Intubation – Laryngoscopes – ETT – Laryngeal Masks Mykonos – April 2012 Product Training Carol Seroussi November 2009 Intubation Anatomy - Reminder Upper Airways Anatomy - Reminder Function Nose, Mouth, Pharynx Humidification/Filtration Warming/Vocalization Upper Airways Definition of Endotracheal Intubation Endotracheal intubation is the placement of a tube into the trachea (windpipe) in order to maintain an open airway in patients who are unconscious or unable to breathe on their own. Oxygen, anesthetics, or other gaseous medications can be delivered through the tube. 5 Endotracheal Intubation • Forms a safe airpassage down into the trachea & prevents aspiration • Makes ideal situation for ventilation as air passes directly into the lower airways • Can be oral or nasal • Can be planned or unplanned • Unconscious patients can be intubated w/o medication • Conscious or semi-conscious patients need sedation or relaxation medications • The use of a laryngoscope allows direct visualisation 6 Indications for Endotracheal Intubation It is of great importance to know how to evaluate & address a patient who may require ventilatory support • Inadequate ventilation can lead to brain injury or death within minutes • Causes can be • • • • • • 7 sedation neuromuscular paralysis obstructed or compromised airway altered mentation loss of consciousness respiratory failure Indications for Endotracheal Intubation In the Operating Room • the need to deliver ventilation = sedated patient • most surgical procedures – involving head and neck – in non-supine positions that preclude manual airway support – involving neuromuscular paralysis – involving cranium, thorax, or abdomen – …etc • protection of the respiratory tract from aspiration of gastric contents 8 Indications for Endotracheal Intubation Some Non-Operative Indications • profound disturbance in consciousness with the inability to protect the airway such as cardio-respiratory arrest or respiratory failure • person in deep coma or unresponsive • shallow or slow respirations (less than 8 per minute) • severe pulmonary or multisystem injury associated with respiratory failure such as: sepsis, hypoxemia and hypercarbia • airway obstruction (no foreign object) • need for prolonged ventilatory support • large hemorrhage with poor perfusion • protection from aspiration • to prevent loss of airway at a later time, i.e.burn patient who inhales hot gases may be intubated initially to prevent his airway from swelling shut 9 Contra-Indications for Endotracheal Intubation • Obstruction of the upper airway due to foreign objects • Cervical fractures • Following conditions require caution before attempting to intubate • • • • • 10 Esophageal disease Ingestion of caustic substances Mandibular fractures Laryngeal edema Thermal or chemical burns Advantages/Drawbacks of Endotracheal Intubation Advantages • Provides an unobstructed airway when properly placed • Prevents aspiration of secretions (blood, mucous, stomach / bowel contents) into the lungs • Can be easily maintained for a lengthy period of time • Facilitates positive pressure breathing without gastric inflation • Facilitates body positioning and movement of the patient • May be utilized to pass medications Drawbacks • Need advanced training to properly perform procedure • Bypasses the nares function of warming and filtering the air • Increased incidence of trauma due to neck manipulation when spinal cord injury is suspected • May increase respiratory resistance • Improper placement 11 Intubation Technique OROTRACHEAL NASOTRACHEAL Intubation Technique 13 Intubation Technique Oral Axis Pharyngeal Axis Laryngeal Axis Jackson-amended position Intubation Grading Scale • Determined by looking at the anatomy of the oral cavity • Based on the visibility of the base of uvula, faucial pillars (the arches in front of and behind the tonsils) and soft palate • Used to predict the ease of intubation • Scoring may be done with or without phonation • Higher Mallampati Score (Class 4) is associated with more difficult intubation 15 Intubation Grading Scale Mallampati Score • Class 1: full visibility of tonsils, uvula and soft palate • Class 2: visibility of hard and soft palate, upper portion of tonsils & uvula • Class 3: soft and hard palate and base of the uvula are visible • Class 4: only hard palate visible Mallampati Classification Grades 1-4 16 Equipment for Endotracheal Intubation - Endotracheal tube • Size of tube is dependent on size of patient • 6,5 to 7 mm (female) & 7.5 to 8.0 (male) are the “universally accepted” size for an unknown victim - 10 cc Syringe – used to fill the cuff - Stylet – a wire inserted into the ETT in order to stiffen it during passage - Water soluble lubrication - Stethoscope – to check for proper placement of the endotracheal tube - Magill forceps – may be used to help guide an endotracheal tube from the pharynx into the larynx - Laryngoscope handle - Laryngoscope blade • Miller blade (straight blade) • Macintosh blade (curved blade) - Oropharyngeal airway (bite block) – to prevent the patient from biting down on the endotracheal tube - Tape – to secure the endotracheal tube in place - Gloves - Resuscitation bag – to facilitate positive pressure ventilation - Suction Device – to clear the airway of debris (blood, mucous, saliva) - Manometer – to ensure cuff pressure is adequate 17 Laryngoscopy • Insertion of a laryngoscope to lift the tongue and the epiglottis • Illumination of the pharyngeal room • Free view to the glottis & vocal cords Technique of Intubation 1.Place patient in supine position 2.Pre-oxygenate patient 3.Place pillow under head, flex the neck 4.Extension of the atlanto-occipital joint. (called "sniffing morning air") 5.Open mouth by separating lips & pulling on the upper jaw with index 6.Hold laryngoscope in the left hand 7.Insert laryngoscope into mouth with blade directed to the right tonsil 8.When tonsil in view, sweep blade to midline keeping the tongue on the left; this brings the epiglottis into view. DO NOT LOSE SIGHT OF IT 9.Advance laryngoscope blade till it reaches the angle between the base of the tongue and the epiglottis 10.Lift laryngoscope upwards and away from the nose - towards the chest 11.This manoeuvre should bring the vocal cords into view, but it may be necessary for an assistant to press on the trachea to improve the direct view of the larynx 12.Take the endotracheal tube in the right hand. 13.Keep the concavity of the tube facing the right side of the mouth 14.This causes least interruption to the view of the vocal cords 15.Watch the tube entering the larynx and insert it through the cords only till the cuff is just below the cords. 16.Inflate the cuff to provide a minimal leak when the bag is squeezed 17.Monitor cuff pressure 18.Listen for air entry at both apices and both axillae to ensure correct placement, using a stethoscope Risks Associated with Endotracheal Intubation Potential complications may include • • • • • • Edema Bleeding Tracheal and esophageal perforation Pneumothorax (collapsed lung) Aspiration Emphysema (obstructive pulmonary disease involving damage to the alveoli) Potential follow up signs and symptoms • • • • • 20 Sore throat Pain or swelling of the face and neck Chest pain Subcutaneous emphysema Difficulty swallowing Risks Associated with Endotracheal Intubation Infections / VAP • Mechanical ventilation (endotracheal intubation) • Longer duration of mechanical ventilation • Advanced age • Depressed level of consciousness • Preexisting lung disease • Malnutrition 21 Product Training Carol Seroussi November 2009 Laryngoscopes Global description Some history The first laryngoscope was invented in 1854 by Manuel Patricio Rodríguez García. Modern day laryngoscope systems initially began in early 1940s by Foregger, USA From a catalogue of surgical equipment published in London in 1930 Global description How to use a laryngoscope •Place patient’s head in Jackson-amended position •Hold laryngoscope in the left hand •Insert laryngoscope into mouth with blade directed to the right tonsil •When tonsil is in view, sweep blade to midline keeping the tongue on the left; this brings the epiglottis into view. DO NOT LOOSE SIGHT OF IT •Advance blade till it reaches the angle between the base of the tongue and the epiglottis •Lift laryngoscope upwards and away from the nose - towards the chest •This manoeuvre should bring the vocal cords into view, but it may be necessary for an assistant to press on the trachea to improve the direct view of the larynx Global description Types of laryngoscopes Warm light • Distal light bulb on the tip of the blade Krypton Bulb Cold light • Integrated light bulb in the laryngoscope handle Halogen Bulb Xenon Bulb LED Bulb Global description Types of laryngoscopes Laryngoscopes Cold light handle Warm light handles fiberoptic standard Cold light blades Warm light blades Disposable/reusable Disposable/reusable Global description Different types of blades The 2 major types of blades Miller – Straight The tip of the straight laryngoscope blade picks up the glottis. Mc Intosh – Curved The epiglottis remains below the tip of the blade Global description Other blade types There are uncountable and various other special blades in the market • Foregger • Patil-Syracuse Henderson = large Miller • Seward Dörges = 3 sizes in 1 • Robertshaw • Mc Coy • Bizzari-Giuffrida • Wisconsin-Forreger • Henderson... Pediatrics Most of them were developed before flexible FO was established Global description Market specification Macintosh 80% Miller 12% Foregger-Magill 3% Special blades Paediatrics Dörges/Henderson 2% 3% Global description • • Since 1943 For standard intubation of patient with normal anatomy Sizes • • • • • Size 5 Size 4 Size 3 Size 2 Size 1 4% 44% 40% 10% 2% Global description Krypton light Different Types of Lights Warm light Halogen light Xenon light Cold light LED light Laryngoscopes by Teleflex Cold Light • X-LITE • Reusable metallic blades all types • Disposable plastic blades Mac & Mill. • X-LITE Take-A-Part • Reusable metallic blade Mac only • Replaceable light holder • SafeView • Plastic disposable blades Mac & Mill. • Metallic disposable blades Mac & Mill. • All include a protection sheath Warm Light • S-LITE • Metallic reusable blades • Plastic disposable blades • Mac & Mill. Mixed System •FOCS •Reusable metallic blades Mac & Mill •Can be used with a standard (warm light) handle as bulb is positioned at the rear of the blade not on the handle Laryngoscopes by Teleflex Handles Safeview - LED handle cold light with battery container (non rechargeable) X-Lite - Xenon handle (cold light) with battery container (non rechargeable) FOCS - Standard handle warm light with battery container (non rechargeable) Laryngoscopes by Teleflex Disposable blades: Out of a survey At the university hospital 12 of the 25 handles (48%) 1 of the 25 blades (4%) At the community hospital 7 of the 13 handles (54%) 3 of the 13 blades (23%) tested positive for occult blood contamination after cleaning and disinfection (the surfaces of laryngoscope handles and blades are irregular and contain potential repositories for infectious material) Laryngoscopes by Teleflex Disposable blades X-LITE General Ideally suited for emergency and ambulant care! Single packed, ready for immediate use Sizes: 2/3/4 Fibreglass light holder The fibreglass light holder makes it possible to use fibreoptic handles Xenon or LED light (depending on type of handle used) Sizes: 0/1 Laryngoscopes by Teleflex Disposable blades SafeView – Plastic & Metallic General Ideally suited for emergency and ambulant care Curved blade, can be used with small mouth opening, easy insertion Protection Sheath secure fixation rounded atraumatic tip medical grade stainless steel Single packed, blade already inserted in protection sheath ready for immediate use No risk of handle contamination Fibreglass light holder The fibreglass light holder makes it possible to use fibreoptic handles reduced height to fit all patients Laryngoscopes by Teleflex Disposable blades SafeView – Plastic & Metallic Xenon or LED Light (depending on type of handle used) Sizes Plastic Metal Mac Intosh 1 to 4 0 to 4 Miller 0 to 2 00 to 4 Laryngoscopes by Teleflex Disposable blades SafeView – Plastic & Metallic How to use the protection sheath Connect the blade in its protection sheath onto the handle. Maintain sheath at connection side and tear out the pre-cut tip of the sheath. Protect the handle by sliding the sheath over it. Once intubation is successful, slide the sheath back onto the blade and dispose blade & sheath. Laryngoscopes by Teleflex Disposable Laryngoscopes – Metallic LED Light Sizes Metal Mac Intosh 1 to 4 Miller 00 to 2 Laryngoscopes by Teleflex Cleaning and sterilisation Please always take a close look at directions for use!!! Always comply with local regulations as they may differ When using any disinfectant or sterilization solutions be sure to follow the manufacturers instructions. Be sure that bulbs are in place before any type of cleaning - Do not remove bulbs Immediately after using instruments should be rinsed in clean tap water to remove any residue. External surfaces should be gently scrubbed in soapy water with a soft brush. Laryngoscopes by Teleflex Cleaning and sterilisation General sterilisation procedures for blades • • • • Gas sterilisation i. e. Formaldehyd, Ethylenoxid Plasma sterilisation i. e. STERRAD Chemical sterilisation i. e. STERIS Autoclave sterilisation at up to 134ºC for 18min (WHO/CDS PH/92.104) Sterilisation of laryngoscope handles Please note that not every technique of sterilisation is usable. The right procedure depends on the type of handle. Laryngoscopes by Teleflex Handles and sterilisation • Handles in general are not to be sterilised with batteries in them • Standard handles should not be immersed in any liquid rather wipe clean and dry oxydation due to aggressive materials used for cleaning which have seeped inside the handle can affect contact between spring and bottom • X-LITE handles can be immersed in cleaning/disinfectant solution and can be sterilised using chemical or plasma or gas-sterilisation Not suitable for autoclave because of too high temperature • The Dolphin handle is absolutely fluid-proof! Therefore, the batteries do not need to be removed during cleaning nor during chemical sterilisation. However the batteries must be removed if the handle is sterilised in autoclave Laryngoscopes by Teleflex Replacement parts Teleflex offers replacement parts as shown in the catalogue • • • • • Lights Lid for handle casing Battery container (without light and without battery) Rechargeable battery Actuator for handle small/large For any other case please note that it is inexpedient to send the instrument back to be repaired because this is more expensive than to buy a new one! Product Training Carol Seroussi November 2009 Endotracheal Tubes Features of the Tube • • • • • • • • • • 56 Material Wall Thickness = ID/OD ratio Markings Size: mm ID Cuff: Design, Material Position Indicator Tip: Magill or Murphy Inflation Line Pilot Balloon Connector: 15 mm Female ISO The Cuff Functions • Seals the airway • Avoids aspiration • Avoids gas leaks Various forms of trachea 57 • Cuffed tubes are generally used in adults, uncuffed in peds although this is changing • Modern trach tube cuffs have a large resting volume & diameter and a thin wall which allow seal without stretching the cuff wall • Cuff size is important Cuff Pressure • Lateral wall pressure = points of contact of the cuff onto the trachea • Intracuff pressure reflects the lateral wall pressure • Optimal cuff is sufficiently large to effect a seal before being inflated to its residual volume = a cuff with a resting circumference higher than tracheal circumference • Ordinary the cuff pressure should not exceed 25cmH2O 58 Cuff Pressure Over inflation induces high lateral wall pressure and can result in : • • • • Sorethroat Mucosal inflammation Ulcerations Cartilagenous destruction • Tracheal stenosis • Cuff rupture with subsequent deflation • Cuff distortion which may lead to airway blockage 59 Cuff Pressure Low Volume - High Pressure Cuff • Cuff resting diameter < tracheal diameter • Cuff pressure monitored is often > 30 cm H2O to seal • Perfusion in the tracheal mucosa is reduced or stopped 60 Cuff Pressure High Volume - Low Pressure Cuff • Cuff resting diameter > tracheal diameter • Cuff pressure is adjustable under a level of 30 cm H2O • Perfusion in the tracheal mucosa is reduced but sufficient for the nutrition of the tissues 61 Cuff in a D-Shaped Trachea Too much pressure leads to necrosis Dilation of the trachea No seal leaks Herniation of the cuff Too much pressure on the wall of the trachea Cuff Sealing High Pressure Deflated Cuff Low Pressure Deflated Cuff High Pressure Inflated Cuff Low Pressure Inflated Cuff Cuff Sealing & Aspiration Discussion Consensus about pressure/volume • All cuffs are High Volume – Low Pressure Discussion is about design & material Until 2007 Manufacturers’ claims were mainly about tracheal wall pressure to ensure lowest patient trauma = battle around cuff thickness PVC Barrel Cuff Covidien Hi-Lo Teleflex Rusch 64 PVC Tapered Cuff Teleflex Sheridan HVT Portex Soft Seal Cuff Sealing & Aspiration Discussion Consensus about pressure/volume • All cuffs are High Volume – Low Pressure Discussion is about design & material Since 2007 – Manufacturers’ claims are mainly about sealing to avoid silent aspiration & reduce VAP occurence Claim: reduces microaspiration by at least 95% compared to the Mallinckrodt™ HiLo™ basic, barrelshaped, PVC cuff PU Barrel Cuff KC Microcuff 65 Claim: reduces microaspiration by at least 81% compared to the Mallinckrodt™ HiLo™ basic, barrelshaped, PVC cuff PU Tapered Cuff Covidien SealGuard PVC Tapered Cuff Covidien TaperGuard Cuff Sealing & Aspiration Discussion Claim1: Covidien SealGuard reduces microaspiration by at least 95% compared to the Mallinckrodt™ Hi-Lo™ basic, barrel-shaped, PVC cuff Claim2: Covidien TaperGuard reduces microaspiration by at least 90% compared to the Mallinckrodt™ Hi-Lo™ basic, barrel-shaped, PVC cuff • Mostly in vitro or bench studies comparing Sealguard/ TaperGuard to Hi-Lo • Patient studies are mostly non-conclusive due to • Number of patients • Patient population • Ventilation time • …etc • Study from Lorente in CCM 2007 • Conclusive about •PU cuff •SSD • Not conclusive about cuff design 66 Main types of tubes Uncuffed tubes • Mainly used for children as the cricoid ring in children is circular and constitutes the smaller part of the larynx. • An ETT of the right size will provide good seal • In adults, the proximal part of the larynx is barely circular, thus seal cannot be done by the tube only. • Usually uncuffed ETT has a black distal tip (15 to 40 mm according to size) to help position it behind the vocal cords and graduation markings through the whole length. 67 Main types of tubes Cuffed tubes • Most used • Used when leakage control is necessary • Cuff presence decreases the ID of the tube (inflation channel) thus increasing the respiratory resistances • Inflation of the cuff must be ckecked periodically • Use in children developing 68 Main types of tubes Armoured tube • Armoured tubes have a better resistance to kinking or compression • Mainly used in situations when a compression or kinking risk exists (trauma, larynx compression…) • Available with or without cuff Special tubes • Preformed tubes – – – – – Nasal or oral Mainly used in oral & maxillo-facial surgery No bulky connections near the operating site Difficult aspiration Oral ETT are usually shorter than nasal ones • Laser tube – Used for ENT surgery – Non flammable • Microlaryngeal 69 Standard Tubes Characteristics • Suitable for anesthesia (short- & medium-term) • Suitable for long-term ventilation in ICU • Made of • Thermo-sensitive PVC (Rüschelit® - latex free - disposable) • Soft Silicone (latex-free - reusable) • Red Rubber (with latex - reusable) • Tubes can be used nasally or orally (except Red Rubber) • Black position indicator (except Red Rubber) • Murphy Eye optional for most tubes • Cuffed or uncuffed versions for most tubes 70 Standard Tubes – Cuffed or Uncuffed Disposable • PVC Reusable • Silicone • Rubber 71 Standard Tubes Disposable - PVC • SafetyClear • Uncuffed • Magill 100380 • Murphy 100382 • Sizes (ID) 2 to10 mm • Super SafetyClear • Low-Pressure Cuff • Magill 112480 • Murphy 112482 • Sizes (ID) 2,5 to10 mm • 112481 Murphy w/Flexislip stylet • Indications: short & medium term intubation; anesthesia or emergency 72 Standard Tubes Disposable - PVC • Main Competitors • Main advantages over competition • Tyco/Mallinckrodt • Cuff enables more resting • Lo-Contour Cuffed & diameter Uncuffed • Less pressure on tracheal wall • Portex • Less trauma • Blue Line Cuffed & Uncuffed • Comparable to Hi-Lo from Tyco • Sheridan at a better price • CF Close Fitting CF Lo-Contour 73 Blue Line Standard Tubes Reusable – Silicone & Rubber • SilkoClear 105102 • Silicone tube w/ preformed