Correspondence end of the Jacques catheter (Fig. 1). Lubrication of the catheter and tube is carried out according to personal preference and, when the patient is prepared for intubation, the distal blind end of the Jacques catheter is inserted into the nostril and carefully pushed on until it is thought to be in the oropharynx. Direct laryngoscopy enables the end of the Jacques catheter retrieved by Magill forceps and brought out through the mouth. The endotracheal tube is then gent!? pushed into the nostril and, when it is seen in the pharynx, a tug on the catheter disconnects the catheter from the tube; intubation can then proceed a s normal. This method is not difficult to master; to succeed the junction of the catheter and tube must not be too firm, and as a corollary to this, the Jacques catheter must not be pulled through the nose in the expectation that the tracheal tube will follow. The essence of the technique is t o push the tracheal tube through the nasal passages with its opening covered by the expanded end of the Jacques catheter. The advantages of the method arethe reduction in trauma to the nasal passages, and the guarantee of a tube not contaminated internally by nasal secretions.
91 1
Department of Anaesthesia, A.G. MACKINNON Queen’s Medical Centre, M.J. HARRISON University Hospital and Medical School, Clifton Boulevard, Nottinghani N67 2UH. Ref erences
1. ROWBOTHAM, S. (1920) lntratracheal anaesthesia by
the nasal route for operations on the mouth and lips. British Medical Journal, 2, 590. 2. NOLAN,R.T. (1969) Nasal intubation. Anaesthesia, 24, 447. M. (1970) Nasal intubation. Anaesthesia, 3. KORNER, 25, 144. 4. DINGLEY, A.R. (1943) Nasal intubation: dangers and difficulties from the rhinological aspect. British Medical Journal, 1, 693. 5 . BARNARD, J. (1948) An unusual accident during intubation. Anaesthesia, 3, 126. 6. COFFIN,S. (1950) Tear of pharyngeal mucous membrane during intubation. Anaesthesia, 5, 104. 7 . BROWN, W.M.(1952) Blind intubation. Anaesthesia. 7, 118. R. (1974) A hazard of blind nasal intuba8. BINNING, tion. Anaesthesia, 29, 366.
Prolonged nasotracheal intubation Some patients admitted to intensive care units require prolonged artificial ventilation. Normally this is started via an endotracheal tube. At some stage the question arises as to should the patient have a tracheostomy. The development of early ulceration in the upper airway is a n indication for tracheostomy but some parts of the upper airway are not easily visualised whilst the tube is in situ. Fear of contact ulceration of the larynx frequently leads to the decision for a tracheostomy. We should like t o question whether this fear is wholly justified given the physical inertness and softness of some modern endotracheal tubes, and would cite the following. A 32-year-old man was admitted to the Intensive Care Unit at Sundsvall Hospital with a Guillain Barre syndrome. This had started with weakness in the legs and had progressed upwards so that a week after his first symptom he had dyspnoea. He was intubated transnasally with a No. 8 Shiley endotracheal tube and artificially ventilated. Two days later his paralysis was complete with the development of total bulbar and facial palsy. The cuff of his endotracheal tube was inflated until it was just airtight at peak inspiratory pressure. The cuff was released for 1-2 min two or three times a day and then carefully re-inflated. Nineteen days after admission his disease began to regress but he could not be safely extubated until 32 days after the intubation. When removed the tube was found t o have been remoulded to fit the contours of his airway. At no time was the endotracheal tube
changed and suction catheters to clear his rather copious tracheal secretions had always been easy to pass through the tube. The day after extubation the patient’s upper airway was examined by a n oto-rhino-laryngologist who passed a fibre-optic bronchoscope through the patient’s nose into the trachea. His report was, ‘with the exception of slight oedema and redness over the processes vocalis the vocal cords are rather pale. There is no sign of ulceration anywhere in the airway. The tracheal membrane is intact but there is redness and some secretion within the trachea where the cuff has been.’ The patient made a full recovery and in particular had no after effects from his prolonged intubation. In the early days of prolonged artificial ventilation early tracheostomy was necessary due to the ulceration caused by the chemical irritants in the red rubber tubes then used. With the advent of plastic tubes this period has extended to 1-2 weeks but in part due to their stiffness ulceration still frequently occurs. With the newer softer plastic endotracheal tubes perhaps this period can be extended further. It would be of interest to know of other people’s experience in this matter. The fibre-optic bronchoscope can readily be passed down a n endotracheal tube without significantly disturbing any artificial ventilation and it is a matter of regret that the most widely available plastic endotracheal tubes are too opaque t o visualise the laryngeal and tracheal epithelium with such a
912
Correspondence
bronchoscope. The Shiley tube is transparent for most of its length and it is possible with a fibreoptic bronchoscope to visualise clearly through the plastic the surface of the upper airway. Unfortunately the cuff of this tube is only translucent and hence it is not possible without disturbing the position of the tube to see whether the cuff is inducing physical changes in the tracheal epithelium. Although in the case reported above periodic fibre-optic bronchoscopy was not used to determine how long to leave the endotracheal tube in position it is suggested that this approach could help. Since tracheostomy is not without hazard periodic fibre-optic bronchoscopy through a transparent endotracheal tube to inspect
regularly the whole of the upper airway in contact with the tube could only lead to an improvement in patient care by removing the guess work as to when or even if the patient should have a tracheostomy. Perhaps manufacturers could be persuaded to make endotracheal tubes totally transparent. Sundsvall Sjirkhus, 851 86 Sundsvall, Sweden. University Department of Anaesthetics, Birmingham.
