To the Editor,
Intubating laryngeal airway (air-Q; Cookgas LLC, Mercury Medical, Clear Water, FL, USA) has been frequently used as a conduit for endotracheal intubation with uncuffed and cuffed endotracheal tubes (ETT).1 Removal of the air-Q over the cuffed ETT can lead to stretching of the pilot tube, because some pilot balloons are often wider than the internal diameter of the air-Q (Figure 1A). This leads to difficulty in the extraction of the pilot balloon through the air-Q. A classical technique described to retrieve the pilot balloon is to fold and squeeze the balloon into the air-Q then pull it out. This can be facilitated by a liberal amount of lubricating jelly. However, lubricating jelly makes the hands very slippery and there is a risk of displacement of the ETT. In spite of gentle pulling, invariably some amount of stretching of the pilot tube occurs. Stretching may damage the pilot tube leading to the inability to inflate, leakage, or even disruption of the pilot balloon from the pilot tube (Figure 1B). This may lead to ineffective ventilation and reintubation. We suggest a modification in the technique to avoid this complication during air-Q removal. Air-Q is provided with a plastic stylet to stabilize the ETT during its removal (Video S1). The same stylet can be used again for pushing the pilot balloon of the cuffed ETT rather than pulling the pilot tube from the air-Q (Figures 1C and 1D). A minimal amount of lubricating jelly should be added to avoid friction between the pilot balloon and air-Q during pushing. This technique is not a replacement of the classic method but is a step further to improve patient safety. This technique can also be used for the removal of a cuffed ETT through other intubating supraglottic devices (Ambu laryngeal airway) with the help of the stylet or gum elastic bougie.
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