Ghafoor A U, Saleem M.
Emergency use of Eschlmann Stylet (Tracheal Tube Introducer) in acute Tracheo Bronchial obstruction during General Anesthesia.
J Pak Med Assoc Jan ;54(5):276-8.

A 40 years old female weighing 80 kilograms was involved in a motor vehicle accident and acquired multiple injuries to limbs and chest and a spiral comminuted fracture of distal femoral shaft. She had fracture of right 4th, 5th and left 5th, 6th ribs along with a right pneumothorax and a right lung contusion. Her preanesthetic work up was normal. The patient was taken to operating room for open reduction and internal fixation of her right femoral shaft fracture. After intravenous rapid sequence induction of general anesthesia, patient was intubated with size 7.0 endotracheal tube. Mechanical ventilation was initiated with tidal volume of 700m1, rate of 9 breaths/min. Her peak airway pressures were 32-35cm of water at these ventilator settings consistently. After approximately one hour of surgery, the peak airway pressure suddenly increased from an average of 30-31 cm of water to 65 cm of water. The capnogram also showed a rise in carbondioxide. At this point position of the endotracheal tube was checked and maneuvers for high peak pressures (decreasing the pressure in endotracheal tube cuff, suctioning of endotracheal tube) were performed. It was noticed that the suction catheter failed to pass beyond a 23cm mark even after multiple attempts. There was no air entry bilaterally on auscultation. However the patient continued to maintain oxygen saturation. Pediatric bronchoscope was passed through the endotracheal tube to find the cause of the obstruction, which showed a clot of blood in the trachea distal to the endotracheal tube, almost completely obstructing the tracheal lumen. At this point Eschmann stylet (15 FR) was passed through the endotracheal tube blindly to open the obstruction. This maneuver successfully decreased the patient`s peak airway pressures to initial values with a bilateral improvement in air entry.

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