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About This Presentation
Www
Slide Content
ENDOTRACHEAL TUBES
Moderator : Dr.Maya Rose Moderator : Dr.Maya Rose
Presenter : Dr.Blessy Baby
Babu
Presenter : Dr.Blessy Baby
Babu
Presenter : Dr.Blessy Baby
Babu
Moderator : Dr.Maya Rose Moderator : Dr.Maya Rose
Presenter : Dr.Blessy Baby
Babu
Presenter : Dr.Blessy Baby
Babu
Presenter : Dr.Blessy Baby
Babu
HISTORY
•
•
•
•
Vesalius in 1543 reported the first tracheal intubation in
an
animal.
Trousseau reported 200 patients suffering from
diphtheria who
were saved by tracheostomy.
Dr.Charles keith is credited with developing the first
endotracheal tube in 1778.
In the early 1870's, Trendelenburg from Germany
performed
thefirstendotrachealanesthesiainman
•
•
•
•
Vesalius in 1543 reported the first tracheal intubation in
an
animal.
Trousseau reported 200 patients suffering from
diphtheria who
were saved by tracheostomy.
Dr.Charles keith is credited with developing the first
endotracheal tube in 1778.
In the early 1870's, Trendelenburg from Germany
performed
thefirstendotrachealanesthesiainman
•
•
•
•
Macewen in 1878 reported the first elective endotracheal
intubation for anesthesia. He isolated the trachea by
packing the
hypopharynx, from leaking of blood and debris.
Later, Rosenberg and Kuhn administered cocaine as local
anesthetic to obtund the cough reflex during intubation.
Tracheostomy and intubation have been broadly used
during
the First World War.
Magill (1888-1986) recognized the advantages of tracheal
intubation. Also, by his efforts, anesthesia has become an
•
•
•
Macewen in 1878 reported the first elective endotracheal
intubation for anesthesia. He isolated the trachea by
packing the
hypopharynx, from leaking of blood and debris.
Later, Rosenberg and Kuhn administered cocaine as local
anesthetic to obtund the cough reflex during intubation.
Tracheostomy and intubation have been broadly used
during
the First World War.
Magill (1888-1986) recognized the advantages of tracheal
intubation. Also, by his efforts, anesthesia has become an
•
•
In 1913 the first anesthetic laryngoscope was invented by
Jackson and modified by the Magill, Miller and Macintosh.
In 1942, curare was introduced as a muscle relaxant for
abdominal relaxation during general anesthesia and
endotracheal intubation became routine in major
abdominal and
other surgeries
•
In 1913 the first anesthetic laryngoscope was invented by
Jackson and modified by the Magill, Miller and Macintosh.
In 1942, curare was introduced as a muscle relaxant for
abdominal relaxation during general anesthesia and
endotracheal intubation became routine in major
abdominal and
other surgeries
DEFINITION:
An endotracheal tube is a device that is inserted through
the
larynx into the trachea to convey gases and vapors to and
from
the lungs.
An endotracheal tube is a device that is inserted through
the
larynx into the trachea to convey gases and vapors to and
from
the lungs.
PROPERTIES OF AN IDEAL ET TUBEPROPERTIES OF AN IDEAL ET TUBE
1) Low cost
2) Inertness, Lack of tissue toxicity
3) Smooth, non-wettable outer surface to avoid damage
to
mucosa & Inner surface to prevent building of
secretions.
4) Non-inflammable
5) Transparent
1) Low cost
2) Inertness, Lack of tissue toxicity
3) Smooth, non-wettable outer surface to avoid damage
to
mucosa & Inner surface to prevent building of
secretions.
4) Non-inflammable
5) Transparent
7) Sufficient body to maintain its shape during insertion &
to
prevent occlusion by torsion, kinking or compression by
the
cuff or external pressure.
8) Sufficient strength to allow thin wall construction
9) Thermoplasticity to conform to anatomic passage and
to be
self centering within the trachea.
10)Nonreactivewithlubricantsoranestheticagents
to
prevent occlusion by torsion, kinking or compression by
the
cuff or external pressure.
8) Sufficient strength to allow thin wall construction
9) Thermoplasticity to conform to anatomic passage and
to be
self centering within the trachea.
10)Nonreactivewithlubricantsoranestheticagents
•Commonly used tubes materials
Red rubber tubes - Can be cleaned , sterilized and reused.
Not transparent
Harden and become sticky
poor resistance to kinking
Become clogged by dried secretions
Latex allergy
Polyvinyl chloride - Disposable tracheal tubes
Inexpensive
compatible with tissues
Red rubber tubes - Can be cleaned , sterilized and reused.
Not transparent
Harden and become sticky
poor resistance to kinking
Become clogged by dried secretions
Latex allergy
Polyvinyl chloride - Disposable tracheal tubes
Inexpensive
compatible with tissues
Less likely to kink
Stiff enough at room temp and soften at body temp.
Prior to use , cooled to make it more firm during
intubation
Smooth surface
Transparent
Silicone - more expensive
Can be sterilized and reused
Stiff enough at room temp and soften at body temp.
