Airway Management Outside the OR

Thank you, Dr. Mort, for your response. I especially agree with your statement, "I believe the primary use and utility of an AEC is to support removal and passage of the ETT. It is optimally combined with VAL, particularly in the difficult patient." Although not routinely used, an AEC may be a tool in experienced hands if there is concern for difficult or high-risk airway exchanges. We do not routinely use it for ventilation/ oxygenation during exchanges, but as you indicated, as a guide while having the capability to perform passive oxygenation if the situation required it or we are preparing for an alternative method. More often, we can utilize other difficult airway devices, techniques, and personnel, such as our difficult airway response team with ENT bedside in case of the need for a emergent surgical airway - but it is still another tool should the situation escalate and require it.

I thoroughly enjoyed your review of critical care airway management, as it captures several important topics that providers face, though you were limited by your two-page summary. However, I have grave concern with the sentence, "Airway exchange catheters are optimal, as they permit oxygenation and ventilation." I believe the primary use and utility of an AEC is to support removal and passage of the ETT. It is optimally combined with VAL, particularly in the difficult patient (which is almost by default, an ICU patient). Using an AEC to provide oxygenation and ventilation is possible but is not to be used by anyone unfamiliar or "rusty" with its method. Most anesthesia professionals likely rarely perform jet ventilation or even understand or feel competent in providing oxygenation and ventilation via an AEC in the SIM lab, let alone in the ICU on a critically ill patient. Our team of ICU anesthesiologists, over the years, realized that providing these support measures via the AEC do much more harm than good. Commencing, interrupting, and re-starting ventilation via the AEC whilst removing the old ETT and replacing a new one is a set up for confusion and errors that lead to patient injury. Performing a rarely utilized task in an urgent/emergent situation, especially by a provider with minimal or no practical experience, is not recommended. Just my two cents.