Minimizing trauma of feeding tube exchange in patients with bleeding diathesis

SIR—The airway endoscopy mask is a special mask used in uncooperative patients during airway endoscopy and difficult intubation, particularly in patients needing deep sedation, high FiO2, positive endexpiratory pressure (PEEP), or positive pressure ventilation. We describe in this letter a technique to make a similar mask out of widely available airway devices. We use an airway mask (Air Cushion Mask with Valve; Hudson RCI, Temecula, CA, USA), a Swivel Y (Bodai suction safe TM Swivel Y; Sontek Medical, Inc., Hingham, MA, USA), and an airway intubator (Williams Airway Intubator; Sun-Med, Inc., Clearwater, FL, USA). The swivel consists of a removable rubber cover (with a 3–4-mm slit) fitting tightly on Y-shaped tubing. This slit allows the fiberscope (Olympus LF-GP; Olympus America Inc., Melville, NY) to pass through the swivel (see Figure 1). The cover is removed in advance and cut vertically on one side, then is replaced on the Y-tubing tightly. The swivel is connected to the mask on one side and to the breathing circuit on the other side. Sufficient ventilation can be used with acceptable airway resistance and no or minimal air leaking through the rubber cover. The tracheal tube (TT) (size no. 7 or smaller) adapter is removed (cutting the adult TT 3–4 cm at its distal part gives the scope more depth in the trachea). The TT is fed over the scope after lubrication. The scope port passes through the rubber cover, the mask and then via the airway intubator. The total length of this set-up ranges from 50 to 60 cm (the TT without the adapter + the mask and the swivel combination + the distance from the teeth to the midtrachea). The length of the working part of the scope is almost 61 cm, which means the tip of the scope will reach easily the midtrachea. When the scope is confirmed in the trachea, the rubber cover is removed by a surgical clamp. The TT and the scope slide together through this set-up towards the trachea for 2–3 cm (to make sure the depth of the scope is adequate in the trachea). Then the TT is pushed smoothly into the trachea. A size-7 tube passes this set-up with little difficulty; smaller tubes pass much more easily. This technique can be used in awake and anesthetized patients. It eliminates the need for a special mask (the endoscopy mask), which is not available in many institutions and more expensive than our set-up. Ahmad Elsharydah Randall C. Cork Department of Anesthesia, Louisiana State University Health Sciences Center, 1501 Kings Highway, Shreveport, LA 71130, USA (email: aelsha@lsuhsc.edu)