Prior to use , cooled to make it more firm during
intubation
Smooth surface
Transparent
Silicone - more expensive
Can be sterilized and reused
General PrinciplesGeneral PrinciplesGeneral PrinciplesGeneral Principles
•
Resistance and work of breathing
Mechanical burden on spontaneously breathing patient.
Adds resistance to gas flow.
Important in pediatric patients.
Several factors determine the resistance to gas flow
1.Internal diameter
Single most important factor
Tube with thick wall more resistance than thin walled with same
outer
diameter.Wall thickness to tube diameter ratio is greater in small
tubes.
Leadingtogreaterincreaseinresistance
•
Resistance and work of breathing
Mechanical burden on spontaneously breathing patient.
Adds resistance to gas flow.
Important in pediatric patients.
Several factors determine the resistance to gas flow
1.Internal diameter
Single most important factor
Tube with thick wall more resistance than thin walled with same
outer
diameter.Wall thickness to tube diameter ratio is greater in small
tubes.
Leadingtogreaterincreaseinresistance
•
2.Length
Decreasing tube length lowers resistance
3.Configuration
Curves in the tube or connector increase resistance.Kinking
increase
resistance.
Dead space
Tracheal tubes and connector constitute mechanical dead
space which
is usually less than that of natural passage.So dead space is
reduced by
intubation.
Inpediatricpatientslongtubes&connectorsmayincreasethe
2.Length
Decreasing tube length lowers resistance
3.Configuration
Curves in the tube or connector increase resistance.Kinking
increase
resistance.
Dead space
Tracheal tubes and connector constitute mechanical dead
space which
is usually less than that of natural passage.So dead space is
reduced by
intubation.
Inpediatricpatientslongtubes&connectorsmayincreasethe
•ANATOMY OF ET TUBE
Has a preformed curve that matches anatomical curve of airway.
Internal and external walls should be circular
Proximal or machine end receives connector and projects from
patient
Distal or patient end inserted into trachea
Distal end has a slanted portion called the bevel.
When held in right hand aperture faces left
Bevel facilitates insertion and allows tip of tube to be seen
passing
between cords
Has a preformed curve that matches anatomical curve of airway.
Internal and external walls should be circular
Proximal or machine end receives connector and projects from
patient
Distal or patient end inserted into trachea
Distal end has a slanted portion called the bevel.
When held in right hand aperture faces left
Bevel facilitates insertion and allows tip of tube to be seen
passing
between cords
•
•
•
•
•
Bevel
Patient end has a slant portion called bevel ,at an acute
angle to the longitudinal axis .
Its opening faces to the left when viewed from the
concave surface.
Angle of bevel is the acute angle between the bevel and
longitudinal axis of tracheal tube.
Angle of bevel in oral tube is 45 degree and in nasal tube
30 degree.
During nasal intubation bevel should be facing up ,to
avoid the tip from impinging on epiglottis.
•
•
•
•
Bevel
Patient end has a slant portion called bevel ,at an acute
angle to the longitudinal axis .
Its opening faces to the left when viewed from the
concave surface.
Angle of bevel is the acute angle between the bevel and
longitudinal axis of tracheal tube.
Angle of bevel in oral tube is 45 degree and in nasal tube
30 degree.
During nasal intubation bevel should be facing up ,to
avoid the tip from impinging on epiglottis.
•Murphy eye - hole in the wall opposite to bevel.
provide a secondary port for gas movement in
and
out of tube when there is bevel occlusion.
Area of murphy eye should be less than 80% of
the
cross- sectional area of the tube.
Disadv - secretions may accumulate
Tracheal tubes lacking murphy eye known as
ill
provide a secondary port for gas movement in
and
out of tube when there is bevel occlusion.
Area of murphy eye should be less than 80% of
the
cross- sectional area of the tube.
Disadv - secretions may accumulate
Tracheal tubes lacking murphy eye known as
ill
Cuffed tubes - have a inflatable cuff a short distance
proximal to
tube tip , seals the space between the tube
and
tracheal wall.
A radioopaque marker is placed at patient end or
along
entire length of tube to aid determination of
position
after intubation.
A transverse black mark on some tubes proximal to
proximal to
tube tip , seals the space between the tube
and
tracheal wall.
A radioopaque marker is placed at patient end or
along
entire length of tube to aid determination of
position
after intubation.
A transverse black mark on some tubes proximal to
Parts of endotracheal tube
•
•
•
•
•
•
STANDARD MARKING OF ETT
The markings are situated on the bevel side above the cuff & are
read from pt end to machine end:
Vocal cord marker
Size: ID in mm
External diameter for tubes size 6 and smaller
Words- oral or nasal or oral/nasal
Manufacturer's name or trade mark
Tube has Graduated markings, showing the distance in cms from
the patient end.
•
•
•
•
•
STANDARD MARKING OF ETT
The markings are situated on the bevel side above the cuff & are
read from pt end to machine end:
Vocal cord marker
Size: ID in mm
External diameter for tubes size 6 and smaller
Words- oral or nasal or oral/nasal
Manufacturer's name or trade mark
Tube has Graduated markings, showing the distance in cms from
the patient end.
•
•
•
Precautions are usually noted: Disposable/Do Not Reuse
Implantation tests (IT) or Z-79 indicating the tube has been tested
for tissue toxicity & accomplish ANSI standard.
