Letters to the Editor
headache after unintentional dural punc- blood patch is being performed and
ture. Anesth Analg 2007;104:747– 8
2. Nafiu OO, Urquhart JC. Pneumocepha-
lus with headache complicating labour
epidural analgesia: should we still be
using air? Int J Obstet Anesth 2006;15:
237–9
3. Yentis SM. Time to abandon loss of resis-
tance to air. Anaesthesia 1997;52:184
4. Aida S, Taga K, Yamakura T, Endoh H,
Shimoji K. Headache after attempted epi-
dural block: the role of intrathecal air.
Anesthesiology 1998;88:76 – 81
5. Artru AA. Nitrous oxide plays a direct
role in the development of tension pneu-
mocephalus intraoperatively. Anesthesi-
ology 1982;57:59 – 61
DOI: 10.1213/01.ane.0000278619.58392.f3
In Response:
The issue raised by Nafiu et al (1)
regarding which medium to use to
identify the epidural space remains
unanswered. Whereas, proponents
of the loss of resistance to saline
technique have called upon the
anesthesia community to “stop
using the loss of resistance to air
technique” (2,3), their advocacy of
the loss of resistance to saline does
not eliminate the serious down-
side of this technique.
The advantage of using loss of
resistance to air is that after identi-
fying the epidural space, any fluid
coming out of the epidural needle
can easily be identified as CSF. Ob-
viously, in the case where the tip of
the epidural needle is clearly in the
intrathecal space, CSF will be gush-
ing out of the epidural needle. The
problem arises when the tip of the
epidural needle only partially pen-
etrates the dura. CSF will come out
of the epidural needle slowly, drop
by drop, and can be easily misiden-
tified as saline when the loss of
resistance to saline technique is
used. Also, any fluid coming out of
the epidural catheter, if loss of re-
sistance to air was used, will indi-
cate that the catheter is in the intra-
thecal space. If loss of resistance to
saline is used, fluid can be aspirated
from the epidural catheter no mater
if it is in the epidural or intrathecal
space. In other words, we can iden-
tify all intrathecal catheters without
the test dose, simply by aspiration.
An even larger problem arises if a
Vol. 105, No. 4, October 2007
2. Van de Velde M. Identification of the
if saline is used to identify the epi-
dural space. If the tip of the epidural
needle only partially penetrates the
dura and is not detected, blood may
be injected into the intrathecal and
not the epidural space. A recent case
report (4) described subarachnoid
hematoma when saline was used to
identify the epidural space. Au-
thors postulated that blood entered
the intrathecal space through the
pre-existing dural hole, but a dural
hole is present during every blood
patch and spinal hematoma is ex-
tremely rare. We propose that the
spinal hematoma occurred because
the authors did not identify the
location of the tip of the epidural
needle. The epidural needle was
probably partially in the epidural
and partially in the spinal space
and this could not be detected be-
cause saline was used to identify
the epidural space. Blood that was
injected intrathecally created a spi-
nal hematoma that compressed the
spinal cord with symptoms that
lasted several months. The authors
of this letter would NEVER use
saline to identify the epidural space
during the blood patch procedure.
Pneumocephalus is not caused by
dural puncture, it is caused by injection
of air into the intrathecal space. That is
why we advise the use of 1–1.5 ml of
air in the epidural syringe with inter-
mittent pressure on plunger.
There is probably no “right” me-
dium for the identification of the
epidural space. Air and saline, both
have some advantages and compli-
cations associated with their use.
The decision on which medium to
use, in the end, may be based on
which complication we are willing
to accept and deal with.
Ivan Velickovic, MD
Rostislav Pavlik, MD
Department of Anesthesiology
SUNY Downstate Medical Center
Brooklyn, New York
Ivan.Velickovic@downstate.edu
REFERENCES
1. Nafiu OO, Bullough AS. Pneumocepha-
lous and headache after epidural anesthe-
sia: should we really still be using air?
Anesth Analg 2007;105:1172–3
© 2007 International Anesthesia Research Society
epidural space: stop using the loss of
resistance to air technique! Acta Anaes-
thesiol Belg 2006;57:51– 4
3. Nafiu OO, Urquhart JC. Pneumocepha-
lus with headache complicating labour
epidural analgesia: should we still be
using air? Int J Obstet Anesth. 2006;15:
237–9
4. Kalina P, Craigo P, Weingarten T. Intra-
thecal injection of epidural blood patch: a
case report and review of the literature.
Emerg Radiol 2004;11:56 –9
A Method of Avoiding Loss
of Airway Control During
Tracheal Tube Change
Using an Airway
Exchange Catheter
To the Editor:
Losing control of the airway dur-
ing tracheal tube change using an
airway exchange catheter has been
described (1,2). We describe a case
of losing control of the airway
while trying to change a double
lumen to a single lumen endotra-
cheal tube over a Cook威 Airway
exchange catheter in a patient with
a difficult airway.