cuff • Nasal/oral Murphy eye • Sizes (ID) 5 to 9 mm • Soft Red Rubber Tube 102000 • Red Rubber tube w/ Silkolatex cuff • Coated with Silkolatex • Nasal/oral Magill type • Sizes (ID) 2.5 to 11 mm • Indication : short/medium term intubation during surgery in anesthesia or emergency • Competition • Phoenix Medical 74 Intensive Care – Emergency Longer term intubation Nasal/Oral • Safety Clear Plus • Super Safety Silk 75 Intensive Care – Emergency Disposable • SafetyClear Plus • Clear PVC • Magill 112080 • Murphy 112082 • High-Volume Low-Pressure Cuff • Sizes (ID) 5 to10 mm • Indication: long term intubation nasal/oral in ICU & Emergency • Main Competitors • Tyco/Mallinckrodt • Hi-Lo Cuffed & Uncuffed (HVLP Cuff) • Sheridan • HVT – High Volume Tapered (HVLP Cuff) • Portex • Blue Line® with HVLP Soft-Seal Profile cuff 76 Tyco Hi-Lo Cuff Blue Line HVT Intensive Care – Emergency Disposable • Super SafetySilk 112680 + 112682 • Extremely soft & highly thermosensitive PVC • Velvet-like surface but not completely smooth inside & outside tube for improved sliding properties • High-volume/low-pressure cuff • Sizes (ID) 5 to10 mm • Hooded soft tip: atraumatic intubation • Indication: long-term intubation, nasal and oral • 112682 • Murphy eye & softer material • Sizes (ID) 3 to10 mm • Fits perfectly for nasal intubation in ICU, ENT surgery or paediatric ICU • Soon to be: DEHP-Free version 77 Intensive Care – Emergency Disposable Competition Portex Ivory • Main Claims • PROFILE SOFT SEAL cuff made from velvet soft PVC material • Larger cuff resting diameter “PROFILE SOFT SEAL cuff combines the benefits of the PROFILE cuff design with a larger cuff resting diameter“ Main advantages 112682 over Ivory • Less traumatic bevel • Inflation channel situated near proximal end of the tube and not in the middle • More sizes available 5 to10 as compared to 5 to 9 + pediatric sizes 3 to 5 • Less expensive • Soon to be: DEHP-Free 78 Intensive Care – Emergency Disposable • Competition Tyco/Mallinckrodt SatinSoft – Hi-Lo™ cuff for added sealing – Soft atraumatic tip – Murphy eye – Oral & nasal intubation • Competition Sheridan Naz-Al – Special PVC blend for added softness – Soft atraumatic tip – Cuff inflation line positioned high reduces nasal trauma 79 Intensive Care – Emergency Disposable • EDGAR tube 111480 (w/ cuff) 111380 (w/o cuff) • Endotracheal Drug and Gas Application during Resuscitation • PVC Magill tube w/ low-press cuff & additional instillation channel with luer-lock adapter • Sizes (ID) • 6.5 mm to 10 mm with cuff • 2.5 mm to 6 mm without cuff (black tip) • Indication: endobronchial application of drugs during cardiopulmonary resuscitation • Emergency, ICU 80 Intensive Care – Emergency Disposable • Competition Sheridan Stat-Med • Cuffed tube with secondary lumen positioned at tip for rapid drug delivery to lungs • May be used to monitor pressure, endtidal CO2 or for tracheal lavage • HVT cuff • Competition Sheridan LITA Laryngotracheal Instillation of Topical Anesthesia • Distribution of lidocaine at the end of an operation so that there is no bucking and coughing during extubation. • 8 holes (6 above the cuff and 2 below) where the lidocaine is sprayed 81 Intensive Care – Emergency Disposable • Aid Instillation Kit 111100 • Instillation catheter + angled plastic connector • Indications • Endotracheal drug application during resuscitation • Application of surfactant in neonatology • Emergency, NICU • Competition • none 82 Intensive Care – VAP Prevention / Intervention Intervention to prevent VAP should start BEFORE intubation • What decisions can be made prior to intubation? –Type of ETT that will be utilized –Has OR staff been educated on VAP and how to prevent it? – Intubate orally rather than nasally – Intubate with a “long-term” ETT if the patient is at risk of ICU stay – Use an ETT that allows subglottic suctioning 83 Once Intubated…. 84 Intensive Care – VAP Prevention / Intervention MARKET NEED: VAP REDUCTION Subglottic Secretion Suctioning (SGS) • Secretions accumulate above the ET tube cuff • Secretions can seep past the cuff into the lower tract, causing pneumonia1 • Drainage of the subglottic secretions is an effective strategy in preventing VAP2 1. 2. 85 American Thoracic Society. Consensus Statement: Hospital Acquired Pneumonia in Adults: diagnosis, assessment of severity, initial antimicrobial therapy, and preventative strategies. Am J Respir Crit Care Med. 1996;151:1711-1725. Dezfulian C, Shojania K, Collard HR, Kim HM, Matthay MA, Saint S. Subglottic secretion drainage for preventing ventilator-associated pneumonia: a meta-analysis. Am J Med 2005; 118:11-18. Intensive Care – VAP Prevention / Intervention The Clinical Challenge – Hospitals find existing solutions cost prohibitive to apply to all patients – 7x more expensive to utilize 100% Evac tubes versus standard – Anesthesiologists are not a stakeholder in VAP prevention – 80% of all hospital-based intubations take place in the Operating Room – Patients that need access to SGS often are not intubated with the appropriate tube – ~ 20% of intubation require long-term ventilation – Difficult to predict who will be long-term versus short-term – If a subglottic secretion suctioning ET tube is not used at initial intubation – Patient must be extubated and re-intubated – – not advised in VAP-Prevention guidelines most clinicians are reluctant – It’s a classic Catch 22: ETT is available to help prevent VAP but clinicians don’t have widespread access to it because of cost. When they decide they need it, they can’t use it because of patient safety concerns. Intervention to prevent VAP has to start BEFORE intubation 86 Intensive Care – VAP Prevention / Intervention Predicting which patient will remain on long-term ventilation and need a special ETT is not always easy Hospitals find existing solutions cost prohibitive to apply to all patients Physicians are reluctant to disturb a patent airway RESULT PATIENT SELECTIVITY AT INTUBATION 87 TELEFLEX ISIS The First Convertible Endotracheal Tube Eliminates selectivity • Convertible endotracheal tube with integrated suction port – Ideal choice for both short and long term intubation – Simplifies tube selection and consolidates inventory • Separate suction line allows for subglottic secretion removal, on demand – Increases the number of patients that can be viable candidates for subglottic suctioning, a clinically proven strategy for VAP reduction 88 TELEFLEX ISIS The First Convertible Endotracheal Tube High Volume Low Pressure Cuff • Effective seal at low pressures • Design reduces pressure on the tracheal wall Placement ring • Provides visual depth marking for tracheal placement Suction Lumen • Allows removal of accumulated secretions • Custom design reduces likelihood of mucus obstruction 89 * Does not replace cuff pressure monitoring Pilot Balloon • Tactile feedback allows for optimal gauge of cuff inflation* • Convenient size printing Integrated suction port • Easy connection to the suction line • Strategically positioned for placement out of patient’s mouth • Cap seals suction port when not in use TELEFLEX ISIS The First Convertible Endotracheal Tube Suction line with integrated sealing caps • Design allows for easy connection to the suction port • Caps protect environment & suction line when line not in use Easy to hold connector • Custom design connector • Enables easy handling when connecting/ disconnecting suction tubing • No extra force applied on patient’s ET 90 Integrated suction port • Easy connection to the suction line • Strategically positioned for placement out of patient’s mouth • Cap seals suction port when not in use TELEFLEX ISIS ANESTHESIOLOGY The Teleflex ISIS is designed to be the right product, every time • Eliminates the need to choose which type of tube to use Distinct features and benefits are targeted at separate audiences • Anesthesiology • Intensive Care 91 • • • • • High Volume Low Pressure Cuff Placement Ring Pilot Balloon with tactile feedback Soft, molded tip Ability to remove secretions after an extended surgical procedure INTENSIVE CARE • Integrated suction port on the ETT • Custom Suction Lumen for Subglottic Secretion Suctioning • Separate suction line with ergonomically designed connector • If clogged, suction line can be changed without reintubating patient • Hight Vomume Low Pressure Cuff • Pilot Balloon with tactile feedback COMPETITIVE OVERVIEW: EVAC First product on the market with subglottic secretion suctioning capabilities • Secretions enter the evacuation port near the cuff and are removed through the suction lumen, which is connected to wall suction Three different variations available • Hi-Lo EVAC – Hi-volume low pressure barrel cuff design • TaperGuard Evac – PVC tapered cuff design • SealGuard Evac – Polyurethane tapered rather than PVC 92 COMPETITIVE OVERVIEW: EVAC CUFF DESIGNS SealGuard Evac • Polyurethane • New design “pear-shape” • Designed to adhere closely to the walls of the trachea to prevent subglottic secretion slippage into the lungs • Similar cuff material to Kimberly Clark MicroCuff TaperGuard Evac • PVC • New design “pear-shape” • Reduces leakage past the cuff by at least 81%, compared with the Mallinckrodt Hi-Lo™ endotracheal tube 93 Example of Mallinckrodt Cuff Comparisons Left Side Tapered – Right Side Barrel COMPETITIVE OVERVIEW: SACETT Portex Blue Line SACETT • Unique blue inflation line • Actual Ivory tube with Soft Seal cuff • Suctioning capabilities are a direct knock-off of the Hi-Lo Evac tube 94 Special Tubes – Preformed • Preformed • AGT • Nasal Safety Silk • Others • Laser • Microlaryngeal • BronchoFlex 95 Special Tubes – Preformed AGT/Oxford Tubes Characteristics • Anatomically shaped preformed tubes • Used for surgery in the head, neck and throat • Allow placement of the breathing circuit away from the surgery field • Avoid tube kinking • Thermo-sensitive PVC (Rüschelit®) for better adaptation to patient’s morphology 96 Special Tubes – Preformed AGT Oral AGT tracheal tube • • • • • • • • • • Anatomically shaped preformed tubes made of PVC Low-pressure cuff; radiopaque line Unique design helps protect against kinking and disconnections Curve can be temporarily straightened to allow easy passage of suction catheter. Available cuffed/uncuffed, oral/nasal Cuffed: hooded Murphy tip with eye; Uncuffed: 2 eyes for peds Indications : short/medium term for head, ENT, neuro- & maxillofacial surgeries when it is necessary to direct breathing circuits away from the operative field AGT cuffed oral 111780 3.5 