Exchange of orotracheal tubes in a patient with difficult airway and hiatus hernia.

To the Editor: A 23-yr-old man (height approximately 155 cm, weight 38 kg) with acute respiratory failure required exchange of endotracheal tubes. He had spastic cerebral palsy at two months of age, had had spastic quadriplegia, mental retardation, severe scoliosis and repeated regurgitation and pneumonia due to hiatus hernia. The head and neck were fixed in a flexed position and the interincisor distance was 3 cm. Previously, tracheal intubation using a laryngoscope had failed, but was accomplished after considerable difficulty using a fibreoptic bronchoscope. The patient was sedated and ventilation assisted mechanically. One month later, pneumonia and fever developed and fibrescopy showed that the tracheal tube was partially obstructed by a sticky sputum, containing streptococci, neisseria species and pseudomonas aeruginosa. There were risks of failed intubation, failed ventilation and pulmonary aspiration during tube exchange. We used the following method to minimize the risk of complications. A size 4 laryngeal mask airway was placed without difficulty while the endotracheal tube was still in place. A fibrescope and a 6.0-mm ID endotracheal tube were passed through the laryngeal mask. After cricoid pressure had been applied to prevent regurgitation, the cuff of the endotracheal tube in place was deflated, and the fibrescope inserted into the trachea, alongside the old tube. The old tube was removed, the new tube was then advanced over the fibrescope into the trachea without difficulty. Time from removal of the endotracheal tube to reintubation was about five seconds, apnea less than ten seconds and SpO2 remained 100%. I believe that the laryngeal mask is a useful adjunct for the exchange of endotracheal tubes.1