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Airway Exchange Failure and Complications with the Use of the Cook Airway Exchange Catheter®

A Single Center Cohort Study of 1177 Patients

McLean, Sheron, MD; Lanam, Carolyn R., BS; Benedict, Wendy, BS; Kirkpatrick, Nathan, BS; Kheterpal, Sachin, MD, MB; Ramachandran, Satya Krishna, MD, FRCA

doi: 10.1213/ANE.0b013e3182a7cd3d
Technology, Computing, and Simulation: Brief Report
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There are limited data on rates of failure and airway injury with the use of airway exchange catheters. We performed a single-center retrospective analysis of airway exchange catheters to determine the incidence and associated factors for tube exchange failure and airway injury. Among 1177 cases, failed intubation during attempted tube exchange was noted in 73/527 (13.8%). Airway exchange failure rates were greatest during exchange catheter use for double-lumen tube insertion and when intubation was attempted over the catheter postoperatively. Pneumothorax was noted after 1.5% of attempted tube exchanges. Difficult tube exchange was encountered in 6 of 8 patients with pneumothorax.

From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan.

Funding: Carolyn R. Lanam was funded through the Student Biomedical Research program of the University of Michigan.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Satya Krishna Ramachandran, MD, FRCA, Department of Anesthesiology, University of Michigan, 1H247 UH, SPC 5048 1500 E Medical Ctr Dr., Ann Arbor, MI 48109-5048. Address e-mail to rsatyak@med.umich.edu.

The introduction of the American Society of Anesthesiologists’ guidelines for difficult airway management was associated with a significant decrease in airway-related claims concerning the induction of anesthesia, but extubation and postoperative airway-related claims did not change.1 In 2012, The Difficult Airway Society released extubation guidelines in which a strategic stepwise approach to extubation was recommended, with a clear emphasis on the use of an airway exchange catheter (AEC)-assisted tracheal extubation in the high risk patient.2 The AEC maintains a conduit with the trachea after extubation to facilitate airway rescue and may also be used for insufflation of oxygen and jet ventilation. In a prospective study of 40 pediatric patients, the risk of airway trauma was found to be low.3 A larger, prospective study of 354 adult patients over a 9-year period confirmed the efficacy of the AEC, with significantly improved reintubation success rates and reduced complications associated with reintubation.4 However, this study included only 53 reintubation events with 4 failures (7.5% failure rate). Both of these studies had inadequate sample size to detect infrequent adverse events. Other studies and case reports have reported barotrauma associated with oxygen insufflation and jet ventilation through an AEC5–8; however, data on failure rates and airway injury related to the use of the AEC are limited to small single-center series and an era before videolaryngoscopy. In this report, we will characterize the failure of tracheal tube exchange with use of the Cook Airway Exchange Catheter® (CAEC®, Cook Medical Inc., Bloomington, IN) at our tertiary care, high volume institution, and describe the complications associated with its use. The goal of the analysis was to describe event characteristics related to CAEC failure and determine whether airway injuries were more likely to occur in cases of AEC failure.

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METHODS

This single-center cohort study had approval from the IRB (University of Michigan, Ann Arbor, MI). Signed patient consent was waived due to the retrospective nature of the analysis. Relevant perioperative data are documented routinely by anesthesiology providers in the electronic health record (EHR) (Centricity; General Electric Healthcare, Waukesha, WI). Predefined pick lists and “free text” are used by clinicians to enter patient information. Each adverse event is reviewed by a member of the department’s Quality Assurance Committee. Data on reported injuries are confirmed by direct communications with the caregivers and by review of the medical records. From this prospectively populated EHR and quality assurance database, a search query was performed to obtain all relevant data for this study. Inclusion criteria were adult (≥18 year old) patients undergoing general anesthesia in which a CAEC was used during intubation, for tube exchange, or as an extubation aide from June 2006 to October 2012. The primary outcome of the study was the presence of CAEC failure, defined as the inability to complete tracheal tube exchange as intended. The secondary outcome was airway injury, defined as a disruption of tissue in the airway including minor (dental injury, lip trauma, and airway edema) and pneumothorax.