We had difficulty “railroading” a
single lumen tracheal tube through
the larynx despite simultaneous la-
ryngoscopy and lifting the oropha-
ryngeal soft tissue. Although we felt
the tracheal tube had been inserted
far enough into the trachea, after re-
moving the airway exchange catheter
(albeit with some difficulty), the
tracheal tube was found to be in the
esophagus. We subsequently intu-
bated the trachea after multiple at-
tempts using a fiberoptic broncho-
scope. What we believe occurred
was that the airway exchange cath-
eter looped into the esophagus be-
fore entering the trachea resulting
in the tracheal tube being inserted
into the esophagus. This complica-
tion might have been avoided by
using a bronchoscope adapter to
verify the position of both the air-
way exchange catheter and the en-
dotracheal tube individually before
removing the airway exchange
catheter. This setup is illustrated in
Figures 1 and 2. The Cook catheter
is passed through the bronchoscope
port of the adapter. The breathing
1173
Letters to the Editor
Figure 1. Circuit attached to the endotracheal side of the bronchoscopy adapter.
Figure 2. Circuit attached to the airway catheter side of the bronchoscopy adapter.
circuit can be attached to the side
port of the adapter and ventilation
can be performed with the presence
of end-tidal CO2 verifying tracheal
intubation. The airway exchange
catheter also comes with an ada-
pter to connect to the circuit and
verify tracheal position. This ap-
proach uses the airway exchange
catheter to the fullest by leaving it
in the trachea until it is certain
that the tracheal tube is indeed in
the trachea.
Swaminathan Karthik
Balachundhar Subramaniam
Beth Israel Deaconess Medical Center
Harvard Medical School
Boston, Massachusetts
skarthi1@bidmc.harvard.edu
REFERENCES
1. Eisenach JH, Barnes RD. Potential disaster
in airway management: a misguided air-
way exchange catheter via a hole bitten
into a univent endotracheal tube. Anes-
thesiology 2002;96:1266 – 8
2. Benumof JL. Airway exchange catheters:
1174 Letters to the Editor
simple concept, potentially great danger.
Anesthesiology 1999;91:342– 4
DOI: 10.1213/01.ane.0000278157.73108.06
Snapping of Cook Exchange
Catheter with Subsequent
Dislodgement in a Double-
Lumen Endotracheal Tube
To the Editor:
Exchange catheters are often used
to assist in the changing of tracheal
tubes. The following case illustrates
one complication of using such ex-
change catheters. A 73-year-old man,
admitted for pneumonia and requir-
ing tracheal intubation for respira-
tory failure, was transferred directly
from the intensive care unit to the
operating room to undergo video-
assisted thorocoscopy. An 8.0 single-
lumen tracheal tube was in place.
After inducing anesthesia with sev-
oflurane, a Cook exchange catheter
(Cook C-CAE-11.0–100-DLT-EF Extra
Firm Exchange Obturator with Rapi
Fit Adapters for Double-Lumen Endo-
tracheal Tube, Cook Critical Care,
Bloomington, IN) was placed
through the 8.0 tracheal tube to the
30-cm mark. The tube was with-
drawn, and the exchange catheter
threaded through the blue bronchial
lumen of a 41F Sheridan double-lumen
endotracheal tube. The double-lumen
endotracheal tube was met with mild
resistance at 20 cm and then inserted to
29 cm at the patient’s lips. Severe resis-
tance was met when attempting to
pull the Cook exchange catheter out
of the double-lumen endotracheal
tube and the exchange catheter
stretched and then snapped. The
broken end of the exchange catheter
was 2 cm into the double-lumen tube
and could not be reached with a
hemostat.
The double-lumen endotracheal
tube was completely withdrawn
along with the broken exchange cath-
eter. Direct laryngoscopy was per-
formed and a 7.5 single-lumen tra-
cheal tube was initially placed, and
then a 41F double-lumen endotra-
cheal tube was placed with proper
position of lung isolation confirmed
with auscultation and fiberoptic
bronchoscopy. The video-assisted
thorocoscopy was then performed
without complication. At the end of
the case, a single-lumen 8.0 tracheal
tube was placed after removal of
the double-lumen tube.
An airway exchange catheter is a
hollow, semirigid catheter that can
be used to assist with changing
tracheal tubes, provide oxygen in-
sufflation and jet ventilation, or be
left in situ for a “trial” extubation
(1–3). These are not without risk
because of complications includ-
ing misplacement, tracheobron-
chial trauma or lung laceration, jet
ventilation-associated barotrauma
and pneumothorax, and laryngeal
or vocal cord trauma from a new
tracheal tube “hanging up” during
the exchange (4 –7). Esophageal
placement has occurred leading to
gastric perforation (8).
In this case, the double-lumen
tube was caught at the glottic
ANESTHESIA & ANALGESIA