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LETTERS TO EDITOR
Year : 2023  |  Volume : 17  |  Issue : 1  |  Page : 121-123

Management of a broken stylet in endotracheal tube


Department of Anaesthesia, AIIMS, Bathinda, Punjab, India

Correspondence Address:
Shashank Paliwal
3016, Housing Type 3 AIIMS Bathinda, Punjab - 151 001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sja.sja_356_22

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Date of Submission02-May-2022
Date of Decision04-May-2022
Date of Acceptance04-May-2022
Date of Web Publication02-Jan-2023
 


How to cite this article:
Paliwal S, Samagh N, Singh N, Sharma J. Management of a broken stylet in endotracheal tube. Saudi J Anaesth 2023;17:121-3

How to cite this URL:
Paliwal S, Samagh N, Singh N, Sharma J. Management of a broken stylet in endotracheal tube. Saudi J Anaesth [serial online] 2023 [cited 2023 Feb 1];17:121-3. Available from: https://www.saudija.org/text.asp?2023/17/1/121/364849



Sir,

Videolaryngoscopes improve the laryngeal view without aligning oral-pharyngeal-laryngeal axes, thus decreasing intubation difficulties. Intubation stylets with varying angulations are widely used to facilitate intubation. We describe a rare complication of stylet breaking into two pieces inside the endotracheal tube during its withdrawal.

A 23-year-old male; a known case of ulcerative colitis was posted for J. pouch ileoanal anastomosis with proximal diverting ileostomy. Preanaesthetic check-up was normal. In the operation theatre standard ASA monitors were attached and induction was done according to institute protocols. Laryngoscopy was done using Mcgrath videolarngoscopy 4 blade, Cormack-lahane grade was 2a and the percentage of glottic opening was 80%. An 8.0 mm internal diameter endotracheal tube preloaded with a malleable aluminum stylet with smooth high density polyethylene outer sleeving having a 4.0 mm outer diameter was used. The distal end of the endotracheal tube along with stylet was angulated to around 60 degrees to align with the angle of videolaryngoscope blade. The tube was introduced smoothly once the appropriate view of glottis was established. However, the stylet got stuck while withdrawing and broke into two on application of force. The proximal part of the stylet which was held by the anesthesiologist came snapping out, while the distal part stayed inside the endotracheal tube [Figure 1]. Otorhinolaryngology team was alerted about possible need of bronchoscopic foreign body removal. The tube was then slowly and carefully removed millimeter by millimeter to avoid the migration of any broken pieces. The tube came out easily along with the distal part of the broken stylet. Check laryngoscopy was done to see for any remains of the stylet in the oral cavity. Both the pieces of broken stylet were analyzed for any missing parts. The patient was again mask ventilated after a thorough and quick analysis of broken stylet and oral cavity. Laryngoscopy was done for the second time and an 8.00 mm endotracheal tube was railroaded over the bougie to achieve successful intubation. Chest X-ray was done to further rule out any missed part of the broken stylet and was found to be normal. It was then decided to proceed with the surgery. The intraoperative period was uneventful and patient was extubated at the end of surgery. The patient was examined for any throat discomfort, irritation, difficulty in breathing. Patient's postoperative stay was uneventful and he was discharged after five days.
Figure 1: Broken stylet with one part inside the tube

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Video- laryngoscopy makes intubation easy and decreases intubation failure by improving the laryngeal view.[1] A malleable stylet is often used as a facilitator for endotracheal tube using videolaryngoscopy. It aids in moulding the shape of the tube, improves manoeuvrability and enables easy and swift tube placement more so in difficult airway cases.[2] Angulation of stylet at 60° has been also found to shorten the time to intubation along with other benefits in a study.[3]

Common complications of stylet use include mild bleeding from mucosa and sore throat, but breakage or shearing and migration of broken pieces leading to airway obstruction have also been reported.[4] Various cases of retention and migration of plastic sheath of endotracheal stylet have been reported in the past.[5]

In our report, the stylet got stuck during withdrawal and broke on pulling. After this event, we noticed stylet had been used many a times and frequently angulated to assist in videolaryngoscopy. This frequent moulding could have created some potential weak points. Secondly, the 60° angulation could have also created some resistance on pulling and subsequent breakage on pulling from the weakest point created by overuse and frequent angulations.

The anaesthesiologist has to be careful in using stylets. It should not be overused and frequently inspected for dents and potential sites of breakage as it may lead to grave complications. Secondly, the assessment of stylet should be done before and after its usage for missing parts.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lewis SR, Butler AR, Parker J, Cook TM, Schofield-Robinson OJ, Smith AF. et al. Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation: A cochrane systematic review. Br J Anaesth 2017;119:369-83.  Back to cited text no. 1
    
2.
Levitan RM, Pisaturo JT, Kinkle WC, Butler K, Everett WW. Stylet bend angles and tracheal tube passage using a straight-to-cuff shape. Acad Emerg Med 2006;13:1255-8.  Back to cited text no. 2
    
3.
Lee J, Kim JY, Kang SY, Kwak HJ, Lee D, Lee SY. Stylet angulation for routine endotracheal intubation with McGrath videolaryngoscope. Medicine 2017;96:e6152.  Back to cited text no. 3
    
4.
Sharma PK, Khan RM, Kaul N. An unnoticed broken sheathed metallic stylet in an endotracheal tube: A case report. Sultan Qaboos Univ Med J 2010;10:126-8.  Back to cited text no. 4
    
5.
Shetty S, Power S, Afshar K. A sheared stylet. BMJ Case Rep 2010;2010:bcr0220102725.  Back to cited text no. 5
    


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