Full text - Journal of the Intensive Care Society

© The Intensive Care Society 2012
Airway injury and haemorrhage
associated with the Frova intubating
introducer
JA Simpson, M Duffy
Introduction
Although the Eschmann tracheal tube Introducer (Smiths
Medical, Ashford, UK) was once considered the gold standard
for assisting intubation, concerns about cross-infection with
multiple-use devices 1,2 have led to an increasing reliance upon
single-use alternatives. 3 The Frova intubating introducer
(bougie) (Cook ® Medical, Bloomington, USA) is a commonly
used example and has a high success rate for tracheal
intubation in manikins. 4-6 There may be however increased
potential for tissue trauma, suggested by both manikin
studies 4,5 and case reports in the literature. 7-12 In common with
airway exchange catheters, 13,14 high-pressure source ventilation
via the hollow lumen of the Frova intubating introducer may
also lead to barotrauma. 15
Case report
A 49-year-old man with pancreatitis secondary to alcohol was
admitted to the intensive care unit (ICU) with multiple organ
failure. Although baseline tests of coagulation (prothrombin
and activated partial thromboplastin times) were within normal
ranges, he had thrombocytopenia. Following a platelet
transfusion, which increased the platelet count from 18 to
26 × 109 /L, a wide-bore double-lumen haemofiltration catheter
was inserted into the right internal jugular vein. Continuous
veno-veno haemofiltration was then commenced without
anticoagulation. Attempts to control the patient’s confusion
and agitation with light sedation led to hypoxia despite airway
manoeuvres to alleviate upper airway obstruction. Peripheral
oxygen saturations fell to 76% with a PaO2 measured at
6.3 kPa on 15 L/min oxygen via an oxygen mask with a
reservoir bag. The decision was taken to perform a rapid
sequence intubation and to initiate mechanical ventilation.
Body mass index was 28 kg/m2 and, following airway
assessment, difficult intubation was not anticipated.
Case reports
Airway trauma is a recognised complication of tracheal intubation when using an intubating introducer. We report such a
case in which a Frova TM intubating introducer (bougie) traumatised the intermediate bronchus, at the junction of the right
middle and inferior lobar bronchi. This caused major tracheobronchial haemorrhage and hypoxia. The injury resulted in
formation of a flap of tissue, which then obstructed the right middle and inferior bronchi with a ball-valve effect. We
discuss the relevant literature and explore other contributory factors to this life-threatening complication.
Keywords: intubation; airway management; trauma; disposable equipment; haemorrhage
Figure 1 Anteroposterior plain chest radiograph showing collapse
of the right lung.
After three minutes of pre-oxygenation, peripheral oxygen
saturations rose to 99%. Fentanyl 250 µg, propofol 40 mg and
suxamethonium 100 mg were administered IV. Direct
laryngoscopy revealed swollen laryngeal structures and dried
encrusted blood. The glottic aperture was not identifiable,
despite manipulation of the cricoid. A 14 Fr Frova intubating
introducer was passed blindly into what was thought to be the
patient’s trachea. The passage was smooth without clicks or
hold-up, leading to suspicion that the introducer was in the
oesophagus and it was therefore removed. The introducer was
immediately advanced again without what the user perceived
as excessive force, this time with clicks then hold-up at
approximately 28 cm. A size 9 mm cuffed tracheal tube
(Portex ® , Smiths Medical, Ashford, UK) was passed over the
introducer to a length of 22 cm at the teeth. Successful tracheal
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Case reports
placement was confirmed by capnography, bilateral chest wall
movement and ausculation of both lung fields. The patient’s
lungs were ventilated with 100% oxygen and oxygen
saturations rose from 88% to 99%.
After a further 10 minutes, oxygen saturations fell again,
from 99% to 84%. Auscultation of the chest revealed reduced
breath sounds on the right. An anteroposterior plain chest
radiograph was performed (Figure 1) which demonstrated
collapse of the right lung and an adequately positioned tracheal
tube. Immediate flexible fibreoptic bronchoscopy revealed
blood throughout the right bronchial tree with active
haemorrhage. Suction improved ventilation to the right upper
lobe. An intraluminal flap of tissue, lacerated from the wall of
the intermediate bronchus, was noted to be causing ongoing
obstruction to the right middle and inferior bronchi with a
ball-valve effect (Figures 2a and 2b). Further extensive
suctioning of the right bronchial tree was performed. After
transfusion of two further pools, the platelet count increased to
63 × 10 9 /L and the bleeding stopped.