Opaque lines may also be included at the patient end or along full
length.
•
•
Precautions are usually noted: Disposable/Do Not Reuse
Implantation tests (IT) or Z-79 indicating the tube has been tested
for tissue toxicity & accomplish ANSI standard.
Opaque lines may also be included at the patient end or along full
length.
SPECIAL TUBESSPECIAL TUBESSPECIAL TUBESSPECIAL TUBESSPECIAL TUBESSPECIAL TUBESSPECIAL TUBESSPECIAL TUBESSPECIAL TUBESSPECIAL TUBESSPECIAL TUBESSPECIAL TUBESSPECIAL TUBESSPECIAL TUBESSPECIAL TUBESSPECIAL TUBESSPECIAL TUBESSPECIAL TUBESSPECIAL TUBESSPECIAL TUBESSPECIAL TUBESSPECIAL TUBESSPECIAL TUBESSPECIAL TUBESSPECIAL TUBESSPECIAL TUBESSPECIAL TUBESSPECIAL TUBES
•Cole tube
The Cole Tracheal Tube was introduced by
anesthesiologist Frank Cole, M.D. (1909-1982),
in 1945, when endotracheal anesthesia in infants
and young children was still uncommon.
It is uncuffed, stepped wall designed ETT.
Patient end is smaller in diameter than the rest of the tube.
Sized according to internal diameter of tracheal portion.
It ranges from 2 to 5mm..
Recommended for neonatal resuscitation
but not for long term intubation.
Disadvantage : cannot be used nasally .
•Cole tube
The Cole Tracheal Tube was introduced by
anesthesiologist Frank Cole, M.D. (1909-1982),
in 1945, when endotracheal anesthesia in infants
and young children was still uncommon.
It is uncuffed, stepped wall designed ETT.
Patient end is smaller in diameter than the rest of the tube.
Sized according to internal diameter of tracheal portion.
It ranges from 2 to 5mm..
Recommended for neonatal resuscitation
but not for long term intubation.
Disadvantage : cannot be used nasally .
• Spiral embedded tubes:
Also known as Armored tube,
flexometallic tube.
These tubes have a metal or nylon spiral
woven reinforcing wire covered both
internally and externally by rubber, PVC or silicone.
The spiral may not extend into the
distal & proximal ends. Stylet may needed for intubation
These tubes are esp useful in situations where the tube is likely to
be
bent or compressed as in head & neck surgery
Also known as Armored tube,
flexometallic tube.
These tubes have a metal or nylon spiral
woven reinforcing wire covered both
internally and externally by rubber, PVC or silicone.
The spiral may not extend into the
distal & proximal ends. Stylet may needed for intubation
These tubes are esp useful in situations where the tube is likely to
be
bent or compressed as in head & neck surgery
•
•
•
Advantages:
Primary advantage of tube is resistance to kinking and
compression.
The portion of the tube outside the patient can be easily
angled away from the surgical field without kinking. This
makes them useful for insertion into patient with
tracheostomy,for submental intubation & retromolar
positioning.
Pass easily over a fiberscope than a conventional tube.
•
•
Advantages:
Primary advantage of tube is resistance to kinking and
compression.
The portion of the tube outside the patient can be easily
angled away from the surgical field without kinking. This
makes them useful for insertion into patient with
tracheostomy,for submental intubation & retromolar
positioning.
Pass easily over a fiberscope than a conventional tube.
•
•
•
•
Disadvantages:
Tube may rotate on the stylet during intubation.
Insertion through nose & intubating LMA is difficult.
Elastic recoil force may increase tendency to
unintentional extubation
If the patient bites the tube it will cause permanent
deformity resulting in obstruction of the tube, so BITE
BLOCK b/w molar tooth should be used to prevent this
(not an oral airway)
•
•
•
Disadvantages:
Tube may rotate on the stylet during intubation.
Insertion through nose & intubating LMA is difficult.
Elastic recoil force may increase tendency to
unintentional extubation
If the patient bites the tube it will cause permanent
deformity resulting in obstruction of the tube, so BITE
BLOCK b/w molar tooth should be used to prevent this
(not an oral airway)
•Preformed tubes
RAE Tube (Ring Adair Elwyn tube) -
RAE tubes named after their inventors Ring , Adair and Elwyn who
described use of their novel oral preformed tube in pediatric patients in
1975
It is preformed to facilitate the head & neck surgeries.
The tubes are available in cuffed, uncuffed ,nasal and oral version.
Oral tubes are shorter than nasal tubes.
There is a preformed bend in the tube that may be temporarily
straightened during insertion.
Each tube has a rectangular mark at the center of the bend.
Distance from this mark to the distal tip is printed on each tube. When
this mark is at the nares or teeth , the tube will be satisfactorily
positionedinthetrachea
RAE Tube (Ring Adair Elwyn tube) -
RAE tubes named after their inventors Ring , Adair and Elwyn who
described use of their novel oral preformed tube in pediatric patients in
1975
It is preformed to facilitate the head & neck surgeries.
The tubes are available in cuffed, uncuffed ,nasal and oral version.
Oral tubes are shorter than nasal tubes.
There is a preformed bend in the tube that may be temporarily
straightened during insertion.
