What’s that about?
I intentionally intubate the esophagus and I demand recognition for it.
This is our latest attempt at the eponymous naming of a controversial procedure that is not based on any evidence whatsoever.
Some time ago we we called to the cath lab where a patient had arrested during PCI. As we arrived compressions were ongoing as the cardiologist desperately tried to open the left coronary. The patient was very obese with a short neck. As we entered the room we could see how his mouth and reservoir mask started filling up with gastric contents. The intubation was a nightmare from the start. A tidal wave of vomit steadily kept welling up into the mouth and upper airway. Suctioning did not help as the mouth kept filling up as soon as we removed the yankauer catheter and tried to intubate. The suction device also clogged several times.
After two gnarly attempts at intubation we gave up. Decision time. The nurse anesthetist ran to get the ILMA for a blind intubation. There wouldn’t be time for that. The next algorithm step would be a surgical airway which, given the layers of fat over the patient’s short neck, would be a complete nightmare. Inserting a LMA was an option but as the patient had arrested with a massive pulmonary oedema it really wasn´t what we wanted. We made a third and final attempt at intubating the patient.
Instead of attempting a blind intubation we shoved the ETT well down the esophagus and inflated the balloon cuff with a 20ml syringe.
The steady flow of vomit immediately stopped and was instead funnelled through the esophageal ETT and drained in copious volumes outside the airway. We could now efficiently suction and clear the mouth of gastric contents.
The glottis became, and remained, visible. I was given the spare ETT loaded on a bougie. With some minor manipulation the patient was easily intubated despite a CL grade 3 view. This whole manoeuvre took less than 30 seconds from esophageal blocking to getting the first capnograph trace.
I discussed the case with a senior colleague of mine. She is an amazing anaesthetist and our favourite consultant. She is also brutally, scary, honest.
First, she suggested that I accidentally intubated the esophagus and had retconned my story in order to look clever. I assured her that was not the case. Then she criticised me ignoring all known emergency airway algorithms. Basically she called me a liar and/or an idiot!
Update: We published these findings – and lo and behold: someone else did too, at the same time. Anyway, now there are two papers out, sort of confirming this might be a decent idea in certain settings.