An airway exchange catheter facilitates removal of the intubating laryngeal airway after tracheal intubation in children

To the Editor, When encountering patients with difficult airways in pediatric anesthesia, clinicians have the option of using a supraglottic airway device as a conduit for tracheal intubation. The Laryngeal Mask Airway (LMA) Classic (LMA North America; San Diego, CA, USA) is the conduit used most commonly for tracheal intubation in the pediatric population. However, numerous challenges arise when the LMA is used to facilitate intubation with an endotracheal tube (ETT), especially during removal of the LMA following successful intubation. In particular, the airway tube of the LMA can be as long as the ETT, making it difficult to maintain control of the ETT while removing the LMA. Several techniques that decrease the likelihood of accidental extubation of the ETT during removal of the LMA have been devised and reported in the literature. These techniques include the use of a long ETT, a double ETT assembly, shortening or splitting the shaft of the LMA, or leaving the LMA in place for the duration of surgery. These techniques are all effective yet imperfect solutions to a procedure commonly encountered in a patient with a difficult airway. The air-Q intubating laryngeal airway (ILA) (Cookgas LLC; St. Louis, MO, USA) is a newer supraglottic airway device that holds several advantages over the LMA when used to facilitate tracheal intubation in the pediatric population. Specifically, the airway tube of the ILA is shorter and wider than the LMA, which allows for greater control of the ETT and unhindered passage of the pilot balloon during removal of the ILA. At our institution, we have intubated the tracheas of hundreds of patients successfully by using the ILA as a conduit for tracheal intubation. It has been noted that the shorter airway tube length greatly facilitates distal control of the ETT and subsequent removal of the ILA after intubation. Unlike the LMA, the ILA has a custom removal stylet that can be used to stabilize the ETT during removal of the ILA device. However, if the manufacturer’s removal stylet is not available or if the clinician is not comfortable with its use, we propose the use of an airway exchange catheter (AEC) (Cook Medical, Bloomington, IN, USA) to facilitate removal of the ILA (Figure). Use of an AEC during removal of the ILA offers advantages to the clinician who otherwise might be hesitant to remove the ILA after tracheal intubation. First, placement of the AEC maintains the ability to supply supplemental oxygen into the trachea and diminishes the possibility of oxygen desaturation. Second, the AEC provides a means for guided reintubation if the ETT is dislodged inadvertently during removal of the ILA device. Generally, the smaller-sized ILAs (1.0 and 1.5) are short enough to facilitate gaining both proximal and distal control of the ETT during removal of the ILA. If an AEC is used, the clinician could cede control of the ETT once its proximal end is flush with the ILA and still retain proximal control of the AEC to ensure it remains in the trachea. The clinician can then remove the ILA until distal control of the ETT is possible, even if outside the patient’s mouth, and then confirm tracheal depth and reintubate over the AEC if necessary. Another potential technique that has been described for tracheal intubation through the LMA is to leave the fibreoptic bronchoscope within the trachea while removing the LMA, then to advance the ETT down the bronchoscope into the trachea. This method is beneficial, as no additional N. Jagannathan, MD (&) R. J. Kozlowski, BS Children’s Memorial Hospital, Northwestern University’s Feinberg School of Medicine, Chicago, IL, USA e-mail: simjag2000@yahoo.com