Each tube has a rectangular mark at the center of the bend.
Distance from this mark to the distal tip is printed on each tube. When
this mark is at the nares or teeth , the tube will be satisfactorily
positionedinthetrachea
•
•
•
Oral tube has a preformed bend on the part of the tube
where it exits the mouth, so that proximal tube passes
down the chin and away from the face, improving surgical
access
The nasal version is bent where it exits the nose so that
the part housing the ISO connector passes upwards to
the forehead.
Main disadvantage of both designs is that the bend in the
tube determines the length of tube that lies within the
patient
•
•
Oral tube has a preformed bend on the part of the tube
where it exits the mouth, so that proximal tube passes
down the chin and away from the face, improving surgical
access
The nasal version is bent where it exits the nose so that
the part housing the ISO connector passes upwards to
the forehead.
Main disadvantage of both designs is that the bend in the
tube determines the length of tube that lies within the
patient
Left 2 nasal tubes ; cuffed and uncuffed . At right 2 oral tubes
Advantage - easy to secure
reduce risk of unintended extubation.
long length make them easy to insert through a
supraglottic
airway device
nasal tube for oral intubation for patient’s in prone
position ,
undergoing otolaryngeal procedures
Disadvantage - difficult to pass suction catheter through them
more resistance
reduce risk of unintended extubation.
long length make them easy to insert through a
supraglottic
airway device
nasal tube for oral intubation for patient’s in prone
position ,
undergoing otolaryngeal procedures
Disadvantage - difficult to pass suction catheter through them
more resistance
Polar tubes
Tube for nasotracheal intubation
Soft PVC material with a preformed curve that takes the
proximal end of the tube along the nose and over the
forehead
Well-suited to maxillofacial surgery
Soft plastic of the Ivory range , relatively atraumatic in the
nose, with the springiness of these tubes makes them
ideal for
‘blind nasal intubation’.
sizes 6.0 and 6.5 mm ID, are a good choice for nasal
fibreoptic
Tube for nasotracheal intubation
Soft PVC material with a preformed curve that takes the
proximal end of the tube along the nose and over the
forehead
Well-suited to maxillofacial surgery
Soft plastic of the Ivory range , relatively atraumatic in the
nose, with the springiness of these tubes makes them
ideal for
‘blind nasal intubation’.
sizes 6.0 and 6.5 mm ID, are a good choice for nasal
fibreoptic
•Microlaryngeal tube
a small internal diameter (ID usually around 4.5–5.5 mm)
but an
adult-sized high-volume low-pressure cuff.
For surgery around the vocal cords and are long enough
for
nasal intubation
High resistance to gas flow in these tubes virtually
obligates
controlled ventilation
Highly flexible difficult to insert without Magill forceps.
Dbk dldih ifhl l
a small internal diameter (ID usually around 4.5–5.5 mm)
but an
adult-sized high-volume low-pressure cuff.
For surgery around the vocal cords and are long enough
for
nasal intubation
High resistance to gas flow in these tubes virtually
obligates
controlled ventilation
Highly flexible difficult to insert without Magill forceps.
Dbk dldih ifhl l
Portex Ivory tracheal tubes.
Upper: north facing
directional (polar) tube. Lower:
microlaryngeal tube with
greater length and cuff size
relative to the tube diameter.
Upper: north facing
directional (polar) tube. Lower:
microlaryngeal tube with
greater length and cuff size
relative to the tube diameter.
•Carden tube
Invented by Edward carden in 1973.
For microsurgery of the larynx. Rarely used now .
It comprises a shortened cuffed tracheal
tube that sits wholly below the glottis
A long catheter for insufflation of gas
A long pilot tube for the cuff
Inserted by grasping the tube with
Magill’s forceps and placing it
under direct vision.
Invented by Edward carden in 1973.
For microsurgery of the larynx. Rarely used now .
It comprises a shortened cuffed tracheal
tube that sits wholly below the glottis
A long catheter for insufflation of gas
A long pilot tube for the cuff
Inserted by grasping the tube with
Magill’s forceps and placing it
under direct vision.
Tubes for laser surgery
Plastic, silicone or rubber may be damaged by the carbon
dioxide, KTP(potassiun titanyl phosphate) or Nd-YAG
laser
beam.
Burn more fiercely in the presence of oxygen or
nitrous oxide than in air and are easily ignited by a direct
or
indirect strike from the laser beam.
Leads to serious upper airway burns and severe distal
inhalation
ij
Plastic, silicone or rubber may be damaged by the carbon
dioxide, KTP(potassiun titanyl phosphate) or Nd-YAG
laser
beam.
Burn more fiercely in the presence of oxygen or
nitrous oxide than in air and are easily ignited by a direct
or
indirect strike from the laser beam.
Leads to serious upper airway burns and severe distal
inhalation
ij
•Mallinckrodt ‘Laser-Flex’ tracheal tubes
single-use tubes for oral intubation
made from a gas-tight metal helix
2 pilot tubes for the double cuff within the lumen of the
airway.
cuffs are not laser resistant, are inflated with saline,
ideally dyed
with some methylene blue, so puncture is obvious.
The function of the proximal cuff is to protect the distal
cuff
The tube must be replaced if either cuff is defective.
