1. BOUGIE
TRACHLITE ,
LARYNGEAL TUBE ,
COMBITUBE ,
I-GEL ,
TRUVIEW
MODERATOR :- Dr. Sushil
Bhati
PRESENTOR :- Dr. Rini

2. BOUGIE
 Endotracheal tube
introducer or
intubation catheter
 It is important for the
clinician, performing
intubation and having
“the epiglottis-only
view”, on the first
attempt

3. BOUGIE (Contd.)
 Originally produced by Portex and called
the Eschmann Stylet
 Often called the gum elastic bougie, it is
neither made of gum nor is it elastic; the
original design is made of beige colored
resin covering a fiberglass core
 The total length of the original version is 60
cm and the distal tip bends at an angle
of 30-45 degrees

4. BOUGIE (Contd.)
 Bent distal end makes bougie easier to
pass under the epiglottis and prevents it
from advancing too far
 narrow diameter (5 mm) provides easier
target visualization compared with a cuffed
tracheal tube
 It may be solid or hollow.
 Hollow bougie allows verification of correct
positioning by fibre optic endoscope , and
aids to monitor CO2

5. TECHNIQUES OF USE
Technique 1:
 Do laryngoscopy
 Hold bougie in pen like manner
 Introduce the lubricated tip of
bougie, pointing anteriorly
 If tip gets stuck in ant. commisure
, rotate it 180 degree and then
advance
 As it advances over tracheal rings
, clicking sensation is observed

6. Contd.
 In lightly
anaesthetised pt. a
cough reflex
suggests tracheal
placement
 Once the bougie is
believed to be in
trachea , an
assistant gently
advances the ETT
over the bougie in
railroad like fashion
 Bougie is then

7. Contd.
 Connect ETT to breathing system
 During nasal intubation, bougie is
advanced through nostril into the
larynx. Laryngoscopy is then done and
bougie is directed toward vocal cord
under direct vision

8. Contd.
Technique 2:
- Preinsert the ETT in bougie so that the tip
protrudes approx. 5 cm beyond tube
#It saves few seconds in intubation
#But makes steering the tip more difficult

9. INDICATIONS OF BOUGIE
 As an aid to difficult intubation, bougie is
considered superior to stylet
 Esp. useful in pt with severly compromised
upper airway, anterior larynx or limited
mouth opening
 OTHER USES
- For exchanging a ETT : insert a bougie
through the existing tube. Existing tube is
then removed and new tube is inserted over
the bougie
- To direct LMA or change existing LMA.

10. PROBLEMS WITH BOUGIE
 TRAUMA : by the force exerted by the tip
or by the chipped/ fractured outer layer of
bougie
 CONTAMINATION

11. TRACHLITE
It is light-guided
intubation device
Uses the principle of
transillumination

12. TRACHLIGHT (CONTD.)
 When the tip of the
lightwand is placed
inside the glottis, a
bright light glow can
be seen easily in the
soft tissue of the
anterior neck.
 No transillumination
can be seen, if the
lightwand is in
oesophagus

13. PARTS OF TRACHLIGHT
 Consists of 3 parts:
1) REUSABLE
HANDLE-
-made of plastic
-lodges alkaline
batteries at one
end
-locking clamp on
front to secure
ETT connector

14. PARTS OF TRACHLIGHT
(contd.)
2) FLEXIBLE WAND-
-:Comes in 3 diff sizes.
-:It‟s a plastic shaft
with bulb at distal end
which blinks off after
30 sec.(to save heat
production and to
depict apnoea time)
-:Connector at
proximal end ,for
attachment of the
wand in the groves of

15. -The length of the wand can be adjusted by sliding
the connector along the handle.
3) RETRACTABLE STYLET-
allows the wand to be shaped in a “J shape” or
"hockey stick" configuration

16. Intubation technique with the TL
Preparation
 Lubricate the internal stylet and introduced it in
the wand
 Wand is now mounted on the handle.
 The length of the wand is adjusted so that the
lightbulb is at the tip of the ETT
 The ETT-TL unit should then be bent at a 90
angle just proximal to the ETT cuff in the
"hockey stick" configuration

17. Oral intubation
 Pt positioned in sniffing position.
 The jaw is lifted upward to elevate the epiglottis.
 TL is introduced from the lateral corner of the
mouth and repositioned in the midline after
entering into the oropharynx.
 The midline position is maintained while the
device is gently advanced forward in a rocking
motion
 The device should not be forced against any
resistance

18. Contd..
 A faint glow seen above the thyroid prominence
indicates that the tip of the ETT-TL is located in
the glosso-epiglottic fold .
 If the ETT-TL enters the esophagus, no glow
can be detected.
 A bright glow observed in the lateral aspect of
the larynx indicates that the tip of the ETT-TL is
placed in the piriform fossa, a redirection to the
midline is then required.

