Bougie, trachlite , laryngeal tube , combitube , i gel ,truview

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  • 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 USETechnique 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. TRACHLITEIt is light-guidedintubation deviceUses the principle oftransillumination
  • 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 slidingthe 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 TLPreparation 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 thecricothyroid membrane suggests a correct positioning of theTrachlightTM tip into the laryngeal inlet: it is now safe tointubate 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 TrachlightUseful 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 otherdevices, such as LMA, the intubating LMA andDirect Laryngoscopy
  • 23. Limitations, difficulties and contraindications ofthe TrachlightTMLimitations Difficulties ContraindicationsNo visualization of Difficulties in controlling Tumours of thepharyngeal and the tip of the device in case upper airwaylaryngeal structures of accidental partial withdrawal of the stylet Infectionsof theSuboptimal upper airwaytransillumination in Unintentional switchinggrossly obese pts off of the light Foreign body in the upper airwayMistaken tracheal Difficulties in withdrawingintubation in very thin styletpts even if light wandis in oesophagus Disturbing effects of the blinking light after 30 sec from switching on
  • 24. LARYNGEALTUBE 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
  • 26. 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
  • 28. INDICATIONS FORLARYNGEAL TUBESame 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
  • 29. DRAWBACKS OF LARYNGEALTUBE Theoretical risk of anaesthesia gas leaking around the laryngeal tube or being insufflated into the stomach Displacement of tube during repositioning the patients head and neck for surgery Apparent ischaemic changes to the tongue were observed, but that improves after deflating the cuff
  • 30. 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
  • 31. 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
  • 32. 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
  • 33. 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
  • 34. When inserted, the laryngeal tube lies along thelength of the tongue.The proximal cuff provides a sealin the upper pharynx and the distal cuff seals theoesophageal inlet
  • 35. 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
  • 37. Lumen # 1(Blue coloured) is sealed at theend but contains fenestrations distal to thepharyngeal balloon .Used to ventilate the patient when the tubehas been blindly inserted into esophagus, (approx 90-95% of the time)Lumen # 2 ends beyond the distal cuffsimilar to an ETTused to ventilate the patient when the tubehas been blindly inserted into the trachea
  • 38. COMBITUBE KIT  Esophageal Tracheal Airway (Combitube), 140m l syringe, 20ml syringe  Suction device with suction catheter
  • 39. 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
  • 40. 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
  • 41. Contd. Advance tube until the patient‟s teeth are between the two black lines
  • 42. 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
  • 43. 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
  • 44. 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.
  • 45. 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
  • 46. 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
  • 47. CONTRAINDICATIONS OFCOMBITUBE 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)
  • 48. 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
  • 49. 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
  • 50. Why use i-gel? Ease and speed of insertion Reduced trauma Superior seal pressure Gastric access Integral bite block Non-inflatable cuff
  • 51. 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
  • 52. 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
  • 53. 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.
  • 54. 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
  • 55. 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
  • 56. TRUVIEW Newly introduced truphatek product Light weight and portable Stainless steel design offers minimal wear n tear Functions both as video and optical laryngoscope
  • 57. 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
  • 58. 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