The tip of the tube is made of a soft plastic for atraumatic
single-use tubes for oral intubation
made from a gas-tight metal helix
2 pilot tubes for the double cuff within the lumen of the
airway.
cuffs are not laser resistant, are inflated with saline,
ideally dyed
with some methylene blue, so puncture is obvious.
The function of the proximal cuff is to protect the distal
cuff
The tube must be replaced if either cuff is defective.
The tip of the tube is made of a soft plastic for atraumatic
Foil wrapped
An alternative approach is to spirally wrap a suitably small
rubber
tube with a narrow strip of silver or copper foil .
The tube is then overwrapped to give a smooth outer
coating.
Rusch Lasertubus is covered in Merocel foam (a porous
sponge),which is soaked in saline to help absorb laser
energy.
This tube is provided with a double cuff arrangement.
An alternative approach is to spirally wrap a suitably small
rubber
tube with a narrow strip of silver or copper foil .
The tube is then overwrapped to give a smooth outer
coating.
Rusch Lasertubus is covered in Merocel foam (a porous
sponge),which is soaked in saline to help absorb laser
energy.
This tube is provided with a double cuff arrangement.
The Rusch Lasertubus (above) and
Sheridan
Laser-Trach (below) laser
resistant single-use tracheal tubes. The
embossed copper foil
of the Sheridan tube is just visible under
the outer covering.
Sheridan
Laser-Trach (below) laser
resistant single-use tracheal tubes. The
embossed copper foil
of the Sheridan tube is just visible under
the outer covering.
Tubes and catheters for ‘jet ventilation’
(high-pressure source ventilation)
•Supraglottic ventilation
Surgical laryngoscope that is used to suspend the larynx
for
surgery fitted with a metal cannula that ends above the
glottis and can be used for ‘jetting’ with high-pressure gas
(supraglottic ventilation).
Anaesthesia must be maintained intravenously.
High-pressure source ventilation may be delivered by a
small
laser-resistant catheter passed through the glottis
(t ltti tilti)
(high-pressure source ventilation)
•Supraglottic ventilation
Surgical laryngoscope that is used to suspend the larynx
for
surgery fitted with a metal cannula that ends above the
glottis and can be used for ‘jetting’ with high-pressure gas
(supraglottic ventilation).
Anaesthesia must be maintained intravenously.
High-pressure source ventilation may be delivered by a
small
laser-resistant catheter passed through the glottis
(t ltti tilti)
Supraglottic jet
ventilation with
cannula
correctly aligned for
effective ventilation.
ventilation with
cannula
correctly aligned for
effective ventilation.
•
•
•
•
•
•
•
Transglottic ventilation -Hunsaker Mon Jet ventilation tube
Introduced in 1994
Narrow-bore dual lumen tube
Laser-resistant and designed for transglottic high-pressure source
ventilation.
The patient end has a basket-shaped distal extension designed to
center the tube.
The OD is 3 mm, and it has an integral lumen for monitoring
airway pressure and respiratory gases
33-cm-long device (4.5 mm at its widest diameter) is made of a
laser-resistant fluoroplastic
This tube has been used to administer one-lung ventilation .
•
•
•
•
•
•
Transglottic ventilation -Hunsaker Mon Jet ventilation tube
Introduced in 1994
Narrow-bore dual lumen tube
Laser-resistant and designed for transglottic high-pressure source
ventilation.
The patient end has a basket-shaped distal extension designed to
center the tube.
The OD is 3 mm, and it has an integral lumen for monitoring
airway pressure and respiratory gases
33-cm-long device (4.5 mm at its widest diameter) is made of a
laser-resistant fluoroplastic
This tube has been used to administer one-lung ventilation .
•Subglottic ventilation: transtracheal catheters
Cannula placed percutaneously into the trachea via the
cricothyroid membrane enables subglottic ventilation
Requires a high pressure gas source for ventilation.
Manually operated, fixed-pressure ventilator (Sanders injector,
4bar)
Manually operated, variable-pressure ventilator (Manujet,
0.5–4 bar)
Automatic ventilator.
High pressure source - risk of barotrauma
Ventilators with airway pressure monitoring is safer.
Cannula placed percutaneously into the trachea via the
cricothyroid membrane enables subglottic ventilation
Requires a high pressure gas source for ventilation.
Manually operated, fixed-pressure ventilator (Sanders injector,
4bar)
Manually operated, variable-pressure ventilator (Manujet,
0.5–4 bar)
Automatic ventilator.
High pressure source - risk of barotrauma
Ventilators with airway pressure monitoring is safer.
•
•
•
•
Laryngectomy tube:
Designed for insertion into a tracheostomy site.
The tube is preformed in a ‘J’ configuration at
the pt end. This allows the part of the tube
external to the patient to be directed away from
the surgical field.
The tip may be short and/or without a bevel to
avoid inadvertent advancement into a bronchus.
Disadvantage -The soft cuff and short distance between the cuff and distal
tip of the tube may cause the bevel to abut the tracheal wall.
•
•
•
Laryngectomy tube:
Designed for insertion into a tracheostomy site.
The tube is preformed in a ‘J’ configuration at
the pt end. This allows the part of the tube
external to the patient to be directed away from
the surgical field.
