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DOI: 10.1055/s-0040-1710702
Bougie through Murphy’s Eye During Airway Exchange: A Near Miss
Abstract
Endotracheal tube (ETT) exchange is a common procedure performed in the operating room and intensive care unit for the purpose of changing damaged or soiled ETT with appropriate one. The exchange procedure is performed over an airway exchange catheter or ETT introducer (bougie). We report an event during ETT exchange over bougie wherein the introducer exited through Murphy’s eye. Here, we intend to re-emphasize the safety concerns pertaining to the use of bougie (with coude tip) as airway exchange conduit and enumerate the precautions to be taken during tube exchange.
Publication History
Article published online:
07 June 2020
© 2020. Indian Society of Neuroanaesthesiology and Critical Care. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).
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References
- 1 Hodzovic I, Wilkes AR, Latto IP. To shape or not to shape—simulated bougie-assisted difficult intubation in a manikin. Anaesthesia 2003; 58 (08) 792-797
- 2 Umesh G, Sushma KS, Sindhupriya M, Swarnamba UN. Gum elastic bougie as a tube exchanger: modified technique. Indian J Anaesth 2015; 59 (12) 827-829
- 3 Nekhendzy V, Simmonds PK. Rigid bronchoscope-assisted endotracheal intubation: yet another use of the gum elastic bougie. Anesth Analg 2004; 98 (02) 545-547
- 4 Nichols KP, Zornow MH. A potential complication of fiberoptic intubation. Anesthesiology 1989; 70 (03) 562-563
- 5 Kubota Y, Toyoda Y, Kubota H. A potential complication associated with a tracheal tube with a Murphy eye. Anaesthesia 1989; 44 (10) 866-867
- 6 Eisenach JHMD, Barnes RDMD. Potential disaster in airway management: a misguided airway exchange catheter via a hole bitten into a univent endotracheal tube. Anesthesiology 2002; 96 (05) 1266-1268
- 7 Kumar KR, Batra RK, Dhir R, Sharma SC. Inadvertent pneumothorax caused by intubating bougie. J Anaesthesiol Clin Pharmacol 2015; 31 (02) 271-272
- 8 Sahin M, Anglade D, Buchberger M, Jankowski A, Albaladejo P, Ferretti GR. Case reports: iatrogenic bronchial rupture following the use of endotracheal tube introducers. Can J Anaesth 2012; 59 (10) 963-967
- 9 Kadry M, Popat M. Pharyngeal wall perforation—an unusual complication of blind intubation with a gum elastic bougie. Anaesthesia 1999; 54 (04) 404-405
- 10 El-Orbany M, Salem MR. The Eschmann tracheal tube introducer is not an airway exchange device. Anesth Analg 2004; 99 (04) 1269-1270
- 11 de Almeida JP, Hajjar LA, Fukushima JT, Nakamura RE, Albertini R, Galas FR. Bronchial injury and pneumothorax after reintubation using an airway exchange catheter. Braz J Anesthesiol 2013; 63 107-109
- 12 Harris K, Chalhoub M, Maroun R, Elsayegh D. Endotracheal tube exchangers: should we look for safer alternatives?. Heart Lung 2012; 41 (01) 67-69
- 13 Nates JL, Berner DK. Mishaps with endotracheal tube exchangers in ICU: two case reports and review of the literature. The Internet J Emerg Intens Care Med 2000; 5 (01) 1-5
- 14 Benumof JL. Airway exchange catheters: simple concept, potentially great danger. Anesthesiology 1999; 91 (02) 342-344
- 15 Udomtecha D. Airway tube exchanger techniques in morbidly obese patients. Anesthesiol Res Pract 2012; 2012: 968642
- 16 Leeson S. The highlight technique: airway exchange catheters with a colored marking may improve safety of airway management. Anesth Analg 2011; 112 (02) 481
- 17 Ayoub CM, Lteif AM, Rizk MS, Abu-Jalad NM, Hadi U, Baraka AS. Facilitation of passing the endotracheal tube over the flexible fiberoptic bronchoscope using a Cook airway exchange catheter. Anesthesiology 2002; 96 (06) 1517-1518