19. 5 A central, clear and bright transillumination on the
cricothyroid membrane suggests a correct positioning of the
TrachlightTM tip into the laryngeal inlet: it is now safe to
intubate the trachea

20. Nasal intubation
 The most difficult aspect of a blind nasal
intubation is to align the tip of the ETT with the
glottis
 Transillumination can assist nasal intubation
 Remove stylet before insertion of the TL which
makes the ETT-TL more pliable.
 Lubricate the nostril
 After advancing the tip of the ETT-TL into the
oropharynx, the light is switched on and nasal
intubation is performed as described in the oral
intubating technique

21. Clinical uses of the Trachlight
Useful option in the case of a difficult
laryngoscopic intubations like ,
 Congenital abnormalities of upper airway
 Acquired abnormalities of upper airway
(trauma, etc.)
 Limited mandibular protrusion
 Short mentohyoid distance
 Short neck
 Mallampati grade 3, 4
 Secretions or blood in the oropharynx

22. The TL can also be used together with other
devices, such as LMA, the intubating LMA and
Direct Laryngoscopy

23. Limitations, difficulties and contraindications of
the TrachlightTM
Limitations Difficulties Contraindications
No visualization of Difficulties in controlling Tumours of the
pharyngeal and the tip of the device in case upper airway
laryngeal structures of accidental partial
withdrawal of the stylet Infectionsof the
Suboptimal upper airway
transillumination in Unintentional switching
grossly obese pts off of the light Foreign body in the
upper airway
Mistaken tracheal Difficulties in withdrawing
intubation in very thin stylet
pts even if light wand
is in oesophagus Disturbing effects of the
blinking light after 30 sec
from switching on

24. LARYNGEAL
TUBE
 Newly developed supraglottic airway device,
introduced in U.S. markets in 2003.
 Latex free, silicone made and are easy to
insert resulting in minimal airway trauma.
 There are six sizes,
-size 0,1,2 for pt. weighing <6 ,6-15, 15-30
kgs
-size 3, 4, 5 for heights <155, 155-180, >180
cm

25. PARTS :
-15 mm connector
-Pilot balloon
-Inflation line
-Teeth marks
-Proximal cuff
-Ventillation holes
-Distal cough

29. VARIENTS OF LT
 There are three other modified versions of
the laryngeal tube:
 single-use laryngeal tube (LT)
 laryngeal tube-Suction II (LTS )and
 single-use laryngeal tube-Suction II . (LTS-
D)
 The laryngeal tube-Suction aims to
separate the respiratory and alimentary
tracts. This device has two lumens: one for
ventilation and the other for the passage of
a gastric tube

30. VARIENTS OF LT

31. INDICATIONS FOR
LARYNGEAL TUBE
Same as for the laryngeal mask airway .
 Surgeries on the extremities, minor
urological and gynaecological procedures,
 “cannot intubate, cannot ventillate” cases
 potentially, have a role in airway
management during CPR

32. DRAWBACKS OF LARYNGEAL
TUBE
 Theoretical risk of anaesthesia gas leaking
around the laryngeal tube or being
insufflated into the stomach
 Displacement of tube during repositioning
the patient's head and neck for surgery
 Apparent ischaemic changes to the tongue
were observed, but that improves after
deflating the cuff

33. Contd.
 May cause injury to the pharynx
 Postoperative airway complications, such
as sore throat, dysphagia, dysphonia or
numb mouth.
 Because the cuffs are thin and relatively
large, they may be torn during use

34. INSERTION OF L.T.
-Achieve appropriate depth
of anaesthesia
-Patient is placed in sniffing
or neutral position.
-Lubricate LT well and hold
it in pen like manner at
black bite mark
-Give jaw thrust
- LT is placed against the
hard palate and then
slide down to the centre
of the mouth until
resistance is felt

35. Contd.
-The second bold
black line on the
tube should just
pass between upper
and lower incisors
-The cuff should be
inflated to a pressure
of 60 cm H2O that
corresponds to an air
volume shown below

36. Contd.
 Due to specially designed inflation line, the
proximal cuff is filled first which stablises
the tube.
 Once the proximal cuff has adjusted to the
anatomy of the pt. , the distal cuff will be
automatically inflated
 LT is now fixed and attached to breathing
circuit

37. When inserted, the laryngeal tube lies along the
length of the tongue.The proximal cuff provides a seal
in the upper pharynx and the distal cuff seals the
oesophageal inlet

38. COMBITUBE
 A double lumen airway device with two
balloon cuffs designed for emergency
ventilation of a patient when visualization of
the airway and endotracheal intubation are
not possible
 The tube is inserted blindly and ventilation
can be achieved with either tracheal or
esophageal placement of tube

39. PARTS OF COMBITUBE

40. Lumen # 1(Blue coloured) is sealed at the
end but contains fenestrations distal to the
pharyngeal balloon .
Used to ventilate the patient when the tube
has been blindly inserted into esophagus
, (approx 90-95% of the time)
Lumen # 2 ends beyond the distal cuff
similar to an ETT
used to ventilate the patient when the tube
has been blindly inserted into the trachea

41. COMBITUBE KIT
 Esophageal
Tracheal Airway
(Combitube), 140m
l syringe, 20ml
syringe
 Suction device with
suction catheter

42. INSERTION OF COMBITUBE
 Place the patient in
a supine position
 Hyperventilate
patient with 100%
oxygen
 Inflate both
balloons prior to
insertion to test the
integrity of the
balloons
 Lubricate the tube