The tip may be short and/or without a bevel to
avoid inadvertent advancement into a bronchus.
Disadvantage -The soft cuff and short distance between the cuff and distal
tip of the tube may cause the bevel to abut the tracheal wall.
Tubes for thoracic surgery (including bronchial
blockers)
•
•
Operations within the thoracic cavity may require the
collapse of a lung to improve access to other organs, to
isolate that lung for its removal or repair, or to prevent
contamination from a diseased lung spreading to the
other side.
This may be achieved in one of three ways.
blockers)
•
•
Operations within the thoracic cavity may require the
collapse of a lung to improve access to other organs, to
isolate that lung for its removal or repair, or to prevent
contamination from a diseased lung spreading to the
other side.
This may be achieved in one of three ways.
•Endobronchial tubes
A long tube passed under endoscopic control, beyond the
carina
into the unaffected lung so that the cuff can be inflated
within a main bronchus.
The other lung is not ventilated and collapses, especially
when the pleura is opened.
Mainly for intubating the left main bronchus (for surgery on
the right lung). because the right upper lobe bronchus
enters its main bronchus very close to the carina and its
lumen would be obstructed by the cuff of the tube.
A long tube passed under endoscopic control, beyond the
carina
into the unaffected lung so that the cuff can be inflated
within a main bronchus.
The other lung is not ventilated and collapses, especially
when the pleura is opened.
Mainly for intubating the left main bronchus (for surgery on
the right lung). because the right upper lobe bronchus
enters its main bronchus very close to the carina and its
lumen would be obstructed by the cuff of the tube.
•Tubes with bronchial blockers
In 1936 ,Magill achieved bronchial blockade using a long tube with
an inflatable cuff at its distal end that was advanced alongside a
single lumen endotracheal tube.
A Tracheal tube through which a fine balloon catheter can be passed
either via the lumen of the tube or through a channel in its wall.
The balloon tip is then passed, usually with the aid of a flexible
endoscope, into the intended main bronchus, which becomes
isolated when the balloon is inflated
Bronchial blockers have a variety of designs to assist placement;
these include fixed angulations, loops for attachment to an
endoscope and a novel design with dual balloons either side of a
self-deploying ‘V’
In 1936 ,Magill achieved bronchial blockade using a long tube with
an inflatable cuff at its distal end that was advanced alongside a
single lumen endotracheal tube.
A Tracheal tube through which a fine balloon catheter can be passed
either via the lumen of the tube or through a channel in its wall.
The balloon tip is then passed, usually with the aid of a flexible
endoscope, into the intended main bronchus, which becomes
isolated when the balloon is inflated
Bronchial blockers have a variety of designs to assist placement;
these include fixed angulations, loops for attachment to an
endoscope and a novel design with dual balloons either side of a
self-deploying ‘V’
Univent tracheal tubes
with endobronchial
blockers. The lower
device allows access
to the lung distal to
the blocker
EZ-Blocker
for lung isolation, deployed through a
conventional tracheal
tube.
with endobronchial
blockers. The lower
device allows access
to the lung distal to
the blocker
EZ-Blocker
for lung isolation, deployed through a
conventional tracheal
tube.
Double lumen tubes
•The first double-lumen tube used for bronchospirometry
and
later for one-lung anaesthesia in humans was introduced
by
Carlens in 1949.
Modifications to the original Carlens tube have been
introduced
by White, Robertshaw and others.
The most commonly used DLTs today are the Carlens and
the
Robertshawtubes
•The first double-lumen tube used for bronchospirometry
and
later for one-lung anaesthesia in humans was introduced
by
Carlens in 1949.
Modifications to the original Carlens tube have been
introduced
by White, Robertshaw and others.
The most commonly used DLTs today are the Carlens and
the
Robertshawtubes
DLT Formed by bonding together two tubes of similar
diameters
but different lengths.
The shorter tube ends in the trachea and seals this with
one cuff
Longer tube is designed to fit a main bronchus and seal
this with a separate cuff.
The cuffs are supplied by separate inflation tubes and pilot
balloons, which are marked and colour-coded to aid
identification.
DLTsareproducedinleft-andright-sidedversions
diameters
but different lengths.
The shorter tube ends in the trachea and seals this with
one cuff
Longer tube is designed to fit a main bronchus and seal
this with a separate cuff.
The cuffs are supplied by separate inflation tubes and pilot
balloons, which are marked and colour-coded to aid
identification.
DLTsareproducedinleft-andright-sidedversions
The bronchial lumen on right-sided versions has a side hole
and a
cuff that is designed so that it does not get occluded.
The bronchial cuff and inflation tube are blue by convention.
Double lumen tubes (both with
malleable
tracheal introducers in place).
Portex right-sided tube (above)
and Mallinckrodt Broncocath left-
sided tube (below). The
scalloping of the distal cuff is just
visible on the right-sided
tube
and a
cuff that is designed so that it does not get occluded.
The bronchial cuff and inflation tube are blue by convention.
Double lumen tubes (both with
malleable
tracheal introducers in place).
Portex right-sided tube (above)
and Mallinckrodt Broncocath left-
sided tube (below). The
scalloping of the distal cuff is just
visible on the right-sided
tube
Sizes
Combined size of the two lumens makes the device bulky
so not used in children.