to 9 mm; nasal 111781 3.5 to 8 mm AGT uncuffed oral 100180 3 to 7 mm; nasal 100181 3 to 6.5 mm NEW Nasal Safety Silk preformed, Murphy with cuff 111782 sizes 3.5 to 8 mm = softer material AGT Nasal 97 Special Tubes – Preformed 98 Nasal Safety Silk Nasal Safety Silk • Softer PVC • All dimension as per existing 111781 except – Tube OD one size up to improve kinking resistance – Proximal tip longer to avoid trauma to patient forehead • Increased curvature/elbow radius in order to have a better kinking resistance • All sizes come with light blue x-ray line • PA white connector bonded to the shaft • Connector vertical to main axis of tube to be less traumatic on patient’s face Main advantages over competition • As soft as silk for nasal or pediatric intubations • Extremely smooth and gliding surface • Atraumatic tip • Optimaldistal length to avoid selective intubation • Available in all sizes and half sizes • Black ring for easy positioning • Pediatric sizes RAE Tracheal Tubes RAE stands for: *and occasionally, Ring, Adair, and Eldwin 99 Portex PDT & Polar Special Tubes – Preformed • Competition Portex® Directional Endotracheal Tube (PDT) • Pediatric and adult sizes • Cuffed or uncuffed • Oral/nasal configurations • THE reference in nasal preformed tube • Nellcor Nasal & Oral RAE® • Available in cuffed and uncuffed styles • Oral/nasal configurations • Tip-To-Tip® radiopaque line • Sheridan • Available cuffed and uncuffed • Oral/nasal configurations • Sheridan’s original design with Dr.'s Ring, Adair, Elwin (RAE) • HVT cuff 100 Tyco RAE Sheridan Special Tubes – Preformed Oxford tube 112880 • • • • • • Anatomically shaped tube Non kinking PVC Low-pressure cuff Sizes = 7 to 10 mm Indications : oral intubation Anesthesia, emergency Competition • • • • 101 Tyco/Mallinckrodt Portex Phoenix Vygon Special Tubes – Laser • Laser tube 102004 • Laser resistant tracheal tube made of white soft rubber • Material: laser-guard foil 17 cm long consisting of Merocel® foam and corrugated silver foil • Special double cuff design with double pilot balloons • Non-kinking design • Sizes 4 to 8 mm • Indications : ENT & mouth laser surgery • Competition Tyco Laser-Flex® • Stainless steel laser-resistant body • Smooth surface and Magill curve minimize trauma during intubation • Patented double cuff design 102 Special Tubes – Laser • Competition Sheridan Laser-Trach •Red rubber design •Embossed copper foil diffuses laser energy minimizing unintended laser damage to tissue •Covered with absorbent polyester knit for fume by-products of combustion •For CO2 and KTP laser surgery • Competition Medtronic-Xomed Laser-Shield® II • Tested for use with CO2 and KTP lasers • Reflective aluminum wrap with smooth fluoroplastic overwrap for atraumatic intubation • Methylene blue is present in the inflation valve to provide immediate detection of inadvertent cuff rupture • All tubes are cuffed 103 Special Tubes – Microlaryngeal • Microlaryngeal tube 112460 • Smaller OD allows easier intubation of airway narrowed by tumor or abnormality & optimal access to the operating field • Made of PVC with low-pressure cuff • Cuff size and tube length like an 8,5 mm classic tube • Sizes (ID) 4 to 6 mm • Indications : surgery in the laryngeal space • Competition Tyco - MLT Sheridan LTS 104 Armoured Tubes Characteristics • Procedures where patient’s head will be flexed, extended or repositioned during surgery; head, neck & throat surgery, maxillofacial, reconstructive, cranial..etc for prevention of tube kinking • When bronchoscopic intubation is performed to remove the breathing circuit from the surgery field • Thermo-sensitive PVC (Rüschelit®) or silicone or latex 105 Armoured Tubes - Disposable • Rüschflex 104201, 104202, 104203 • Made of soft PVC able to keep perfectly the curved form • Fixed white connector • Soft and frosty balloon • Soft and atraumatic formed tip Frost cuff & hooded tip 106 Armoured Tubes - Disposable THE RUSCHFLEX Four types to offer the right solution • 104201 Magill, from 3.5 to 10mm • 104202 Murphy eye, 3.5 to 10mm • 104203 Magill with Flexi Slip stylet • 104203 Murphy with Flexi Slip stylet Mainly for facial, ENT and neuro-surgery 107 Armoured Tubes - Disposable • Competition Tyco • Milky tube • No radiopaque detection below cuff • Clinician cannot determine tip placement on X-ray, • Higher pressure • Thinner wall • Less kinking resistance • Cuffed 5 to 9,5 mm • Uncuffed 3 to 5 • Competition Portex • Difficult to insert due to straight shape • Competition Sheridan Spiral-Flex • Oral ref with preloaded stylet and bite guard available • Less kinking resistant 108 Armoured Tubes - Disposable • Bronchoflex set 104100 • Tracheal tube for oxygen insufflation during fiberoptic or rigid bronchoscopy • Double lumen ID 7,5 mm & 3 mm • Uncuffed • ICU, endoscopic departments • Set composed of armoured tube, oxygen tube, plastic bite block with fixation flange & neck band 109 Armoured Tubes - Disposable • Silkolatex tube with cuff 103040 • Removable connector to allow fiberoptic intubation • Sizes 3 to 10.5 mm • SilkoClear Flex with flexible thin-wall cuff 105702 • Fixed connector • Sizes 3.5 to 10 mm • Short/middle-term anesthesia • Competition • Bivona Fome-Cuf® Wire Reinforced Fome-Cuf material automatically adjusts to trachea and helps protect from aspiration. 110 Pediatric Tubes • Usually tubes w/o cuff due to difference between anatomical structures & ped airway fragility • Increased demand for cuffed tubes since high pressure low volume cuffs on the market • Disposable and reusable tubes • With & w/o spiral • Made of PVC, Latex, Silicone, Rubber 111 Pediatric Tubes Uncuffed tracheal tubes for infants and children • • • • • • • • 112 100280 – SilkoClear, silicone, oral/nasal, Magill, 2 to 4.5 mm 100380 – SafetyClear, PVC, oral/nasal, Magill, 2 to 6.5 mm 100382 – SafetyClear, PVC, oral/nasal, Murphy, 2 to 6.5 mm 100480 – SafetyClear Soft, PVC, oral/nasal, Magill, 2 to 5.5 mm 100780 – AGT preformed, PVC, oral, 2 eyes, 2 to 6.5 mm 100181 – AGT preformed, PVC, nasal, 2 eyes, 2 to 6.5 mm 103600 – Armoured, PVC, nasal/oral, Magill, 2,5 to 6.5 mm 105400 – Armoured, silicone, nasal/oral, Magill, 2 to 6.5 mm Pediatric Tubes Cuffed tracheal tubes for infants and children • • • • • • • • 113 102000 – Soft red rubber, oral/nasal, Magill, 2,5 to 6 mm 112480 – Super SafetyClear, PVC, oral/nasal, Magill, 2,5 to 6 mm 112482 – Super SafetyClear, PVC, oral/nasal, Murphy, 2,5 to 6 mm 111780 – AGT preformed, PVC, oral, 1 eye, 3,5 to 6 mm 111781 – AGT preformed, PVC, nasal, 1 eye, 3,5 to 6 mm 104201 – Rüschflex, PVC, nasal/oral, Magill, 3,5 to 6.5 mm 104202 – Rüschflex, PVC, nasal/oral, Murphy, 3,5 to 6.5 mm 112682 – Safety Silk, soft PVC, nasal, Murphy, sizes 3.5 to 4.5 mm Teleflex Laryngeal Masks Overview Introduction It provides an “oval seal around the laryngeal inlet” once it is inserted and the cuff inflated Once in place, it lies at the crossroads of the digestive & respiratory tracts 115 Indications of the Laryngeal Mask • Laryngeal masks are indicated for use as an alternative to the face mask for achieving and maintaining control of the airway • Laryngeal masks are not indicated as a replacement for the endotracheal tube • Laryngeal masks are indicated for use in • Routine and emergency anesthetic procedures • Known or unexpected difficult airways • Establishing an airway during resuscitation in the profoundly unconscious patient with absent glossopharyngeal and laryngeal reflexes when tracheal intubation is not possible • May be used as a fiberoptic conduit when intubation is difficult, hazardous or unsuccessful • Can be used for bronchoscopy in the awake or asleep patient 116 Contraindications of the Laryngeal Mask • As a routine airway, laryngeal mask is contraindicated in patients who • • • • • • • • • Are not fasted or where fasting cannot be confirmed May have retained gastric contents Greater than 14 to 16 weeks pregnant Have multiple or massive injury Have massive thoracic injury Have massive maxillofacial trauma Are at risk of aspiration Morbidly obese patients Obstructive or abnormal lesions of the oropharynx NOTE: Not all contraindications are absolute • As an emergency airway, it is contraindicated in patients who • • • 117 Are not fasted Are not profoundly unconscious May resist insertion Side-Effects of the Laryngeal Mask • Throat soreness • Dryness of the throat and/or mucosa • Side effects due to • Improper placement • Overinflation of the cuff 118 Teleflex Laryngeal Masks Insertion Technique Laryngeal Mask - Preparation for Insertion Size OD (mm) ID (mm) Description & weight capacity* Cuff Volume Standard Single Use and Reusable 1 5.3 8 Neonates/Infants up to 5 kg < 4ml 1.5 6.1 10 Infants 5-10 kg < 7ml 2 7.0 11 Infants/Children 10-20 kg <10 ml 2.5 8.4 13 Children 20-30 kg <14 ml Step 1: Size Selection 3 10 15 Children 30-50 kg <20 ml Verify that the size of the laryngeal mask is correct for the patient 4 10 15 Adults 50-70 kg <30 ml 5 11.5 17 Adults 70-100 kg <40 ml 6 11.5 17 Adults >100 kg <50 ml Flexible Single Use and Reusable *Patient weight is a guide only, clinical judgement is key 120 1 5 7 Neonates/Infants up to 5 kg < 4ml 1.5 5 7 Infants 5-10 kg < 7ml 2 5.1 9 Infants/Children 10-20 kg <10 ml 2.5 6.1 10 Children 20-30 kg <14 ml 3 7.6 11 Children 30-50 kg <20 ml 4 7.6 11 Adults 50-70 kg <30 ml 5 8.7 12 Adults 70-100 kg <40 ml 6 8.7 12 Adults >100 kg <50 ml Laryngeal Mask - Preparation for Insertion Step 1: Size Selection • Size 4 is the normal adult size for male & female • Many adults will comfortably take a size 5 • Size 3 is mostly a pediatric size • Or small adults for whom size 4 does not stay • When in doubt –> use a larger size with small inflation volumes rather than a smaller size excessively inflated • If the mask is too small • The aperture may be below the level of the glottis, causing obstruction • Overinflation may be needed to obtain a seal *Patient weight is a guide only, clinical judgement is key 121 Laryngeal Mask - Preparation for Insertion Step 2: Examination of the Laryngeal Mask • Visually inspect the laryngeal mask cuff for tears or other abnormalities • Inspect the tube to ensure that it is free of blockage or loose particles Step 3: Deflation & Inflation of the Laryngeal Mask • Deflate the cuff to ensure that it will maintain a vacuum & form a smooth flat wedge shape which will pass easily around the back of the tongue and behind the epiglottis. This can be performed by pushing down the mask on a flat surface, with 2 fingers pushing the tip • Inflate the cuff