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Correspondence  |   May 2006
Unforeseen Esophageal Misplacement of Airway Exchange Catheter Leading to Gastric Perforation
Author Affiliations & Notes
  • Michael Reay, M.D., F.R.C.A.
    *
  • *University Hospital of Michigan, Ann Arbor, Michigan.
Article Information
Correspondence
Correspondence   |   May 2006
Unforeseen Esophageal Misplacement of Airway Exchange Catheter Leading to Gastric Perforation
Anesthesiology 5 2006, Vol.104, 1111-1112. doi:
Anesthesiology 5 2006, Vol.104, 1111-1112. doi:
To the Editor:—
We would like to highlight a case of gastric perforation secondary to the misplacement of an airway exchange catheter (AEC).
An AEC was used as a bridge to full extubation in a patient with a known difficult airway secondary to external radiation to the face for an orbital basal cell carcinoma. Uneventful general anesthesia proceeded with an awake fiberoptic intubation using a 7.0-mm single-lumen endotracheal tube. Placement position was verified by visualizing the carina and secured at 22 cm to the lip. Once fully awake with intact neuromuscular function, the patient was underwent extubation over a 14.0-size Cook AEC (Cook Critical Care, Bloomington, IN) secured with tape at 35 cm at the lips to allow a margin of safety from accidental dislodgment. The patient’s vitals were stable throughout emergence and extubation. Oxygen, 2 l/min, was insufflated through the Cook AEC via  a Luer connector for transfer to postanesthesia care unit. The patient was noticed to have an occasional belch during transfer. On arrival, oxygen through the Cook AEC was discontinued, and he was placed on oxygen via  facemask. The plan was to leave the AEC in place until it was certain that no residual anesthetic was present and the need for reintubation was unlikely.
During his stay in the postanesthesia care unit, the patient was switched from facemask to oxygen through AEC; the reason for this is unclear. Unfortunately, the flow rate of oxygen insufflation at that time was not known. Approximately 1 h into his stay in the postanesthesia care unit, the patient reported pain disproportionate to his surgery. On physical examination, the patient’s abdomen was noted to be remarkably distended, associated with belching. Oxygen through the AEC was discontinued. Portable chest (fig. 1) and abdominal (fig. 2) radiographs were ordered, illustrating free air under the diaphragm and massive gastric distention. A surgical consult highlighted the need for emergent surgery for probable gastric perforation. The patient was scheduled to undergo an emergent laparoscopy. On repeat fiberoptic intubation for the subsequent surgery, the AEC was noted to be in the esophagus. Diagnostic laparoscopy revealed a small perforation on the lesser curvature of the stomach consistent with gastric overdistension, which was subsequently repaired laparoscopically. Whether the perforation was caused directly by the device or gastric distension from oxygen insufflation is unknown. The patient subsequently made a full recovery and was discharged from hospital a week later.
Fig. 1. Chest radiograph demonstrating gas under the diaphragm. Note the Cook catheter within the insufflated esophagus which appears to lie within the trachea. 
Fig. 1. Chest radiograph demonstrating gas under the diaphragm. Note the Cook catheter within the insufflated esophagus which appears to lie within the trachea. 
Fig. 1. Chest radiograph demonstrating gas under the diaphragm. Note the Cook catheter within the insufflated esophagus which appears to lie within the trachea. 
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Fig. 2. Abdominal radiograph demonstrating gastric distension from oxygen insufflation. 
Fig. 2. Abdominal radiograph demonstrating gastric distension from oxygen insufflation. 
Fig. 2. Abdominal radiograph demonstrating gastric distension from oxygen insufflation. 
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The literature suggests four potential risks associated with the use of AECs: misplacement, bronchial or lung trauma, laryngeal trauma, and barotrauma related to jet ventilation.1,2 This incident illustrates the consequence of unforeseen AEC misplacement. The key issues leading to this complication were as follows: (1) failure to confirm endotracheal placement highlighting the necessity of end-tidal carbon dioxide monitoring (end-tidal monitoring can be facilitated through the Luer lock mechanism provided with the Cook AEC kit; a lateral chest radiograph may be of some benefit to confirm placement; however, the practicality of this investigation could be debated); (2) belching as an early sign of esophageal placement; (3) the questionable benefit of oxygen insufflation through an AEC (apart from its role as a means for jet ventilation) in a patient able to saturate adequately via  facemask; and (4) ensuring appropriate length of placement (in this case, the AEC was inserted too far; the literature recommends 22–25 cm for oral placement and 27–30 cm for nasal placement).1 
In summary, we believe that an AEC should be treated as an endotracheal tube, and its placement should never be assumed to be correct until objective data support that conclusion.
*University Hospital of Michigan, Ann Arbor, Michigan.
References
Loudermilk EP, Hartmannsgruber M, Stoltzfus DP, Langevin PB: A prospective study of the safety of tracheal extubation using a pediatric airway exchange catheter for patients with a known difficult airway. Chest 1997; 111:1660–5Loudermilk, EP Hartmannsgruber, M Stoltzfus, DP Langevin, PB
Eisenach JH, Barnes RD: Potential disaster in airway management: A misguided airway exchange catheter via  a hole bitten into a Univent endotracheal tube. Anesthesiology 2002; 96:1266–8Eisenach, JH Barnes, RD
Fig. 1. Chest radiograph demonstrating gas under the diaphragm. Note the Cook catheter within the insufflated esophagus which appears to lie within the trachea. 
Fig. 1. Chest radiograph demonstrating gas under the diaphragm. Note the Cook catheter within the insufflated esophagus which appears to lie within the trachea. 
Fig. 1. Chest radiograph demonstrating gas under the diaphragm. Note the Cook catheter within the insufflated esophagus which appears to lie within the trachea. 
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Fig. 2. Abdominal radiograph demonstrating gastric distension from oxygen insufflation. 
Fig. 2. Abdominal radiograph demonstrating gastric distension from oxygen insufflation. 
Fig. 2. Abdominal radiograph demonstrating gastric distension from oxygen insufflation. 
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