External shape of the device is circular in cross-section
lumens of the two tubes are each ‘D’-shaped and the size
cannot
be quoted in terms of an internal diameter.
Sizes are quoted in French gauge (Fr).
This scale is constructed from the external diameter of the
widest
part of the device, measured in millimetres, multiplied by a
factor
Combined size of the two lumens makes the device bulky
so not used in children.
External shape of the device is circular in cross-section
lumens of the two tubes are each ‘D’-shaped and the size
cannot
be quoted in terms of an internal diameter.
Sizes are quoted in French gauge (Fr).
This scale is constructed from the external diameter of the
widest
part of the device, measured in millimetres, multiplied by a
factor
•Insertion
Difficult to insert due to their bulk and double angulations
left-sided are easier to insert
largest possible left-sided DLT is selected and the cuffs are
checked for leaks.
Left-sided tubes are appropriate for most procedures
except
for left pneumonectomy.
Inserted under direct laryngoscopy and once through the
larynx it
is rotated counter-clockwise so that the tip enters the left
Difficult to insert due to their bulk and double angulations
left-sided are easier to insert
largest possible left-sided DLT is selected and the cuffs are
checked for leaks.
Left-sided tubes are appropriate for most procedures
except
for left pneumonectomy.
Inserted under direct laryngoscopy and once through the
larynx it
is rotated counter-clockwise so that the tip enters the left
Two connectors are then joined on to those on a twin tube
adapter
which links the tubes to the breathing system.
The tracheal cuff is then inflated and manual ventilation is
commenced via both lumens.
Visible equal bilateral chest movement ,confirmed by
auscultation.
The tracheal adapter on the catheter mount is then
occluded with
a hose clamp so all ventilation is directed down the
bronchial
adapter
which links the tubes to the breathing system.
The tracheal cuff is then inflated and manual ventilation is
commenced via both lumens.
Visible equal bilateral chest movement ,confirmed by
auscultation.
The tracheal adapter on the catheter mount is then
occluded with
a hose clamp so all ventilation is directed down the
bronchial
The left bronchial cuff is then slowly inflated whilst aus-
cultating the right lung until a seal is achieved, at which
point gas entry to the right lung stops. The tracheal
lumen is then released so that the tube can be used as
intended.
Insertion of right-sided tubes involves clockwise rotation of
the
DLT and similar checking of left lung inflation with the
added
proviso that gas entry should also be confirmed over the
iht
cultating the right lung until a seal is achieved, at which
point gas entry to the right lung stops. The tracheal
lumen is then released so that the tube can be used as
intended.
Insertion of right-sided tubes involves clockwise rotation of
the
DLT and similar checking of left lung inflation with the
added
proviso that gas entry should also be confirmed over the
iht
Visual confirmation with a fibreoptic scope is the most
accurate
method of determining the true position of these tubes
Bronchial cuff should be visible (when the fibreoptic
scope is advanced beyond the end of the tracheal lumen)
at or just beyond the carina, and with right-sided tubes the
origin of the right upper lobe bronchus must be confirmed
to lie adjacent to the side hole of the bronchial tube.
accurate
method of determining the true position of these tubes
Bronchial cuff should be visible (when the fibreoptic
scope is advanced beyond the end of the tracheal lumen)
at or just beyond the carina, and with right-sided tubes the
origin of the right upper lobe bronchus must be confirmed
to lie adjacent to the side hole of the bronchial tube.
Tubes to assist intubation
• Mallinckrodt Endotrol tracheal tube
Has a control wire connected to the distal tip that runs in
the
wall of the tube on the inner aspect of the curvature.
Traction on this wire decreases the tube's inside radius ,
that
moves the tip anteriorly and facilitates intubation.
Used for blind intubations, intubation utilizing
a lighted intubation stylet; and intubation using
a laryngoscope.
• Mallinckrodt Endotrol tracheal tube
Has a control wire connected to the distal tip that runs in
the
wall of the tube on the inner aspect of the curvature.
Traction on this wire decreases the tube's inside radius ,
that
moves the tip anteriorly and facilitates intubation.
Used for blind intubations, intubation utilizing
a lighted intubation stylet; and intubation using
a laryngoscope.
Patient’s with suspected cervical spine injury, in cervical
traction
& who is breathing spontaneously are excellent candidate
for use
of this technique.
Disadvantage –
Kinking during prolong use.
Tip of tube may abut the tracheal wall.
Endotrol tracheal tube. The pull ring loop
(trigger)) is attached to the tip by a cablelike
mechanism that allows the tip to be
maneuvered
traction
& who is breathing spontaneously are excellent candidate
for use
of this technique.
Disadvantage –
Kinking during prolong use.
Tip of tube may abut the tracheal wall.
Endotrol tracheal tube. The pull ring loop
(trigger)) is attached to the tip by a cablelike
mechanism that allows the tip to be
maneuvered
•ETView tracheal tube
A video camera is incorporated in the tip of the tracheal
tube
allowing visual confirmation of the passage of the tube tip
during insertion and constant observation of the tracheal
lumen
after placement.
