Introduction: A 77-year-old man with a history of tonsillar cancer, HFrEF, BMI 39, and LUL nodules had IR biopsy complicated by desaturation and hemoptysis underwent easy video laryngoscopy intubation. Active airway bleeding was observed and bronchial blocker/double lumen ETT declined by intensivists. One hour later, during a difficult ICU bronchoscopy, a high risk ETT exchange was requested to upsize existing ETT due to concern of obstruction contributing to difficulty visualizing/clearing the airway and suspicion of soft tissue injury during intubation.
Description: Having confirmed risk, ETT exchange need, and intubated the patient, the airway team prioritized tracheal clot diagnosis due to known bleeding rather than unlikely new airway injury. Paralysis, positioning, hemodynamic and ventilator optimization, followed by MAC videolaryngoscopy with 15LNC apneic oxygenation were utilized to visualize 14Fr airway exchange catheter (AEC) passage via elbow adapter through indwelling 8.0 ETT. Next a “double park” technique - positioning replacement tube (a second 9.0 tube) just proximal to laryngeal opening - until original (indwelling 8.0) ETT is withdrawn. When the 8.0 ETT cuff was taken down, blood blew back out of the larynx, soiling video view, preventing exchange. After cuff reinflation, cleaning of video port, positioning, and reacquisition of laryngeal view, a 15Fr coudé bougie was passed intratracheally, alongside the indwelling cuff up 8.0 ETT with the AEC remaining inside - “double catheters”. The 9.0 was loaded over the indwelling bougie and guided proximal to laryngeal inlet – “double park”. After ventilation pause, verifying airway pressure nadir, 8.0 ETT cuff deflation, with direct and video view of withdrawal of 8.0 tube over AEC, without blood blow back, simultaneously advancing and inserting 9.0 tube over indwelling bougie while keeping AEC in place, with new cuff up in 5 seconds.
Discussion: Airway exchanges in ventilator dependent patients can be high risk procedures. This case utilized layered techniques of apneic oxygenation, combination direct and video laryngoscopy , “double catheter” (airway exchange catheter and bougie) and “double park” techniques for soiled airway rapid railroad assisted ETT exchange. This is the first description of this novel combination of techniques.
