Wire-guided catheter exchange after failed direct laryngoscopy in critically ill adults

To describe a technique for tracheal intubation after failed direct laryngoscopy using a Laryngeal Mask Airway (LMA) to secure the airway and to establish ventilation, and as a conduit for fiberoptic intubation utilizing a pre-packaged, convenient, and commercially available wire-guided catheter exchange kit.

Retrospective case series.

University hospital.

The cases of 5 critically ill adult patients who required intubation for respiratory failure, and in whom direct laryngoscopy was unsuccessful and unanticipated, were reviewed. Difficult intubation was defined as > or = two attempts by direct laryngoscopy and use of an airway adjunct/alternate airway device, or > or = three attempts by direct laryngoscopy. Occurrence of hypotension, hypoxemia, and the time required to accomplish the intubation were recorded.

Patients' tracheas were intubated in the emergency department (n = 2), the intensive care unit (n = 2), and the radiology department (n = 1). An Eschmann endotracheal tube (ETT) introducer was used in 4 of the 5 patients, and a GlideScope was used in the fifth patient. After failed direct laryngoscopy, an LMA Classic was inserted to gain an airway, after which a fiberoptic bronchoscope and wire-guided catheter exchange set was used to change the LMA to a conventional ETT. Ventilation was maintained via the LMA with an attached bronchoscope adapter throughout the procedure.

In all 5 patients, the trachea was successfully intubated within three minutes on the first attempt, using a wire-guided exchange, without hypoxemia or hypotension.