Endotracheal tube exchange over bougie through submental route in a patient with panfacial trauma

Dear Editor, Submental intubation is a safer alternative to tracheostomy for airway management during complex maxillofacial surgeries.[1-3] A 68-year-old male patient, following a road traffic accident, had sustained right zygomatico maxillary, mandible, maxillary LeFort 1 and 2 fractures.He was posted for open reduction and internal fixation, which required submental intubation. Following intravenous induction and neuromuscular blockade, the patient was intubated orally with an 8.0-mm cuffed flexometallic endotracheal tube (ETT) using a C-MAC videolaryngoscope. As he had a long superficial cut under the chin, the incision for submental intubation was placed on the left lateral part of the lacerated wound, 2cm medial to the lower border of the mandible. By blunt dissection using tonsil forceps, an opening was made in the floor of the oral cavity at the inner aspect of the mandible at the junction between the premolar and canine tooth at the gingiva. The deflated pilot balloon followed by the proximal end of ETT was pulled out extraorally, through the incision. The circuit was connected and the pilot balloon was inflated. It was noticed that the pilot balloon was repeatedly getting deflated and a cuff leak was suspected. By that time, correct tracheal placement of ETT was confirmed with auscultation and by the appearance of regular end-tidal carbon dioxide (ETCO2) waveforms using high fresh gas flows. As the ETT was already in place submentally, we decided to pass a bougie through the defective ETT and attempt reintubation by railroading a new ETT over the bougie without losing the airway. A gum elastic bougie was then passed through the ETT. After thorough oral suction, the cuff was fully deflated and the ETT was pulled out over the bougie extraorally [Figure 1a] leaving the bougie in situ [Figure 1b]. A new 8.0-mm flexometallic ETT was then railroaded over the bougie into the trachea [Figure 1c]. The cuff was then inflated, the bougie was removed, and the breathing circuit was connected. Correct ETT placement was confirmed with auscultation and ETCO2. ETT was then secured to the skin and surgery was performed.Figure 1: (a) Defective ETT being pulled out over bougie, (b) Bougie in situ, (c) New ETT being railroaded over bougie submentallyETT damage is rare (1.19%) during submental intubation.[4] The reason for the cuff leak in our patient could be damage to either the pilot balloon or inflation line during exteriorizing. It would be ideal to rule out malposition of ETT using a fiberoptic bronchoscope before attempting tube exchange over the bougie. We did not do it as the bronchoscope was not immediately available. The potential pitfalls with this method are that accidental displacement of bougie, endobronchial intubation, and soft tissue injury to the structures in the floor of the mouth. Railroading a new tube into a soft tissue track can result in cuff damage. A potential false track can form if railroading is not successful in the first time. As this is a potentially blind procedure, the final position of ETT should be confirmed by fiberopticscope to detect malposition early and rectify it. It is concluded that following submental intubation if the ETT cuff is found defective, exchanging defective ETT over a bougie with a new ETT may be attempted after making preparations for oral intubation, if the technique fails. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.