Extraluminal Bougie-Assisted Endotracheal Tube Exchange Performed by Helicopter Emergency Medical Services

The transport of intubated patients is a common but high-risk scenario for air medical transport crews. In the case presented, a physician-nurse HEMS crew responded for the interfacility transfer of a patient with severe angioedema who had undergone awake fiberoptic nasotracheal intubation in the referring emergency department. The endotracheal tube had been damaged, however, and could not be adequately secured for transport. To facilitate tube securement, the crew elected to convert from nasotracheal to orotracheal intubation. Recognizing the high likelihood of anatomic difficulty and to minimize the risk of airway loss, the crew performed an airway exchange by passing a bougie adjacent to the existing endotracheal tube, while using the in situ tube to provide continued ventilation. This case highlights the importance of familiarity with airway exchange procedures and presents a novel technique of extraluminal bougie-assisted endotracheal tube exchange.