152
2a
2b
Figures 2a and b Intra-luminal flap of tissue obstructing the
right middle and inferior bronchi with a ball-valve effect.
Figure 3 Anteroposterior plain chest radiograph showing partial
improvement, one hour after flexible bronchoscopy.
Figure 4 Anteroposterior plain chest radiograph showing linear
atelectasis at the right base, two months after discharge from
hospital.
The patient was paralysed and ventilated with a lung
protective strategy. Oxygenation and radiographic appearances
(Figure 3) improved significantly over the subsequent hours.
In view of this, he was managed conservatively following
advice from a thoracic surgeon at 12 hours. His trachea was
extubated three days later. He was discharged from ICU after a
further three days and from hospital after two weeks. The plain
chest radiograph continued to improve (Figure 4) and he made
a full recovery.
Discussion
Airway complications confer high mortality and morbidity in
critically ill patients. 13 These patients are at particular risk of
iatrogenic injury16 and complications such as oesophageal
intubation and failed rescue techniques are more common. 13
This case demonstrates several issues related to their
management.
Volume 13, Number 2, April 2012 JICS

Significant airway trauma can result from the use of airway
adjuncts such as the Frova intubating introducer, 7-13 even when
used with what the user perceives to be minimal force.
Although it has a high success rate for tracheal intubation, 7
manikin studies have shown it to exert a greater force at its tip
compared to the Eschmann tracheal tube introducer, 4,5 which
may result in increased potential for tissue damage. 9,10 This is
especially relevant when hold-up is used to detect tracheal
placement, 7 which has led to the suggestion that it should only
be sought in the absence of clicks. 7,10 Iatrogenic airway trauma
associated with bougies (type not clarified) and airway
exchange catheters was recognised as a cause of morbidity in
the 4th National Audit Project (NAP4) of the Royal College of
Anaesthetists and Difficult Airway Society (DAS). 13 The NAP4
authors recommended that when using airway exchange
catheters, the tip should not reach the carina (ie it should be
inserted to a maximum distance of 26 cm at the lips) and when
using bougies ‘great care should be taken to avoid using
excessive force.’ 13
Concerns about cross-infection with multiple-use devices
have led to an increasing use of single-use alternatives. 3
However, if the performance of single-use alternatives is
inferior, there is clearly a balance to be struck between the risk
to patients from cross-infection and the risk to patients from
using substandard equipment. 17 The current recommendation
from the Association of Anaesthetists of Great Britain and
Ireland is that single-use devices are used where appropriate,
with the balance of risk requiring ‘local determination based on
an assessment of patient safety, the available facilities and cost.’ 3
Conclusion
As the use of disposable equipment grows, it is necessary to
ensure that performance and safety profiles are properly
benchmarked against established gold standards. It is also
important that devices are used in a manner that minimises the
risk of patient harm. The Frova intubating introducer is an
effective device4-7 and has obvious advantages in terms of
infection control. However its potential to cause tissue
damage, 8-12 particularly in association with hold-up, 7 is of
concern. There must always be a willingness to adapt practice
as traditional techniques may not translate to single-use
equipment. However, as the Frova intubating introducer
instructions for use state, it ‘should not be advanced past the
carina,’ 18 it cannot be used when following the current DAS
guidelines19 for difficult tracheal intubation, in which using
hold-up is a recommended technique.
Acknowledgement
Published with the written consent of the patient.
Competing interest
No external funding and no competing interests declared.
Commentary:
Drs Simpson and Duffy’s case report illustrates several
points. Firstly, the case illustrates how critically ill patients
References
Case reports
1. Letheren M. Sterilisation of gum elastic bougies. Anaesthesia 1994;49:921.
2. Jerwood DC, Mortili D. Disinfection of gum elastic bougies. Anaesthesia
1995;50:376.
3. Association of Anaesthetists of Great Britain and Ireland (AAGBI).
AAGBI Safety Guideline: Infection control in Anaesthesia. Anaesthesia
2008;63:1027-36.
4. Hodzovic I, Latto IP, Wilkes AR et al. Evaluation of Frova, single-use
intubation introducer, in a manikin. Comparison with Eschmann
multiple-use introducer and Portex single-use introducer. Anaesthesia
2004;59:811-16.
5. Janakiraman C, Hodzovic I, Reddy S et al. Evaluation of tracheal tube
introducers in simulated difficult intubation. Anaesthesia 2009;64:309-14.
6. Whitcombe A, Strang T. A comparison of multiple-use and single-use
bougies. Anaesthesia 2005;60:416-17.