43. Contd.
 The patient‟s lower
jaw is grasped
between the thumb
and forefinger of the
non-dominant
hand, and a jaw lift
is given
 Insert the
Combitube so that it
curves in the same
direction as the
natural curvature of
the pharynx
 If resistance is
met, withdraw tube
and attempt to

44. Contd.
 Advance tube until
the patient‟s teeth
are between the
two black lines

45. Contd.
 Inflate
oropharyngeal
balloon first with
the large syringe
(blue dot) with 85
cc (40-85) of air
 Then with small
syringe, inflate
distal cuff with 12
cc (5-12) of air

46. Contd.
 Because of the
high probability of
esophageal
placement (90-
95%)
 Begin ventilation
through the blue
tube labeled #1.
 If breath sounds
are good and
gastric inflation is
negative, continue

47. Esophageal Placement
 If the Combitube is
placed in the
esophagus, the distal
balloon will occlude
the esophagus.
 Ventilation is then
provided through
fenestrations in the
pharyngeal tube.
Stomach contents can
then be safely
expelled via the hole in
the end of the tube.

48. Tracheal Placement
 If tube gets inserted in
the trachea, it functions
as an ETT, with the distal
balloon preventing
aspiration.
 Ventilations are then
provided via the hole in
the end of the tube as in
an ETT.
 Stomach contents can
then be safely expelled
via fenestrations in the
pharyngeal tube

49. Removal of CombiTube
 Tube placement cannot be determined
 Patient no longer tolerates tube
 Patient vomits past either distal or proximal
tube
 Palpable pulse and spontaneous breathing

50. CONTRAINDICATIONS OF
COMBITUBE
 The patient has intact gag-reflex
 The patient is less than 5 feet tall or under
16 years old
 History of esophageal disease
 History of ingestion of caustic substance
 Burns involving the airway
 The patient has an allergy or sensitivity to
latex
(the pharyngeal balloon contains latex)

51. ADVANTAGES OF COMBITUBE
 Effective ventilation and oxygenation with
moderate protection against aspiration.
 Blind insertion without the need for
light, laryngoscope, or direct visualisation
 Proximal pharyngeal balloon solves the
problem of poor mask seal.
 Gastric contents can be aspired through
lumen #2 when the device is in the
esophagus

52. I-GEL
 Innovative second generation supraglottic
airway device from Intersurgical , launched
in 2007
 soft, gel-like, non-inflatable cuff, designed
to provide an anatomical, impression fit
over the laryngeal inlet

53. Why use i-gel?
 Ease and speed
of insertion
 Reduced trauma
 Superior seal
pressure
 Gastric access
 Integral bite
block
 Non-inflatable
cuff

55. INDICATIONS FOR I-GEL
 Use by the ambulance crew in difficult
intubations in a pre-hospital setting
 To quickly secure and maintain a clear
airway in OT
 In difficult intubation cases , for intubating
the patient, by passing ETT through the
device
 In difficult intubation cases, to pass a fibre-
optic endoscope through the device, to aid
intubation

56. METHOD OF INSERTION:
 Achieve adequate depth of anesthesia
 In the final minute of pre-oxygenation,
grasp the i-gel along the integral bite block
and lubricate the back, sides and front of
the cuff
 The patient should be in the „sniffing the
morning air‟ position

57. Contd.
 The chin should be gently pressed down
 Introduce the i-gel such that the cuff
outlet is facing towards the chin of the
patient in a direction towards the hard
palate.
 Glide the device downwards and
backwards along the hard palate with a
continuous but gentle push until a definitive
resistance is felt.

58. Contd.
 The incisors should be
resting on the integral
bite-block
 Tape it down from
„maxilla to maxilla’
 If required, an
appropriate size
nasogastric tube may
be passed down the
gastric channel

59. CONTRAINDICATIONS OF I-
GEL
 Non-fasted patients
 Inadequate levels of anaesthesia which
may lead to coughing, bucking, excessive
salivation causing retching, laryngospasm
or breath holding
 Conditions that increase the risk of a full
stomach e.g. hiatus hernia , morbid
obesity, pregnancy or a history of upper
gastro-intestinal surgery etc.
 Do not leave the device in situ for > 4 hrs

60. TRUVIEW
 Newly introduced
truphatek product
 Light weight and
portable
 Stainless steel
design offers
minimal wear n tear
 Functions both as
video and optical
laryngoscope

61. Contd.
 Offers a clear and enlarged view
onscreen
 Oxygen flow via a side channel on the
handle provides continuous
oxygenation which delays
desaturation during laryngoscopy
 Oxygen flow also improves view by
preventing fogging of lens and
clearing secretions

75. REFERANCES
 Understanding Anaesthesia Equipment, 5th
Edition, Jerry A. Dorsh and Susan E. Dorsh
 Clinical Anaesthesiology, 4Ih Edition, GE
Morgan
 Benumoff s - Airway management
 Airway management- Rashid M. khan
 Drugs & equipments in anesthetic practice-
Arun k paul