[Two tracheal tubes inserted for endotracheal tube replacement in a patient with severe obstructive sleep apnea: a...

A 34-year-old obese, small-jawed and short-necked woman, had severe obstructive sleep apnea syndrome (OSAS) with bronchial asthma. A surgical removal of a lingual tumor using a laser knife was scheduled under general anesthesia with sevoflurane. A small diameter tracheal tube for laser surgery (internal diameter (ID) of 5.5 mm) was used. The tube was inserted using bronchofiberscopy under spontaneous respiration. Extubation was designed to be performed when the patient resumed adequate spontaneous respiration and was awake. However, her ventilation deteriorated postoperatively as spontaneous breathing continued (PaO2 98 mmHg, PaCO2 88 mmHg at FIO2 1.0). This seemed to have been induced by worsened patient-ventilator synchrony and increased airway resistance due to the use of a small diameter tube. We decided to replace the tube with the one with larger diameter. An ID 7.5 mm tube was inserted with the use of fiberscope through the opening of the vocal cord while the tube for laser surgery was left in space. After confirming that the two tubes were inserted securely, the tube for laser surgery was withdrawn. The patient's ventilation improved significantly afterwards and the extubation was performed successfully. Our method for replacing a tracheal tube seemed to be effective and safe.