7. Hodzovic I, Wilkes AR, Stacey M et al. Evaluation of clinical
effectiveness of the Frova single-use tracheal tube introducer. Anaesthesia
2008;63:189-94.
8. Vila Caral P, Castillo Omedas R, Llubiá Maristany C. Laceración
traqueal durante la intubación traqueal con guía de intubación Frova.
Revista Espanola de Anestesiologia y Reanimacion 2010;57:599-602.
9. Umesh G, Jasvinder K. Frova introducer for tracheal intubation – our
comments and experience. Anaesthesia 2008;63:1260-61.
10.Hodzovic I, Wilkes AR, Stacey M et al. Frova introducer for tracheal
intubation – our comments and experience [a reply]. Anaesthesia
2008;63:1261-62.
11.Hodzovic I, Latto IP. Singe-use introducers may not be fit for purpose.
Anaesthesia 2007;62:1189-90.
12.Evans H, Hodzovic I, Latto IP. Tracheal tube introducers: choose and use
with care. Anaesthesia 2010;65:859.
13.Cook TM, Woodall N, Frerk C. Fourth National Audit Project of the
Royal College of Anaesthetists and the Difficult Airway Society: Major
Complications of Airway Management in the United Kingdom. BJA
2011;106:632-42.
14.Scottish Courts Fatal Accident Enquiry into the death of Gordon Ewing.
Glasgow, April 2010; www.scotcourts.gov.uk/opinions/2010FAI15.html
(accessed 27th Jan 2012).
15.Rao A, Webster L, Turner M. Bougie induced airway trauma. Presented at
the Difficult Airway Society Annual Congress, Cheltenham 2010;Poster
83C
16.Rothschild JM, Landrigan CP, Cronin JW et al. The Critical Care Safety
Study: The incidence and nature of adverse events and serious medical
errors in intensive care. Crit Care Med 2005;33:1694-700.
17.Rowley E, Dingwall R. The use of single-use devices in anaesthesia:
balancing the risks to patient safety. Anaesthesia 2007;62:569-74.
18.Frova Intubating Introducer Data Sheet. Cook ® Medical, Bloomington,
USA.
19.Henderson JJ, Popat MT, Latto IP. Difficult Airway Society guidelines for
management of the unanticipated difficult intubation. Anaesthesia
2004;59:675-94.
James A Simpson Registrar in Anaesthesia
james.simpson2@nhs.net
Mike R Duffy Consultant in Anaesthesia and Intensive Care
Derriford Hospital, Plymouth
are at increased risk of major sequelae when complications of
airway management occur. The 4th National audit project of
JICS Volume 13, Number 2, April 2012 153

Case reports
the Royal College of Anaesthetists and Difficult Airway Society
has hopefully made it clear that airway management in the ICU
must be treated with great respect.
Secondly we must choose and use airway equipment
carefully. There is a wide array of bougies, introducers and
airway exchange catheters (AECs) available and most ICUs
will possess several. They vary in length, stiffness, shape and
rigidity of the tip and also in intended purpose. All users
should familiarise themselves before using them, including
reading the instructions for use.
Finally, there is a more specific lesson to learn.
Tracheobronchial trauma during intubation is a serious
complication. Subsequent positive pressure may compound the
injury. If a bougie or AEC is advanced beyond the carina, the
risk of bronchial damage and of the device wedging in the
airway increases. If pressure is applied through the lumen of a
wedged device, especially if a high-pressure source is used,
there will be no route of egress for the gas and barotrauma is
almost inevitable. The case of Gordon Ewing is a potent
example of this (see Sherriff Ruxton’s report into his death
154
http://www.scotcourts.gov.uk/opinions/2010FAI15.html )
Such injuries can be vastly reduced by three simple actions:
A bougie or AEC should never be inserted beyond 26 cm
from the lips (mid-trachea). Attaching tape as a marker at
26 cm is useful, but manufacturers could act on this too by
marking devices with the maximum insertion depth.
It is rarely, if ever, necessary to deliver oxygen through a
bougie/AEC. The devices can be used only for passage of a
tracheal tube, it takes but a few seconds. Their use as
oxygenating devices should be reserved for life-threatening
situations.
No force should ever be applied to the bougie when it holds
up (at whatever level), and there is an argument that holdup
should not be used as a sign of tracheal insertion at all.
Tim Cook Consultant in Anaesthesia and Intensive Care
Medicine, Bath
timcook007@googlemail.com
Volume 13, Number 2, April 2012 JICS