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

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

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to be in trachea , an assistant gently advances the ETT over the bougie in railroad like fashion Bougie is then withdrawn

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: 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 handle.

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

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

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

27. VARIENTS OF LT

28. 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

29. 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

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 H 2 O 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 the length of the tongue.The proximal cuff provides a seal in the upper pharynx and the distal cuff seals the oesophageal 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

36. PARTS OF COMBITUBE

37. 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

38. COMBITUBE KIT Esophageal Tracheal Airway ( Combitube ), 140ml 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 reinsert

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 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 )

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