to ensure that it does not leak maximum air in cuff should not exceed the recommended guidelines 122 Laryngeal Mask - Preparation for Insertion Step 4: Lubrication of the Laryngeal Mask • • • • Use a water soluble lubricant Only lubricate just prior to insertion Lubricate the back of the mask thoroughly Avoid excessive amounts of lubricant on the anterior surface of the cuff or in the bowl of the mask as inhalation of the lubricant following placement may result in coughing or obstruction Step 5: Positioning of the airway • • • • • 123 Open the mouth Extend the head and flex the neck Pull the lower jaw downwards Visualize the posterior oral airway Ensure that the laryngeal mask is not folding over in the oral cavity as it is inserted Laryngeal Mask – Insertion Technique Insertion Video - Intersurgical Insertion Video - LMA 124 Laryngeal Mask Insertion Grasp the laryngeal mask by the tube, holding it like a pen as near as possible to the mask end Place the tip of the laryngeal mask against the inner surface of the patient’s upper teeth 125 Step 1 Laryngeal Mask Insertion Under direct vision, press the mask tip upwards against the hard palate to flatten it out Using the index finger, keep pressing upwards as you advance the mask into the pharynx to ensure the tip remains flattened and avoids the tongue 126 Step 2 Laryngeal Mask Insertion Keep the neck flexed and head extended Press the mask into the posterior pharyngeal wall using the index finger Keep mouth open for better visualization by pushing lower jaw downwards 127 Step 3 Laryngeal Mask Insertion Continue pushing with your index finger Guide the mask downward into position Push the mask into the hypopharynx until resistance is felt 128 Step 4 Laryngeal Mask Insertion Grasp the tube firmly with the other hand Withdraw your index finger from the pharynx Press gently downward with your other hand to ensure the mask is fully inserted 129 Step 5 Laryngeal Mask Insertion • Inflate the mask with the recommended volume of air to obtain a “just-seal” • Maximum recommended pressure is 60 cmH2O • Do not touch the laryngeal mask tube while it is being inflated unless the position is obviously unstable. • Make sure the black line remains aligned with nasal septum & upper lip at all times • Normally the mask will rise up slightly out of the hypopharynx as it is inflated, to find its correct position 130 Step 6 Verify & Secure Placement Step 7 • Inflate the cuff • Connect the laryngeal mask to a Bag-Valve Mask device or low pressure ventilator (20 cmH2O for correct seal) • Check for leaks: ventilate the patient while confirming equal breath sounds over both lungs in all fields and the absence of ventilatory sounds over the epigastrium • Insert a bite block or roll gauze • Affix the laryngeal mask 131 Removal of the Laryngeal Mask • Mask should be left in place until • patient recovers his reflexes • patient can spontaneously open his mouth upon verbal request • Patient may remove the mask as soon as protective reflexes are back – this occurs with the cuff inflated… • Should the cuff be deflated prior to removal of the mask? • If the cuff is fully inflated – Secretions will be removed – High risk of patient trauma • If the cuff is fully deflated – Secretions will fall past the cuff into the bronchus – Risk of laryngospasm – Suctioning can be necessary • If the cuff is moderately inflated – Secretions will be removed – Suctioning should not be necessary 132 Issues with Laryngeal Mask Insertion Failure to press the deflated mask up against the hard palate or inadequate lubrication or deflation can cause the mask tip to fold back on itself. Once the mask tip has started to fold over, this may progress, pushing the epiglottis into its down-folded position causing mechanical obstruction 133 If the mask tip is deflated it can push down the epiglottis causing obstruction If the mask is inadequately deflated it may either push down the epiglottis penetrate the glottis Teleflex Laryngeal Masks Product Information Introduction • A laryngeal mask consists of • A mask or cuff (with or without epiglottis bars) • A tube with an inflation line • A 15 mm connector • A pilot balloon Teleflex Sure Seal Laryngeal Mask 15mm Connector Silicone Cuff Product Information Tube Black Line Epiglottis Bars 135 Inflation Line Cuff Pilot (or Standard Pilot Balloon) Laryngeal Masks – RUSCH Crystal Airway Mask 136 Laryngeal Masks – RUSCH Crystal Airway Mask 137 Item Code Description Color Packaging 111000-00010 Rüsch CAM, Size 1.0 Clear 10 / Case 111000-00015 Rüsch CAM, Size 1.5 Blue 10 / Case 111000-00020 Rüsch CAM, Size 2.0 Green 10 / Case 111000-00025 Rüsch CAM, Size 2.5 Light Purple 10 / Case 111000-00030 Rüsch CAM, Size 3.0 Orange 10 / Case 111000-00040 Rüsch CAM, Size 4.0 Pink 10 / Case 111000-00050 Rüsch CAM, Size 5.0 Yellow 10 / Case Laryngeal Masks – RUSCH Crystal Airway Mask Key Features Rotationally-moulded laryngeal cuff • Produces a cuff with stronger yet thinner wall • Posterior aspect of cuff (top) is reinforced –Reduces possibility of distal portion of cuff folding back on itself upon insertion • Support wedge between cuff and tube –Prevents cuff from pushing back against the tube –Prevents leaks around epiglottis and base of tongue • Smooth transition from tube to cuff • No risk of a “disconnect” of the cuff from the tube 138 Laryngeal Masks – RUSCH Crystal Airway Mask Key Features Location of pilot balloon line attachment • Attaches to ventilation tube just below the 15 mm connector –Integrated through the wall of the tube • Produces a stronger connection to inflation lumen • Protects the point of connection • Angles out at a 450 angle to keep out of patient’s face Latex Free Cuff • Safety for both clinician and patient • Prevents any kind of anaphylactic reaction Single Use • Ease of use; prevents cross contamination Seven Sizes Available • To accommodate a wide range of patients Color Coded • To help easily identify different sizes 139 Laryngeal Masks – Sure Seal Product Range Product design as per customer’s preference • • • • • • • • Anatomical shape of the cuff – proven & trusted, best seal Atraumatic & thin tip – better seal, less trauma Silicone cuff for all products – best proven seal, less trauma Epiglottis bars – a plus compared to no bars Rigid yet smooth enough tube – easy insertion Smooth transition from tube to cuff – no trauma Inflation line attached to the cuff – better ID/OD tube 15 mm ISO connector A full offering to cover most needs • Reusable range • • standard & reinforced 8 sizes available – to fit all patients including obese • Disposable range • • • 140 standard & reinforced w/ Standard Pilot Balloon (SPB) or Cuff PilotTM (CP) 8 sizes available – to fit all patients including obese Laryngeal Masks – Sure Seal Product Range Reusable products – Standard & Reinforced • Supplied with a standard pilot balloon Cuff PilotTM cannot be re-sterilized • Autoclavable pilot balloon color differentiated = blue • Transparent connector • Non sterile: same as competition, before use, hospital will sterilize • Single-packed 10 in a cardboard box • No color code for packaging – no need, will be discarded at sterilisation • 3 years shelf-life • Each reusable mask is supplied with a unique serial number & a card with this serial number stamped on it • Each time the mask is sterilized the sterilization staff dates & signs the card – To confirm it has been sterilized – To track the number of uses of each mask 142 Laryngeal Masks – Sure Seal Product Range Disposable products – Standard & Reinforced • Disposable masks are available – 100% silicone with Cuff Pilot – PVC/Silicone with Standard Pilot Balloon – PVC does not contain DEHP – DBP – BBP DEHP-Free PVC – It is not phthalate-free as it contains DINP • Disposable masks are supplied – Sterile ready to use – Single-packed 10 in a flat pack – With a clear standard pilot balloon – non autoclavable – Or with a Cuff Pilot – non autoclavable – 2 years shelf-life – Packaging is color coded for sizes – Blue connector with & without Cuff Pilot 143 Laryngeal Masks – Sure Seal Product Range Features & Benefits Features TM Unique Cuff Pilot technology Benefits Constant pressure monitoring ; tenders lockout by differentiating feature Comprehensive range of products Fulfill most tender requests Single use sterile mask Prevents cross infection; ready to use; convenience; time gain Reusable mask Fully autoclavable at 138°C - guaranteed for 40 uses Reinforced flexible masks Prevents occlusion of the airway tube; suitable for use in head and neck procedures; airway tube may be positioned as required Design as per market leader 200M uses; proven clinical performance Epiglottis Bars Avoids epiglottis to fall & obstruct the airway Straight tube construction Allows easy access of suction catheter, ETT or flexible fibre optic devices Tube Pliability Designed to facilitate insertion & minimize mucosal pressure Silicone extra-soft cuff Soft & atraumatic to patient's laryngeal space; ensures the best possible consistent seal with the least possible mucosal pressure; smoother insertion and quicker sealing time Cuff wedge shape Designed for anatomical fit in the hypopharynx & easy placement Tapered anatomical cuff tip Resists folding over during insertion and plugs the upper esophageal sphincter & reduces gastric insufflation 144 Laryngeal Masks – Sure Seal Product Range Features & Benefits Features Disposable units available as 100% Silicone Disposable units available with PVC tube & Silicone Cuff All units (except reinforced) contain no metal parts Available in 8 clearly marked sizes Cuff inflation volume and patient weight clearly marked on tube Mask size conveniently located at proximal tip of tube Convenient depth marks Inflation line separate from the tube Soft pilot balloon Clearly marked radio opaque black line Individually numbered reusable masks Color coded packaging 145 Benefits Touch & Feel of reusable product Cost effective solution; clear view in case of secretions Allows use in MRI scans Fits all patients Easy replacement Easier identification of correct size Monitoring of correct position Risk of inflation line being bitten is reduced Provides precise tactile indication of degree of inflation Easy insertion Product identification and traceability Easy size identification Laryngeal Masks – Sure Seal Product Range How does Cuff PilotTM work? • Safe cuff inflation is about pressure not volume – optimal maximum cuff pressure in laryngeal masks is – 60 cm of water pressure in adults – 40 to 50 