A novel set-up to allow suctioning during direct endotracheal and fiberoptic intubation
To the Editor:
When intubating the tracheas of patients with gastrointestinal bleeding, vomiting, or copious secretions, standard suction often is inadequate to provide good intubating conditions. As soon as the suction catheter is removed and the endotracheal tube (ETT) is picked up, the liquid reaccumulates, preventing visualization of the airway structures. In these situations, we attach a neonatal meconium aspirator (Neotech Products, Inc., Valencia, CA, USA) to the end of the ETT, then connect the ETT to suction (Fig. 1). By occluding the suction-activation hole with a finger tip, the ETT becomes a large-bore suction catheter. This action allows for continuous removal of the blood/secretions throughout ETT placement and provides a clear view of the glottic structures; the patient’s trachea then is intubated with the same ETT. The trachea then may be suctioned before the meconium aspirator is disconnected.
One disadvantage of this method was that the ETT could not contain a stylet to allow for easier manipulation. We therefore devised the simple set-up, as shown in Fig. 2. This consists of the ETT attached to a common swivel adapter with a perforated rubber head (Bodai Swivel, Sontek Medical, Inc., Hingham, MA, USA). A meconium aspirator is then attached to the swivel adapter and suction. This configuration allows a styletted ETT to be used in the manner mentioned above (Fig. 3).
In the course of using this simple set-up, we realized that it may also provide a means to add suction to a number of fiberoptic stylets. One of the failings of these devices, as compared with standard intubating bronchoscopes, is the absence of a suction channel. Fig. 4 shows a Bonfils fiberscope (Karl Storz Endoscopy, Tuttlingen, Germany) with attached swivel adapter, ETT, and meconium aspirator. Depending on the model of fiberoptic scope, a small portion of the ETT will need to be removed in order for this set-up to fit; the depicted ETT was cut at 28 cm. This set-up allows suctioning during intubation and clearing of the fiberoptic camera without having to remove the scope from the mouth.
A potential disadvantage of this set-up is that the ETT may be soiled by the patient’s secretions. Nevertheless, we have used this set-up in many difficult airway situations and find that it offers excellent potential to improve airway visualization.
Note: We have, since publishing this piece, moved to having an assistant occlude the hole under the direction of the intubator or by watching the video laryngoscope screen to determine when suction is needed. (the latter a la R. Strayer)