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LETTERS TO EDITOR
Year : 2020  |  Volume : 21  |  Issue : 2  |  Page : 157-158
 

A unique use of endotracheal tube as a cuffed nasopharyngeal airway as an interface for noninvasive ventilation during weaning from mechanical ventilator


Department of Anaesthesiology and ICU, Goa Medical College, Bambolim, Goa, India

Date of Submission04-May-2020
Date of Acceptance05-Jun-2020
Date of Web Publication19-Sep-2020

Correspondence Address:
Dr. Nimisha Mahesh Parkar
House No. 1136, Tukaram Krupa, Kamaxi Temple Road, Thal, Shiroda - 403 103, Goa
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_51_20

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How to cite this article:
Kamble D, Parkar NM, Pandey S. A unique use of endotracheal tube as a cuffed nasopharyngeal airway as an interface for noninvasive ventilation during weaning from mechanical ventilator. Indian Anaesth Forum 2020;21:157-8

How to cite this URL:
Kamble D, Parkar NM, Pandey S. A unique use of endotracheal tube as a cuffed nasopharyngeal airway as an interface for noninvasive ventilation during weaning from mechanical ventilator. Indian Anaesth Forum [serial online] 2020 [cited 2020 Oct 30];21:157-8. Available from: http://www.theiaforum.org/text.asp?2020/21/2/157/295384




Sir,

The utility of noninvasive ventilation (NIV) following extubation of invasively ventilated patients in intensive care unit (ICU) is often hindered due to patient compliance issues.[1] The most common NIV interface being oronasal mask; its ill-fit, tightness of straps, associated claustrophobia, and excessive leakage demand repeated adjustments for effective application.[2] Facial soft-tissue trauma and nasal bridge necrosis[3] are undesired consequences of prolonged NIV usage further reducing patient cooperation.

To address these issues in our setup with resource limitation and economic constraints, we developed a unique NIV interface derived from cuffed endotracheal tube and effectively delivered NIV postextubation to an elderly diabetic female in ICU, postlaparotomy following peritonitis. Although decision to extubate was taken after ensuring satisfactory hemodynamic parameters, afebrile status, a successful spontaneous breathing trial for 2 h on pressure support (PS) ventilation (PS: 5 cm H2O, PEEP: 5 cm H2O, FIO2: 0.4), PaO2/FIO2 ratio of 380, Rapid Shallow Breathing Index 73.6 and SpO294%, we anticipated extubation failure in view of patient's age, obesity, suboptimal glycemic control, and marginally elevated intra-abdominal drain output. At the same time, we intended to curtail the number of days on invasive mechanical ventilation and prevent re-intubation. The design of interface ascertained to avoid uncooperativeness, aerophagia, intra-abdominal hypertension, and consequent wound dehiscence. Hence, extubation to NIV was planned, to serve as a back-up in case of a likely respiratory failure following extubation.

Cuffed endotracheal tube no. 7.5 was cut smoothly at 20 cm mark, with cuff and inflation tubing with pilot balloon preserved, and 15 mm universal connector placed at the proximal end. The device served as a cuffed nasopharyngeal airway [Figure 1]. Following patient's consent, Xylometazoline drops were instilled in each nostril, and the above airway lubricated with 2% lignocaine jelly, was inserted atraumatically in the patient's right nostril and fixed at 12 cm, length of which corresponded with that measured from alae nasii to tragus, and cuff was inflated. It was further connected using ventilatory circuit to VELA™ Ventilator with active humidification on noninvasive positive pressure ventilation/continuous positive airway pressure (CPAP) mode with PEEP 5 cm H2O, PS 8 cm H2O, and FiO2 of 0.4. Patient's oxygenation-ventilation status and hemodynamics parameters were monitored, which remained satisfactory over the next 48 h on NIV.
Figure 1: Cuffed nasopharyngeal airway as an interface to deliver noninvasive ventilation

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The modified cuffed nasopharyngeal airway can be proposed as an alternative NIV interface providing better compliance, eliminating strap tightness, preventing nasal bridge necrosis,[3] and facial bruising. The patient retains ability to vocalize, cough and expectorate with the device in situ. Aerosolized bronchodilator can be delivered using nebulizer connected to the circuit. Inflation of cuff enables steadiness and better fixation of the position in the nasopharynx.

By means of connection to ventilator, delivered CPAP improves oxygenation and titrated pressure support helps in generating desired tidal volume and minute ventilation.

We suggest its utility to provide NIV in instances of ill-fitting oronasal masks, in individuals with craniofacial abnormalities, in pediatric population and in obstructive sleep apnea.

On disconnecting from ventilator, one can connect T-piece with nebulization chamber and oxygen source which serves as low flow, variable performance oxygen delivery device, with lower apparatus dead space than facemask.

However, the disadvantages of this interface include increased resistance to spontaneous respiration, lumen occlusion with mucus plugs, nasal irritation, and traumatic insertion, mucosal erosion, and bleeding. Major source of leakage in this apparatus is through the patient's mouth; hence, it can be proposed to use facemask concurrently.

Cuffed nasopharyngeal airway has previously been used in difficult intubation cases in order to maintain anaesthesia and as a landmark to guide fiberoptic laryngoscopy.[4]

Hence, we suggest the usage of cuffed endotracheal tube of desired internal diameter and modified length to suit as cuffed naso pharyngeal airway, as a simple, inexpensive, and safe alternative interface to provide NIV in specific clinical scenarios, to avoid re-intubation and subsequent invasive ventilation in situ ations of extubation failure.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflict of interest.



 
  References Top

1.
Callegari J, Magnet FS, Taubner S, Berger M, Schwarz SB, Windisch W, et al. Interfaces and ventilator settings for long-term noninvasive ventilation in COPD patients. Int J Chron Obstruct Pulmon Dis 2017;12:1883-9.  Back to cited text no. 1
    
2.
Tomori Z, Donic V, Torok P, Firment J. Anatomical, physical, and psychological factors of NIV interfaces. In: Esquinas A, editor. Noninvasive Mechanical Ventilation. 2nd ed.. Switzerland: Springer, Cham; 2016. p. 641-7.  Back to cited text no. 2
    
3.
Brill AK, Pickersgill R, Moghal M, Morrell MJ, Simonds AK. Mask pressure effects on the nasal bridge during short-term noninvasive ventilation. ERJ Open Res 2018;4. doi: 10.1183/23120541.00168-2018.  Back to cited text no. 3
    
4.
Ralston SJ, Charters P. Cuffed nasopharyngeal tube as 'dedicated airway' in difficult intubation. Anaesthesia 1994;49:133-6.  Back to cited text no. 4
    


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