cm of water pressure in infants • Cuff Pilot constantly monitors pressure in the cuff detecting changes due to temperature, nitrous oxide levels & movements within the airway • The integrated device provides at-a-glance feedback, alerting physician instantly to changes before they affect patient safety 146 Laryngeal Masks – Sure Seal Product Range How does Cuff PilotTM work? The integrated device has a valve for inflation and contains 3 coloured zones & 1 clear zone • Green Zone indicates optimal cuff pressure (40 to 60 cmH2O) • Yellow Zone indicates possible under inflation (<40) or decreased cuff pressure • Clear Zone between Green & Red indicates pressure between 60 & 70 – serves to optimize pressure by alerting of pressure deviation & informing of slight deflation need • Red Zone indicates possible over inflation or increased cuff pressure 147 Sure Seal USP – Cuff Pilot Why should we promote Cuff PilotTM? LMA Cuff Pressure – An audit – ASA 2009 – Haldar & Immanuel Anaesthetic Department, Queen's Hospital, Burton-on-Trent, UK “The LMA has many advantages over the face mask and the endotracheal tube. But it can also be associated with morbidities like sore throat, malposition, nerve damage if it is not used correctly. Thus it is important to avoid over inflation of the laryngeal mask cuff at any given time. If the cuff is under inflated, on the other hand, it can produce an inadequate seal making positive pressure ventilation and airway protection from above the cuff ineffective (…) Although cuff pressure monitoring is recommended by the manufacturers, little evidence exists for this in clinical practice. Better awareness on this aspect will reduce the preventable morbidity related to LMA. We recommend that LMA cuff pressure should be monitored routinely when it is used in clinical practice.” 148 Sure Seal USP – Cuff Pilot Why should we promote Cuff PilotTM? Venous congestion of the neck; its relation to laryngeal mask cuff pressures - R. J. Lenoir Portsmouth, UK «This audit has demonstrated that much higher volumes of air are used to inflate LMAs than are necessary, and that after nitrous oxide diffusion, this can lead to very high cuff pressures, well above the standard of 60 cm water recommended. The incidence of venous congestion was also reduced in association with lower cuff volumes, and not observed at all in patients in whom the LMA cuff was inflated just above airway leak pressure. This would have particular relevance in patients undergoing general anaesthesia for eye or head and neck surgery, where raised venous pressure may lead to raised intra-ocular pressure or increased bleeding. In any circumstances, obstructed venous drainage of the head and neck cannot be beneficial» 149 Sure Seal USP – Cuff Pilot Why should we promote Cuff PilotTM? • Nandwani N, Fairfield MC, Krarup K, Thompson J. The effect of LMA insertion on the position of the internal jugular vein. Anaesthesia 1997; 52: 77–83 (on USB Key) • Margot R. Pressure exerted by the laryngeal mask airway cuff upon the pharyngeal mucosa. Br J Anaesth 1993; 70: 25–9 (abstract on USB Key) • Colbert SA, O’Hanlon DM, Flanagan F, Page R, Moriarty DC. The laryngeal mask airway reduces blood flow in the common carotid artery bulb. Can J Anaesth 1998; 45: 23–7 (abstract on USB Key) • Wong JG, Heaney M, Chambers NA, Erb TO, VON Ungern-Sternberg. Impact of laryngeal mask airway cuff pressures on the incidence of sore throat in children. Paediatr Anaesth. 2009 Mar 5. Department of Anaesthesia, Princess Margaret Hospital for Children, Subiaco, WA, Australia (abstract on USB Key) • Brimacombe J, Holyoake L, Keller C, et al. Emergence characteristics and postoperative laryngopharyngeal morbidity with the laryngeal mask airway: a comparison of high vs low initial cuff volume. Anaesthesia 2000; 55: 338-43 • Asai T, Brimacombe J. Cuff volume and size selection with the laryngeal mask. Anaesthesia 2000; 55: 1179–84 (abstract on USB Key) 150 Sure Seal USP – Cuff Pilot Why is Cuff PilotTM the best option for cuff pressure monitoring? • Blanch Paul B. Comparison of 4 cuff pressure indicators - Respiratory care 2004, vol. 49, no2, 166-173. Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA (study on USB Key) – 4 cuff inflators tested – All differ in bias and precision – None of them accurately measure cuff pressure – None allowed cuff-pressure checks without decreasing cuff pressure • Integrated device – Attaching a monitor to an ET tube cuff can be extremely dangerous – ICU space is already too crowded with other systems – Always at the ready to avoid hassle factor with locating a separate device • Disposable device – The practice of taking an Endotest from room to room is a potential source for cross-contamination – Patients in contact isolation rooms may not get cuff pressure checked higher incidence of tracheal fistulas and other symptoms of excessive cuff pressure – No need for cleaning &/or checking cleanliness of device • Need to assure & document proper pressure from a liability perspective 151 Sure Seal Features & Benefits Why promote a silicone cuff ? • • • • Good seal with less pressure on the hypopharynx Risk of patient trauma reduced Consistent seal pressure throughout the mask (better than PVC) When deflated, the silicone cuff will retract perfectly to allow for easier insertion & removal Why is a laryngeal mask with PVC cuff less efficient ? • • • 152 PVC masks are more rigid more trauma PVC must get warmed up first before – Most OR’s are at 16 – 19C degrees centigrade – Human body obviously is a lot warmer – Some anaesthetists put PVC masks in hot water for a few minutes to make them more pliable prior to using them to make sure – they “adapt” to the pharyngeal space – they provide an adequate seal – PVC cuff can take some minutes before a seal can be achieved Silicone seal – Silicone contours are softer than PVC – Silicone adapts immediately to patient anatomy Sure Seal Features & Benefits Why should pressure be always monitored when using a silicone cuff ? Nitrous oxide diffusion into the cuffs of disposable laryngeal mask airways - P. Maino, A. Dullenkopf, V. Bernet and M. Weiss Departments of Anaesthesia and Intensive Care, University Children’s Hospital Zurich, Switzerland «In conclusion, we found that the susceptibility to cuff pressure increases due to N2O in disposable laryngeal mask airways is mainly influenced by the type of material from which the cuffs are constructed, with considerable advantages seen with cuffs constructed from PVC compared to silicone.» DON’T MISINTERPRET THIS STUDY SILICONE CUFF IS OFTEN THE PREFERED OPTION IT IS LESS TRAUMATIC AND EASIER TO INSERT. BUT CUFF PRESSURE SHOULD ALWAYS BE MONITORED TM HENCE Cuff Pilot 153 Sure Seal Features & Benefits What is the use of epiglottis bars according to Dr Brain? The purpose of aperture bars is to prevent a large epiglottis from falling into the aperture, blocking it and occluding the airway. Aperture bars in the bowl of the mask tend to elevate the epiglottis and thus protect against its migration into the mask aperture. The aperture bars need to be flexible enough so an endotracheal tube can pass through them and push them aside and yet firm enough to withstand the pressure of an epiglottis Jonathan L. Benumof MD - San Diego, California “ I found that in most of these patients the epiglottis entered the breathing shaft of the aperture bar-less Portex laryngeal mask, which made it difficult to identify supralaryngeal and laryngeal anatomy. In order to identify anatomy and intubate the trachea fibreoptically in these patients, I had to pull the Portex back approximately 0.5 to 1.0 cm; the pull back allowed disengagement of the epiglottis from the breathing shaft of the mask (of varying degrees from partial to total) and identification of the anatomy.” Epiglottis bars value • hold epiglottis back • prevent airway obstruction • prevent damage to the epiglottis 154 Sure Seal Features & Benefits Why did we choose to have epiglottis bars? - Many physicians believe it is really useful to avoid epiglottis falling back & obstruct the airway Others just « don’t care » No adverse literature exist – only a few studies showing it is not as useful as LMA has always claimed We cannot carry both ranges – would double the nb of ref. Cost of good is the same with & without epiglottis bars Consequently, we believe that - 155 It’s more an advantage to have them than a drawback Not having them can stop us from selling, having them will rarely impede our chances of success Sure Seal Features & Benefits Why promote single use devices? • Better infection control – Sterile, single use products fully eliminate cross infection risks – Risk of pathogens survival is still high after sterilisation • Convenience – Always at the ready – No need for follow-up cards – Long & fastidious cleaning & sterilisation process is avoided • Cost effectiveness – Sterile single use devices are less expensive in the long run – Sterilisation is costly in equipment & human resources – Cost better known = 1 and for all… • Revenue stream for Teleflex & partners…. 156 Sure Seal Features & Benefits Why promote single use devices? Costs Associated with the Use of Reusable Laryngeal Masks 3 - Use in OR 2 - Transfer to OR 5 - Cleaning 1 - Sterilisation 6 - Visual Check* 10 - Storage 7 - Packaging 9 - Follow Up Card 157 4 - Transfer to Sterilisation Unit * For discoloration, cut, ruptures, chemical degradations… 8 -Sterilisation Sure Seal Features & Benefits Why promote single use devices? Costs Comparison between Reusable & Single Use Laryngeal Masks Soulias – CHU Dijon - AFAR 2006 (abstract on USB Key) “Disposable LM cost was calculated as the sum of product cost and elimination cost. Reusable LM were autoclaved after hospital purchasing in two separate sterilizing processing units of the same hospital. Reusable LM cost was determined combining material and labor costs. RESULTS: The reusable LM cost depended on the sterilizing processing unit concerned and varied between € 9.59 and 9.69 vs €8.38 for the single-use LM. CONCLUSION: With the cost savings made possible by use of disposable LM in both labor and consumables, this practice should be considered. 