JON GJESSING
P.J. TOMLIN
An attack on tracheostomy Tracheal intubation cannot be avoided in prolonged mechanical ventilation for the intensive care patient, but is it not time the pendulum swung away from tracheostomy in these cases, except for special situations? Whilst both the laryngeal and direct tracheal routes have their own advantages and disadvantages, and certainly neither is ideal, the avoidance of unnecessary infection is surely a paramount goal in the gravely ill, and it has rightly led to the current trend towards non-invasive techniques. Bacterial contamination of the tracheostomy wound is almost unavoidable, and whilst this does not necessarily lead to infection, there is always the risk of this, and the sicker the patient the greater the danger. Normally harmless organisms may be lethal in such patients. The soggy lungs of the adult respiratory distress syndrome are a perfect medium for such bacteria and we know that the grave lesions and mortality of this condition are aggravated by sepsis.'-3 Improvements in cuff design may have reduced the risk of lung infection from inhalation of infected material or secretions4 but the risk remains, and it is aggravated by tracheost~my.~.~ Whilst the specific complications of prolonged endotracheal intubation cannot be ignored, the price of avoiding them by tracheostomy may therefore be too high in the gravely ill. Moreover children and babies, with far smaller airways, are satisfactorily managed without tracheostomy in many centres, in one remarkable case for over three years.' Tracheostomy has another major hazard, namely, the risk of haemorrhage, besides the aggravated risk of later stenosis. How many deaths can be directly attributed to endotracheal intubation, and how lethal is cord ulceration ? Does the admittedly easier tracheal toilet with a tracheostomy certainly reduce the net incidence and gravity of pulmonary complications, including sepsis, despite the above evidence? Can we really be sure that tracheostomy, despite its major disadvantages, has more to offer, or
a t least is no more harmful to the sick ventilator patient than endotracheal intubation? T o adapt a currently popular expression, I suggest that on present evidence such a patient needs a hole in his neck like he needs a hole in the head-only when there is also extensive injury to these areas! Whilst the role of high frequency positive pressure ventilation (HFPPV) in the intensive care patient has yet to be fully explored,* it seems possible that its use in combination with very narrow endotracheal tubes might eventually lead to a technique of management which greatly reduces cord damage and the need for tracheostomy. National Heart Hospital, Westmoreland Street, London W I M BBA.
