 1, 2).

Endotracheal intubation is frequently necessary in critically ill patients suffering from ARDS. Every effort should be taken confirm tube placement and choose the most appropriate tube size. Ventilatory strategies for Covid-19 patients predominately involve low tidal volume and high positive end-expiratory pressure (PEEP). Due to these high pressures and changes in patient positioning, endotracheal tubes are at increased risk of being displaced. This should be taken into account when choosing the size of an endotracheal tube for a particular patient [3]. When a tube exchange is planned, experienced practitioner on standby should be available with delegation of clear roles and sequence to minimize oxygenation as these patients are prone to desaturation very rapidly.

Though laryngotracheal stenosis is a concern with prolonged mechanical ventilation, the primary focus must remain on adequate ventilation and oxygenation. Endotracheal tubes in these patients should be re-evaluated frequently for positioning and cuff pressures. If a patient requires the exchange of their endotracheal tube, every effort should be taken to maintain a secure airway and to minimize aerosolization of viral particles [4].

Declaration of competing interest

No disclosures for both authors.