158 Tim M Cook, Consultant Anaesthetist Royal United Hospital, Bath – 2004 (editorial on USB Key) “Other reasons cited to change to single-use devices include cost and convenience. In the UK, a cLMA costs approximately £90 and sterilization £1–3. Single-use laryngeal masks cost £3.50–7.00 with the price decreasing as a result of competition. Some reports suggest the average cLMA is used less than 20 times. • Reusable device = £90 + (£2x30) = £150 • Single use device = £4x30 = £120 • Cross infection costs not included: ICU stay, hospital stay, antibiotics, nursing-time….” Sure Seal Features & Benefits Why promote single use devices? Risks Associated with the Use of Reusable Laryngeal Masks “Supplementary cleaning does not remove protein deposits from re-usable laryngeal mask devices” • • Canadian Journal of Anesthesia 51:254-257 (2004) Joseph Brimacombe, MB CHG FRCA MD, Tisha Stone, MB BS & Christian Keller, MD Purpose • To determine if supplementary cleaning facilitates removal of protein deposits from the laryngeal mask Results • Staining was similar before and after supplementary cleaning Conclusion • 159 Supplementary cleaning does not remove protein deposits from reusable laryngeal masks … the infectious risk associated with the protein deposits remains to be determined. Sure Seal Features & Benefits Why do we have a SureSeal with PVC tube & a full PVC Crystal Clear? • • • • • PVC tube is clear & thermosensitive Good visibility through tube during use Gas exchange can be easily visualized: condensation on the tube Blood traces or gastric aspiration may be seen through the tube at all times Best price options Why do we have such a large range, including reusable? • • 160 To be able to provide products for each & every request based on – Quality – Patient safety – Tenders – Preference – Price One-stop shopping strategy Products Part Numbers & Positioning Si ng St le a n Us Pi da e lo rd tB al lo on Si ng l C eU uf f P se ilo tT M R eu St sab an le B da al rd lo on Pil ot T y pe of produc t R ang e P os itioning 161 Fanatics of reusable products Brand Name P art Numbers Sure Seal Laryngeal Mask 100% Silicone 105000 Sure Seal Reinforced Laryngeal Mask 100% Silicone 105010 Sure Seal Laryngeal Mask PVC Tube Silicone Cuff 105200 For those who Sure Seal Laryngeal Mask understand pressure issues & 100% Silicone care for infections Sure Seal Reinforced Laryngeal Mask 100% Silicone Sure Seal Laryngeal Mask PVC Tube Silicone Cuff Sure Seal Laryngeal Mask For everyone else 100% Silicone Sure Seal Reinforced Laryngeal Mask 100% Silicone 105210 105220 105300 105310 105320 Teleflex Laryngeal Masks Competitive Review Competitive Information - LMA 165 Classic Unique • Reusable Silicone • 8 sizes • Single Use PVC • 7 sizes • Sterile Competitive Information - LMA Flexible Reusable & Single Use 166 Competitive Information - LMA Proseal (Reusable) & Supreme (Single Use) – what they claim • Strong cuff allowing 2 x seal at the same pressure • High seal pressure up 30 cmH20 • Provides a tighter seal against the glottic opening with no increase in mucosal pressure • Enables use of higher PPV w/ and w/o muscle relaxants • Built-in drain tube designed to channel fluid away and permit gastric access 167 Competitive Information - LMA Fastrach Reusable & Single Use • Designed for difficult airway & CPR • Facilitates continuous ventilation during intubation • Rigid curved tube for an 8mm cuffed ETT • Rigid handle to facilitate one-handed insertion, removal & adjustment of the position to enhance oxygenation & alignment with the glottis • Can be inserted in a confined environment • No need to move patient’s head • No need to insert finger in patient’s mouth • Epiglottic elevating bar in mask aperture to lift epiglottis as ETT is passed through and a ramp which directs the tube • Available in 3 sizes • Comes with a specially designed reusable LMA Fastrach™ ETT 168 Competitive Information - AMBU Aura40 & AuraOnce – what they claim • Unique feature: special curved molded tube – Replicates the natural human anatomy – Helps avoid abrasion of the upper airway • Special reinforced tip to resist folding • Cuff and airway tube are a single unit • Depth marks on the tube • Available in 8 sizes • Soft cuff to ensure good seal (0.4mm) • Color coded pilot balloon & pouch to identify mask size AuraOnce Aura40 170 Competitive Information - AMBU Non-curved version also available Why? Not as good a seal with the curved version in adults • Does not suit 10 to 20% of patients’ anatomy • Inner rings (at curve) may prevent insertion of bronchoscopes Cuff and airway tube single moulded • Flexible tip with risk of folding over (requires finger to prevent folding) Airway tube has a smaller diameter • Increased work of breathing • Smaller area to view condensation 171 Competitive Information - PORTEX Portex (Smiths Medical) • Provider of medical devices for the hospital, emergency & home markets • Evolution through acquisitions to become a strong provider of respiratory and anesthesia/critical care devices • Comprehensive range in airway management SoftSeal Single Use Launched in 2003 PVC no epiglottis bars 172 Silicone Single Use Launched in 2007 Silicone with epiglottis bars “we listened to you” Competitive Information - INTERSURGICAL Intersurgical Co Solus • Solus in May 2005 (developed by a former LMA engineer) • Solus MRI in 2006 • Non-ferrous valves guaranteed not to interfere with the magnet in an MRI unit • Packaging clearly marked 'MRI compatible‘ • Yellow pilot balloon & valve plunger for differentiation 173 Competitive Information - INTERSURGICAL Solus Sales Claims • Classic cuff shape – mostly like CAM • Firm smooth back plate – same as CAM, can hit soft palate causing trauma to patient. • Clear airway tube – same as most products • Non removable ink – irrelevant for single use product • Accurately aligned cuff indicators – Is the patients anatomy accurately aligned? • Optimal airway tube flexion – irrelevant as placement is all down to technique • Two Piece Design – Risk of separation • Limited details on cuff inflation 174 Competitive Information - INTERSURGICAL I-Gel • Launched early 2007 –1.5M units sold in 2009 • Non-inflatable gel cuff, fits onto perilaryngeal wall • 6 sizes, adult from 30 over 90 kgs, pediatric from 2 to 35 kgs • Intubation through I-gel possible (6 to 8 mm ETT) • Epiglottis blocker: prevents epiglottis from down-folding • Suction channel available (suction cath 12 & 14) • Integral bite block + “buccal cavity stabilizer” = widened part to eliminate potential for rotation after insertion 175 Competitive Information – CUFF PILOT Reusable Devices • Endotest-like devices • The Rusch EndoTest is an accurate endotracheal tube cuff inflator and manometer that can monitor the pressure of high volume, low pressure cuffs. The function adapted design enables the device to be used with one hand • Cross contamination risk • Not available at all times, at all beds • Management and inventory hassle • Calibration requirements • Replacement when needed • Pressure Monitors • • • • 176 Expensive 1 per bed needed Not enough space in the ICU Inflation line attached to the ETT??? Sure Seal Sales Strategy • Focus on our Unique Selling Proposition = Cuff PilotTM • Sure Seal is a « mind-changer » – First pressure monitoring laryngeal mask – Could change the way laryngeal masks are considered • Promote pressure monitoring & Cuff PilotTM to all departments & users – Anesthesiologists – Nursing Staff – Pharmacy – Infection Preventionists – Purchasing Dpt • Remember other key benefits • Comprehensive range & sizes • Single Use – Sterile - maintain focus on infection control argument – Ready to use – involve nursing staff – Money & time gain – involve budget holders and senior management to reallocate budgets if needed • 100% silicone – Potential for reduction of sore throat & trauma – talk to anesthesiologists – Better seal with less pressure – talk to anesthesiologists • ‘Basket deals’ where possible • ETT + LM + Circuits + Filters….etc – get to know purchasing people • Mak ‘em try!!! 177 Double Lumen Tubes Anatomy of the bronchi • • • • Trachea Bifurcation Carina Left and right mainstem bronchus • Lobe bronchi 179 Anatomy of the bronchi Adult trachea • Fibrocartilaginous tube about 15cm long • Thoracic portion is 5-6 cms long and terminates a the carina • Extends from lower end of cricoid cartilage • Tracheal diameter is roughly the same as patient’s index finger • C- shaped anteriorly due to the presence of 16-20 cartilages rings joined posteriorly by fibroelastic tissue and muscle 180 Anatomy of the bronchi Mainstem Bronchi • Are circular • Right bronchus – About 2,5cms long – Upper lobe starts at 2 cms – Vertical angle at 25° – Has 3 lobes and 10 bronchopulmonary segments • Left bronchus – About 5 cms long – Upper lobe starts at 5 cms – Vertical angle is 45° – Has 2 lobes and 8 segments 181 Lung isolation techniques A reliable method for lung isolation is essential for a variety of thoracic surgical procedures. Currently two types of devices are used as the basis of modern lung isolation techniques. • The double-lumen endo-bronchial tube (DLT) • Several bronchial blockers (BB) positioned through the single lumen endo-tracheal tubes (ETT) Indications for lung isolation and one-lung ventilation (OLV) are primarily related to the type of surgery, and include different • Lung-, • Cardiac-, • Oesophagus-, and • Vascular surgical procedures. 