The EHR intraoperative record database was queried for all terms that relate to use of CAEC: “cook cath,” “cook airway,” “caec,” “cook,” “airway exchange,” “exchange cath,” “tube exchange,” “tube changer,” and “ETT exchange.” For each case identified by these broad search criteria, a 3-person (WB, CRL, SKR) review of the EHR was performed to collect the data elements in Table 1. Adjusted Wald method was used to calculate 95% confidence intervals (CIs) for the point estimates. Patients with and without CAEC failure were compared on airway management and injury rates. Data analysis was performed on SPSS® version 19 (SPSS Inc., Chicago, IL) using Pearson χ2 test (with Yates correction if the count on any of the cells was <5). Significance was set at P < 0.05.

Table 1

Table 1

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RESULTS

Of 1177 uses, the CAEC was used for tube exchange in 527 patients and as part of the extubation plan in the remaining patients (Fig. 1). The overall failure rate for tracheal tube exchange using a CAEC was 13.8% (73/527; 95% CIs, 11.2%–17.1%). When used for tube exchange, the airway injury rate was 7.8% (41/527; 95% CIs, 5.7%–10.4%) with 1.5% rate of pneumothorax verified by chest radiography (8/527; 95% CIs, 0.7%–3.0%). Failure of tube exchange was noted in 2 of 9 cases where postoperative emergent intubation was attempted over the CAEC that was left in situ after tracheal extubation.

Figure 1

Figure 1

During the study period, there were 126,162 placements of single-lumen tubes (SLT) with 0.25% CAEC use and 3496 placements of double-lumen tubes (DLT) with 6.0% CAEC use. The failure rates of tube exchange were 9.3% (30/319) for SLT to SLT exchange, 39.9% (43/110) for exchange of SLT to DLT, and 0% (0/98) for DLT to SLT (P < 0.001). There was no instance of complete airway loss. CAEC failures were managed with reintubation with the original tube or removal of the CAEC and tracheal intubation using alternate airway equipment (direct laryngoscopy or flexible or rigid videolaryngoscopy).

In 6 of the 8 patients with pneumothorax, significant difficulty was noted with either primary intubation or subsequent tube exchange, needing multiple attempts (Table 1). Failed tube exchange may not be associated with pneumothorax (4.1% [3/73] vs 1.1% [5/462]; P = 0.114), or minor airway injury (8.2% [6/73] vs 4.2% [19/454]; P = 0.132) when compared with successful exchange. There were 2 cases with missing data, so no specific missing data analyses were performed.

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CONCLUSIONS

The CAEC may be used to mitigate risk in patients with difficult airways, but there are significant risks of failure and associated airway injury with its use. Use of the CAEC for insertion of a DLT is associated with greater risk of failure to achieve tube exchange. Difficult tube exchange may be associated with greater risk of airway injury. The risk of pneumothorax with a failed tube exchange was surprisingly high. There may be a high failure rate when emergent reintubation is attempted over a CAEC that is left in situ after extubation. The limitations of this study include biases from the single-center design and retrospective nature of the analysis. Underreporting of both CAEC use and complications could have influenced the point estimates. There is also a need to evaluate multicenter data to understand variances in center-specific rates of failure or injury. In this study, the exact mechanisms of failure were unknown but have been described previously.4 Inadequate data on the size of the CAEC used limits any further evaluation of size versus failure or injury. Despite these limitations, this study provides valuable new insight into the risks of using CAEC devices.

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DISCLOSURES

Name: Sheron McLean, MD.

Contribution: This author helped design and conduct the study, analyze the data, and write the manuscript.

Attestation: Sheron McLean has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is the author responsible for archiving the study files.

Name: Carolyn R. Lanam, BS.

Contribution: This author helped design and conduct the study, analyze the data, and write the manuscript.

Attestation: Carolyn R Lanam has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

Name: Wendy Benedict, BS.

Contribution: This author helped conduct the study and analyze the data.

Attestation: Wendy Benedict has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

Name: Nathan Kirkpatrick, BS.

Contribution: This author helped conduct the study and write the manuscript.

Attestation: Nathan Kirkpatrick has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

Name: Sachin Kheterpal, MD, MBA.

Contribution: This author helped design and conduct the study and write the manuscript.

Attestation: Sachin Kheterpal has reviewed the analysis of the data and approved the final manuscript.

Name: Satya Krishna Ramachandran, MD, FRCA.

Contribution: This author helped design and conduct the study, analyze the data, and write the manuscript.

Attestation: Satya Krishna Ramachandran has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

This manuscript was handled by: Maxime Cannesson, MD, PhD.

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REFERENCES

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