In Response.

October 15, 2017 • Volume 9 • Number 8 www.anesthesia-analgesia.org 249 In Response We thank Dr Duggan and coworkers for sharing their thoughts on our case report1 and the safe use of airway exchange catheters (AECs). We aimed to spark both awareness and discussion by publishing this complication, in hopes of preventing future adverse outcomes associated with the use of AECs. After highlighting our primary conclusions, the authors suggest that manufacturers should omit the lumen in AECs. We sympathize with the fact that, in search for patient safety, they not only consider caretakers’ actions but also consider the characteristics of devices used. Nonetheless, and despite the complications reported, we still believe that oxygen delivery through the AEC may be lifesaving in cases where timely (re)intubation is not possible, and other routes of delivering oxygen prove ineffective. Indeed, this is in line with some of the guidelines mentioned in our article.2 Also, AECs have been reported as successful primary airway management tools for the oxygenation and ventilation, in both adult and pediatric cases, where other options were less attractive.3,4 However, we learned that oxygen should be delivered only if pressure can be either monitored or limited. Manufacturers may contribute by marketing products to facilitate such practice, eg, easy to assemble pressure valves and gauges. Furthermore, the use of the Rapi-Fit 15 mm (instead of the Rapi-Fit Luerlock; Cook Medical, Bloomington, IN) connector invites users to only assemble pressure-limited devices, such as an ambu-bag, waters-, or anesthetic machine circuit with an adjustable pressure valve. We also feel that caretakers who intend to use an AEC for rescue oxygenation should have a detailed plan for safe jet oxygenation. Limitation of flow may prolong pressure buildup, but does not ultimately prevent pressure leveling with the oxygen source, which is 4800 cm H2O in our institution. Finally, we would like to emphasize the fact that the use of other modes of oxygen administration, eg, oxygen tube via mouth or nose, does carry the risk of inducing subcutaneous emphysema or even perforation of the stomach. Altogether we strongly agree with Dr Duggan and her coworkers that the practice of insufflating oxygen through an AEC carries a significant risk. When confronted with an emergency situation such as the case we reported, insufflating oxygen can be the only lifesaving option. Therefore, all caretakers using AECs should be acquainted with measures to prevent complications. Abraham H. Hulst, MD Hans J. Avis, MD, PhD Markus W. Hollmann, MD, PhD Markus F. Stevens, MD, PhD Department of Anesthesiology Academic Medical Center University of Amsterdam Amsterdam, the Netherlands m.w.hollmann@amc.uva.nl