The tracheal tube with a leaking cuff is a vexing problem, especially if the original intubation was difficult. A method of replacing the tube without losing control of the tracheal lumen is preferred. This can be achieved by passing a guide down the defective tube, withdrawing the tube while leaving the guide in place, and introducing a new tube over the guide and into the trachea.
A number of different guides have been described (e.g., simple nasogastric tubes, 18 Fr Salem sump tubes , feeding tubes), but they are poor substitutes for a designated tube exchanger such as the TTX "tracheal tube exchanger" (Sheridan Catheter Corporation, Argyle, NY) or a similar commercially available device. The advantages of the designated tube exchanger are that it is stiff enough to prevent dislodgment when the endotracheal tube is introduced, it is ready to use without modification, it has a printed scale to aid in determining depth of placement, and if replacement is prolonged, the patient may be oxygenated using the exchanger and wall oxygen.
Procedure
Prior to the procedure, the patient is properly sedated or restrained. The patient is hyperventilated before placing the guide through the existing tube. The guide is lubricated and advanced into the defective tube so that it is well within the tracheal lumen (adults, 30 cm). While applying cricoid pressure (Sellick maneuver), the defective tube is withdrawn over the guide, and care is taken not to dislodge the guide when removing the tube. The replacement tube is then slid over the guide and is gently advanced into the trachea . At this juncture, it may be helpful to perform a jaw thrust or chin lift to facilitate passage through the pharynx. Resistance may be encountered at the laryngeal inlet or vocal cords; if this occurs, withdraw the tube 1 to 2 cm, rotate it 90° counterclockwise, and readvance it. With the tube clearly in the trachea, remove the guide, inflate the cuff, and ventilate the patient. After correct placement has been verified, the new tube can be secured.
Complications are related to the time required to change the tube. A successfully performed procedure can be accomplished within 30 seconds. Laryngeal injury from forcing the guide or the tube is a possibility to consider when replacing a tube
A number of different guides have been described (e.g., simple nasogastric tubes, 18 Fr Salem sump tubes , feeding tubes), but they are poor substitutes for a designated tube exchanger such as the TTX "tracheal tube exchanger" (Sheridan Catheter Corporation, Argyle, NY) or a similar commercially available device. The advantages of the designated tube exchanger are that it is stiff enough to prevent dislodgment when the endotracheal tube is introduced, it is ready to use without modification, it has a printed scale to aid in determining depth of placement, and if replacement is prolonged, the patient may be oxygenated using the exchanger and wall oxygen.
Procedure
Prior to the procedure, the patient is properly sedated or restrained. The patient is hyperventilated before placing the guide through the existing tube. The guide is lubricated and advanced into the defective tube so that it is well within the tracheal lumen (adults, 30 cm). While applying cricoid pressure (Sellick maneuver), the defective tube is withdrawn over the guide, and care is taken not to dislodge the guide when removing the tube. The replacement tube is then slid over the guide and is gently advanced into the trachea . At this juncture, it may be helpful to perform a jaw thrust or chin lift to facilitate passage through the pharynx. Resistance may be encountered at the laryngeal inlet or vocal cords; if this occurs, withdraw the tube 1 to 2 cm, rotate it 90° counterclockwise, and readvance it. With the tube clearly in the trachea, remove the guide, inflate the cuff, and ventilate the patient. After correct placement has been verified, the new tube can be secured.
Complications are related to the time required to change the tube. A successfully performed procedure can be accomplished within 30 seconds. Laryngeal injury from forcing the guide or the tube is a possibility to consider when replacing a tube
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