ALANGILSTON
References I . WALKER,L. & EISEMAN, B. (1975) The changing
pattern of post-traumatic respiratory distress syndrome. Annals of Surgery, 181, 693. 2. COLLINS, JA. (1977) The acute respiratory distress syndrome. Adcances in Surgery, 11, 171. 3 . WILSON, R.F.& SIBBALD, W.J. (1976)Acute respiratory failure. Critical Care Medicine, 4, 79. 4. SPRAY,S.D.,ZUIDEMA, G.D. &CAMERON, J.L.(1976) Aspiration pneumonia: incidence of aspiration with endotracheal tubes. American Journal of Surgery, 131, 700. 5. EL NAGGAR, M.,SADAGOPAN, S. e t a l . (1976)Factors influencing choice between tracheostomy and prolonged nasolaryngeal intubation in acute respiratory failure: a prospective study. Anaesthesia and Analgesia: Current Researches, 55, 195. 6. POLK,H.C. (1975)Quantitative tracheal cultures in surgical patients requiring mechanical ventilatory assistance. Surgery, 18, 455. 7. ZELT,B.A.&LOSSASO, A.M. (1972)Prolonged nastrotracheal intubation and mechanical ventilation in the management of asphyxiating thoracic dystrophy: a
91 1
Department of Anaesthesia, A.G. MACKINNON Queen’s Medical Centre, M.J. HARRISON University Hospital and Medical School, Clifton Boulevard, Nottinghani N67 2UH. Ref erences
1. ROWBOTHAM, S. (1920) lntratracheal anaesthesia by
the nasal route for operations on the mouth and lips. British Medical Journal, 2, 590. 2. NOLAN,R.T. (1969) Nasal intubation. Anaesthesia, 24, 447. M. (1970) Nasal intubation. Anaesthesia, 3. KORNER, 25, 144. 4. DINGLEY, A.R. (1943) Nasal intubation: dangers and difficulties from the rhinological aspect. British Medical Journal, 1, 693. 5 . BARNARD, J. (1948) An unusual accident during intubation. Anaesthesia, 3, 126. 6. COFFIN,S. (1950) Tear of pharyngeal mucous membrane during intubation. Anaesthesia, 5, 104. 7 . BROWN, W.M.(1952) Blind intubation. Anaesthesia. 7, 118. R. (1974) A hazard of blind nasal intuba8. BINNING, tion. Anaesthesia, 29, 366.
Prolonged nasotracheal intubation Some patients admitted to intensive care units require prolonged artificial ventilation. Normally this is started via an endotracheal tube. At some stage the question arises as to should the patient have a tracheostomy. The development of early ulceration in the upper airway is a n indication for tracheostomy but some parts of the upper airway are not easily visualised whilst the tube is in situ. Fear of contact ulceration of the larynx frequently leads to the decision for a tracheostomy. We should like t o question whether this fear is wholly justified given the physical inertness and softness of some modern endotracheal tubes, and would cite the following. A 32-year-old man was admitted to the Intensive Care Unit at Sundsvall Hospital with a Guillain Barre syndrome. This had started with weakness in the legs and had progressed upwards so that a week after his first symptom he had dyspnoea. He was intubated transnasally with a No. 8 Shiley endotracheal tube and artificially ventilated. Two days later his paralysis was complete with the development of total bulbar and facial palsy. The cuff of his endotracheal tube was inflated until it was just airtight at peak inspiratory pressure. The cuff was released for 1-2 min two or three times a day and then carefully re-inflated. Nineteen days after admission his disease began to regress but he could not be safely extubated until 32 days after the intubation. When removed the tube was found t o have been remoulded to fit the contours of his airway. At no time was the endotracheal tube
changed and suction catheters to clear his rather copious tracheal secretions had always been easy to pass through the tube. The day after extubation the patient’s upper airway was examined by a n oto-rhino-laryngologist who passed a fibre-optic bronchoscope through the patient’s nose into the trachea. His report was, ‘with the exception of slight oedema and redness over the processes vocalis the vocal cords are rather pale. There is no sign of ulceration anywhere in the airway. The tracheal membrane is intact but there is redness and some secretion within the trachea where the cuff has been.’ The patient made a full recovery and in particular had no after effects from his prolonged intubation. In the early days of prolonged artificial ventilation early tracheostomy was necessary due to the ulceration caused by the chemical irritants in the red rubber tubes then used. With the advent of plastic tubes this period has extended to 1-2 weeks but in part due to their stiffness ulceration still frequently occurs. With the newer softer plastic endotracheal tubes perhaps this period can be extended further. It would be of interest to know of other people’s experience in this matter. The fibre-optic bronchoscope can readily be passed down a n endotracheal tube without significantly disturbing any artificial ventilation and it is a matter of regret that the most widely available plastic endotracheal tubes are too opaque t o visualise the laryngeal and tracheal epithelium with such a
912
Correspondence
bronchoscope. The Shiley tube is transparent for most of its length and it is possible with a fibreoptic bronchoscope to visualise clearly through the plastic the surface of the upper airway. Unfortunately the cuff of this tube is only translucent and hence it is not possible without disturbing the position of the tube to see whether the cuff is inducing physical changes in the tracheal epithelium. Although in the case reported above periodic fibre-optic bronchoscopy was not used to determine how long to leave the endotracheal tube in position it is suggested that this approach could help. Since tracheostomy is not without hazard periodic fibre-optic bronchoscopy through a transparent endotracheal tube to inspect
regularly the whole of the upper airway in contact with the tube could only lead to an improvement in patient care by removing the guess work as to when or even if the patient should have a tracheostomy. Perhaps manufacturers could be persuaded to make endotracheal tubes totally transparent. Sundsvall Sjirkhus, 851 86 Sundsvall, Sweden. University Department of Anaesthetics, Birmingham.