182 Main Indications for Bronchial Intubation Surgical exposure with strong indication Thoracic aortic aneurysm repair Pneumonectomy Upper lobectomy Mediastinal exposure Thoracoscopy Vascular surgery Lung transplant (uni & bilateral) Surgical exposure with moderate indication Middle and lower lobectomy Subsegmental resection Esophageal resection Procedures on the thoracic spine Minimal invasive procedures using VAT & VATS (Video Assisted Thoracoscopy Video Assisted Thoracic Surgery) Post-cardiopulmonary bypass status Severe hypoxemia from unilateral pulmonary process Requirement for differential ventilation for critical care 183 Indications for lung isolation 1. To avoid contamination of a non-diseased lung • Infection (e.g. unilateral pulmonary abscess) • Massive pulmonary hemorrhage • Unilateral pulmonary lavage 2. Control of distribution of ventilation • • • • • 184 Bronchopleural fistula Bronchopleural cutaneous fistula Surgical opening of major conducting airway Tracheobronchial tree disruption Life-threatening hypoxemia due to unilateral lung disease Contra-Indications for bronchial intubation Absolute Contraindications • Airway (especially laryngeal or tracheal) mass that may be occluding, dislodged, traumatized, or hemorrhaging Relative Contraindications • Patients requiring rapid intubation to prevent aspiration of gastric contents • Patients who are likely to be difficult to intubate 185 Various types of endobronchial tubes •Single lumen tube •Double lumen tube left or right - known also as Robertshaw •Double lumen tube left with hook – known also as Carlens • Carina hook used for securing the tube in the correct position • Positioned in the left lung usually for left lung sealing •Double lumen tube right with hook – known also as White • Positioned in the right lung usually for right lung sealing •DLTs offer the flexibility of switching ventilation from one lung to the other lung (for bilateral procedures) or to two-lung ventilation simply by clamping or unclamping lumens •Ability to suction blood or secretions easily from either lung. •Main features • • • • 186 Low-pressure, high volume cuff Transparent tube Coloured endobronchial cuff for ease of bronchoscopic recognition Angled tip Positioning of a DLT • Insertion of right sided tube into right bronchus for right side sealing • Insertion of left sided tube into left bronchus for left side sealing 187 Positioning of a DLT Right tube for right lung occlusion Left tube for left lung occlusion 20° angle tube 30° angle tube Bronchial cuff 3 lobes in right lung Bronchial cuff Eye for ventilation of right upper lobe Left bronchus Tracheal cuff 2 lobes in left lung Tracheal cuff 188 DLT issues • • • • • • • • • • • • 189 Failed intubation Incorrect tube position & inability to achieve adequate lung isolation particularly in case of airway abnormalities Traumatic injury to the airway during placement or removal Hoarseness Sore throat Ecchymosis of the mucous membranes Vocal cord rupture or paralysis Tracheal or bronchial laceration or rupture Right bronchial cuff blocking right upper lobe bronchus can lead to • failure of ventilation of the right upper lobe • collapse of right upper lobe Hypoxia Amputation of the hook from a Carlens & resulting airway foreign body Hemorrhage DLT issues • Inadvertent relocation of the double-lumen tube after insertion • during patient positioning • by surgical traction • during lung volume reduction surgery Malpositioned DLTs have been reported to be found at bronchoscopy in 37-78 % of cases in which auscultatory findings suggested correct placement. «We suggest that fiberoptic bronchoscopy should be performed through both the tracheal and bronchial lumen of a DLT to check the position, and repeated after lateral positioning.» Positioning the double-lumen endobronchial tube Jae-Hyon Bahk, MD, Ho-Geol Ryu, MD and Byun-Moon Ham, MD 190 Placement of blockers and DLT’s There is a wealth of scientific publications elaborating on the difficulties in placement, the trauma caused by those devices, the dislocation of the devices while moving the patient, the dislocation of the devices while manipulating the lung, hereunder an example; “With the increasing demand for one-lung ventilation in both thoracic surgery and other procedures (e.g., spine surgery), identifying the most effective device (double-lumen endotracheal tube or bronchial blocker) for the anesthesiologist with limited experience in lung isolation techniques would benefit our patients. However, we were unable to demonstrate any advantage associated with the use of any of the three devices* tested. In fact, we observed a high incidence of placement failure or device malpositioning with all three techniques. Failure to properly place the three devices was similar among faculty (39%) and senior residents (36%) despite each participant having received a tutorial before each study.” Devices for Lung Isolation Used by Anesthesiologists with Limited Thoracic Experience: Comparison of Double-lumen Endotracheal Tube, Univent(R) Torque Control Blocker, and Arndt Wire-guided Endobronchial Blocker®Campos, Javier H. M.D.; Hallam, Ezra A. B.A.; Van Natta, Timothy M.D.; Kernstine, KempH. M.D., Ph.D. Anasthesiology. February 2006 - Volume 104 - Issue 2 - pp 261-266 191 Insertion of a double lumen tube - video DLT Insertion Video http://www.youtube.com/watch?v=J-UnmZj7ylg 192 Teleflex bronchial tubes • Disposable and reusable • BRONCHOSAFE single lumen bronchial tubes • Right and left sided • BRONCHOPART double lumen bronchial tubes • Robertshaw • Carlens • White • Tracheostomy 199 Single lumen tubes BRONCHOSAFE • Optimally suited for post-operative ventilation after pneumonectomy Disposable PVC • Left-side intubation 115900 • Right-side intubation 115901 • For emergency intubation • Sizes 6.5 mm & 8 mm • Colour-coded cuffs & pilot balloons 200 Double lumen tubes Single-use Robertshaw (without hook) Carlens / White (with hook) Carlens Left White Right 201 Reusable Double lumen tubes BRONCHOPART • Robertshaw type • Disposable, made of PVC • For left side intubation 116100 • For right side intubation 116200 • Set composed of • Tube • 2 suction catheters • 2 angled connectors • Y connector 202 Double lumen tubes BRONCHOPART • Carlens = left with Carina Hook • For left-side intubation • Disposable PVC 116101 • Reusable Soft rubber 116000 • White = right with Carina Hook • For right-side intubation • Disposable PVC 116201 • Reusable Soft rubber 116300 203 Double lumen tubes TRACHEOPART Double lumen tracheostomy tube • • • • 204 Disposable PVC For left side intubation 116400 For right side intubation 116401 Set composed of • Tube • Neck band • 2 suction catheters • 2 angled connectors • Y connector Competition SHERIDAN - Sher-i-Bronch • No carina hook • Right Bronch double-cuff supposed to facilitate positioning in right mainstem bronchus 205 Competition MALLINCKRODT – BronchoCath • No right-sided tube with hook • Hook is rigid increased risk of breakage • More traumatic for the vocal cords & the carina 206 Bronchus Blockers • Used in lieu of DLTs • Advantages • Less trauma • Less stock – • 1 size for all (adults) • can be used right or left • No hook needed • Easily inserted in the working channel of the bronchoscope • No need for DLT replacement if patient needs ventilation • Guidelines: use of a fibroscope to confirm placement 207 Size comparison DLT’s vs ETT Double lumen tubes are considered to be extremely large and therefore uneasy to position and often traumatic. Size 8.0 ETT seldom used & largest size for women DLT 35 Fr seldom used & smallest size for women EZ-Blocker® requires a standard ETT from size 7.0 onwards (7.5 is best) Diameter of the bronchus (usually the left) to be found from standard chest X-ray. Once this is known, the correct size DLT can be selected. See table. Manufacturer •Sheridan •Mallincrodt •Portex •Rusch 208 X-Ray size mm 28Fr 9.6 8.2 - 32Fr 9.3 - 35Fr 11.4 11.3 10.8 11.2 37Fr 12.2 12.2 11.8 12.4 39Fr 12.5 12.5 12.1 12.5 41Fr 12.8 13.0 12.8 13.0 Bronchus Blockers Teleflex has 3 different p/n 330600 • Inserted in the working channel of the bronchoscope after biopsy to stop bleeding • Insert the bronchus blocker • Inflate the cuff • Opening end of the bronchus blocker is used for instillation • Possibility to remove the bronchoscope without removing the tube (long enough – need only remove the connector) • 330600 can be positionned at any of those sites 209 Bronchus Blockers 330601 • Inserted in a standard ETT to replace a single lumen tube or a DLT • Insert the ETT • Pass the bronchus blocker inside • Inflate the cuff to block the main bronchus • Main advantage is cost 330602 • Same as 330601 except • Latex free cuff • Curvature of the tip makes it easier to insert 210 Bronchus blockers Coopdech Blocker (Portex) Univent & Uniblocker (Fuij) Cohen (Cook Medical) Arndt blocker with 2 types of cuff (Cook medical) 211 Product Training Carol Seroussi November 2009 Accessories Other Intubation Devices • Guedel airways • For quick and safe airway opening with or without intubation • Dimensions according to ISO 5364 • Colour coded • Various materials available : • Disposable : PE 124900, PVC 124700 • Reusable : soft red rubber 124501, 124400 for FO intubation, 124500 soft black rubber • Nasopharyngeal airways • For quick and safe airway opening with or without intubation • Mainly used in UK, Germany & USA • Used in OR or post-op. in lieu of O2 canulas • 185420, single use, Wirupren, with adjustable flange • 125410, single use, soft transparent PVC • 125200, reusable, soft rubber with adjustable flange • 125600, reusable, soft rubber with adjustable flange & oxygen channel 213 Accessories • • • • 214 Intubation Stylets Universal Adapters Pressure Gauge Silicone Spray Accessories Intubation Stylets – PVC, Red Rubber, Flexislip Universal Adapters Manometer Silicone spray 215 Accessories - Intubation Stylets • EndoGuide T 503100 & 503110 • Device to be used as a tube exchanger for tracheal and tracheotomy tubes & intubation aid in standard and difficult situations • Stainless steel guide wire imbedded in the wall of the tube allows pre-forming of the tube if necessary • Large lumen allows oxygen supply or jet ventilation during the whole procedure of intubation or tube exchange • Oxygen supply: guide wire needs not be removed • Connection system: safe and easy either 15 mm standard or Luer Lock connector For use with REF Describtion 503100 - 000025 EndoGuide T tracheal / tracheostomy tubes 3 - 6 mm ID 503100 - 000060 EndoGuide T tracheal tubes 6´.5 - 11 mm ID tracheostomy tubes & intubation aid for 503110 - 000060 EndoGuide T tracheal tubes 6´.5 - 11 mm ID 216 ID (mm) 1,4 3,2 3,2 OD (mm) Length (mm) 2,6 700 5 830 5 525 Accessories - Intubation Stylets • EndoGuide T 503100 • size 2.5 length 700 mm • to use with tracheal tubes from 3 - 6 mm ID • size 6.0 length 830 mm • to use with tracheal tubes from 6.5 - 11 mm ID • EndoGuide T 503110 • Size 6 length 525 mm • to use with tracheal & tracheostomy tubes from 6.5 - 11 mm ID 217 Accessories - Intubation Stylets Competition 218 • Eschmann stylet (Portex) bent tip 60cm 17ch, nonhollow • Vygon stylet – same as Eschman – hollow single use Accessories - Intubation Stylets Competition • Cook 219 Accessories – Universal Adapters • Universal Mainz adapter 514800 / 514805 • For fiberoptic intubation during ventilation • Connector for fibroscopy on face masks, tracheal tubes and laryngeal masks • Feeding tube insertion • Lateral connector for anaesthetic circuit • Double sealing cap made of silicone • Angled connector 514900 • Plastic angled connector • Double sealing cap made of silicone • Rotating connectors 220 Accessories - Others Hand pressure gauge 112700 • To inflate the cuff and measure the cuff pressure Silicone spray 556000 • To prevent incrustations on rubber, latex & PVC devices • To prevent devices to stick to the mucosa 221 Thank you for your attention
