**10.1 Endotracheal tube exchange**

On the ICU there are times the ETT may need to be changed, either due to blockage or damage to the cuff. This is usually done with a tube exchanger, with the new ETT railroaded over the bougie. The lungs of a COVID-19 patient are diseased and more prone to trauma. It is advised to avoid blindly introducing a bougie into the trachea with the possibility of advancing it too deep, and thus damaging the airways, with a potential to cause a pneumothorax. If the airway is not predicted to be difficult, paralyzing the patient, preoxygenation, extubation and then reintubation with a fresh ETT using a video-laryngoscope would be the gentler way to do it.