JON GJESSING
P.J. TOMLIN
An attack on tracheostomy Tracheal intubation cannot be avoided in prolonged mechanical ventilation for the intensive care patient, but is it not time the pendulum swung away from tracheostomy in these cases, except for special situations? Whilst both the laryngeal and direct tracheal routes have their own advantages and disadvantages, and certainly neither is ideal, the avoidance of unnecessary infection is surely a paramount goal in the gravely ill, and it has rightly led to the current trend towards non-invasive techniques. Bacterial contamination of the tracheostomy wound is almost unavoidable, and whilst this does not necessarily lead to infection, there is always the risk of this, and the sicker the patient the greater the danger. Normally harmless organisms may be lethal in such patients. The soggy lungs of the adult respiratory distress syndrome are a perfect medium for such bacteria and we know that the grave lesions and mortality of this condition are aggravated by sepsis.'-3 Improvements in cuff design may have reduced the risk of lung infection from inhalation of infected material or secretions4 but the risk remains, and it is aggravated by tracheost~my.~.~ Whilst the specific complications of prolonged endotracheal intubation cannot be ignored, the price of avoiding them by tracheostomy may therefore be too high in the gravely ill. Moreover children and babies, with far smaller airways, are satisfactorily managed without tracheostomy in many centres, in one remarkable case for over three years.' Tracheostomy has another major hazard, namely, the risk of haemorrhage, besides the aggravated risk of later stenosis. How many deaths can be directly attributed to endotracheal intubation, and how lethal is cord ulceration ? Does the admittedly easier tracheal toilet with a tracheostomy certainly reduce the net incidence and gravity of pulmonary complications, including sepsis, despite the above evidence? Can we really be sure that tracheostomy, despite its major disadvantages, has more to offer, or
a t least is no more harmful to the sick ventilator patient than endotracheal intubation? T o adapt a currently popular expression, I suggest that on present evidence such a patient needs a hole in his neck like he needs a hole in the head-only when there is also extensive injury to these areas! Whilst the role of high frequency positive pressure ventilation (HFPPV) in the intensive care patient has yet to be fully explored,* it seems possible that its use in combination with very narrow endotracheal tubes might eventually lead to a technique of management which greatly reduces cord damage and the need for tracheostomy. National Heart Hospital, Westmoreland Street, London W I M BBA.
ALANGILSTON
References I . WALKER,L. & EISEMAN, B. (1975) The changing
pattern of post-traumatic respiratory distress syndrome. Annals of Surgery, 181, 693. 2. COLLINS, JA. (1977) The acute respiratory distress syndrome. Adcances in Surgery, 11, 171. 3 . WILSON, R.F.& SIBBALD, W.J. (1976)Acute respiratory failure. Critical Care Medicine, 4, 79. 4. SPRAY,S.D.,ZUIDEMA, G.D. &CAMERON, J.L.(1976) Aspiration pneumonia: incidence of aspiration with endotracheal tubes. American Journal of Surgery, 131, 700. 5. EL NAGGAR, M.,SADAGOPAN, S. e t a l . (1976)Factors influencing choice between tracheostomy and prolonged nasolaryngeal intubation in acute respiratory failure: a prospective study. Anaesthesia and Analgesia: Current Researches, 55, 195. 6. POLK,H.C. (1975)Quantitative tracheal cultures in surgical patients requiring mechanical ventilatory assistance. Surgery, 18, 455. 7. ZELT,B.A.&LOSSASO, A.M. (1972)Prolonged nastrotracheal intubation and mechanical ventilation in the management of asphyxiating thoracic dystrophy: a