A video camera is incorporated in the tip of the tracheal
tube
allowing visual confirmation of the passage of the tube tip
during insertion and constant observation of the tracheal
lumen
after placement.
•Intubating LMA tracheal tube
Both in reusable and single-use versions available.
It is a reinforced silicone tube with a soft bullet-shaped
silicone tip.
Tip reduces the likelihood of impingement on the arytenoids
and
eliminates ‘hold-up’ of the tracheal tube during insertion.
Reduces failure, speeds insertion and minimizes the
likelihood of
laryngeal trauma.
Both in reusable and single-use versions available.
It is a reinforced silicone tube with a soft bullet-shaped
silicone tip.
Tip reduces the likelihood of impingement on the arytenoids
and
eliminates ‘hold-up’ of the tracheal tube during insertion.
Reduces failure, speeds insertion and minimizes the
likelihood of
laryngeal trauma.
Tubes with additional ports/lumens
LITA tube
The extra lumen in this tube has ten small side holes,
eight
above and two below the cuff for the ‘Laryngotracheal
Instillation of Topical Anaesthetic’.
There is evidence demonstrating better tolerance of
intubation in
sedated patients and conflicting evidence regarding
suppression
of response to extubation
LITA tube
The extra lumen in this tube has ten small side holes,
eight
above and two below the cuff for the ‘Laryngotracheal
Instillation of Topical Anaesthetic’.
There is evidence demonstrating better tolerance of
intubation in
sedated patients and conflicting evidence regarding
suppression
of response to extubation
Sheridan LITA (Laryngotracheal
Instillation of
Topical Anaesthetic) tube. A black
horizontal line indicates
uppermost opening.
Instillation of
Topical Anaesthetic) tube. A black
horizontal line indicates
uppermost opening.
TUBE CHOICE - CUFFED VS UNCUFFED
•Cuffed
Cuffed routinely used in adults
Advantages - Improve accuracy of monitoring endtidal
gases ,
tidal volume , compliance , and oxygen consumption.
Decreased risk of aspiration
Able to use high inflation pressures and low fresh gas
flow
Less operating room pollution
Decresed risk of fire
•Cuffed
Cuffed routinely used in adults
Advantages - Improve accuracy of monitoring endtidal
gases ,
tidal volume , compliance , and oxygen consumption.
Decreased risk of aspiration
Able to use high inflation pressures and low fresh gas
flow
Less operating room pollution
Decresed risk of fire
Drawbacks - Overinflation of cuff result in excessive
pressure
against mucosa
Risk of injury to vocal cord.
Larger external diameter lead to difficult
extubation.
Size - Smaller diameter tubes easy to insert but higher
resistance
Larger tubes with less risk of occlusion and lower
resistance but increased incidence of postop sore
tht
pressure
against mucosa
Risk of injury to vocal cord.
Larger external diameter lead to difficult
extubation.
Size - Smaller diameter tubes easy to insert but higher
resistance
Larger tubes with less risk of occlusion and lower
resistance but increased incidence of postop sore
tht
•Uncuffed
With uncuffed tubes, the size should be large enough to provide
effective ventilation but not so large as to cause pressure on the
mucosa. This is commonly achieved by allowing a leak between
the tube and the wall of the trachea at high peak airway pressures
(20 to
25 cm H 2 O)
In pre pubescent children narrowest part of airway is cricoid ring
Even a small degree of edema in airway lead to respiratory
compromise.
Uncuffed tubes preferred in pediatrics , small enough to leave an
audible
With uncuffed tubes, the size should be large enough to provide
effective ventilation but not so large as to cause pressure on the
mucosa. This is commonly achieved by allowing a leak between
the tube and the wall of the trachea at high peak airway pressures
(20 to
25 cm H 2 O)
In pre pubescent children narrowest part of airway is cricoid ring
Even a small degree of edema in airway lead to respiratory
compromise.
Uncuffed tubes preferred in pediatrics , small enough to leave an
audible
•
•
•
CUFF SYSTEM :
consists of the cuff & inflation system.
It provide a seal between tube & tracheal wall to prevent
passage of pharyngeal contents into the trachea
Ensures no gas leaks past the cuff during positive
pressure ventilation.
The cuff also serves to center the tube in trachea.
•
•
CUFF SYSTEM :
consists of the cuff & inflation system.
It provide a seal between tube & tracheal wall to prevent
passage of pharyngeal contents into the trachea
Ensures no gas leaks past the cuff during positive
pressure ventilation.
The cuff also serves to center the tube in trachea.
•
•
•
•
1)
2)
3)
4)
CUFF:
The cuff is a inflatable sleeve near the patient end of ETT.
The cuff material should be strong and tear resistant but
thin, soft and pliable.
Cuffs are usually made of the same material as the ETT.
Type of cuffs
Low volume,high pressure cuff
High volume,low pressure cuff
Foam cuff
Lanz cuff
•
•
•
1)
2)
3)
4)
CUFF:
The cuff is a inflatable sleeve near the patient end of ETT.
The cuff material should be strong and tear resistant but
thin, soft and pliable.
Cuffs are usually made of the same material as the ETT.
Type of cuffs
Low volume,high pressure cuff
High volume,low pressure cuff
Foam cuff
Lanz cuff
a) Low volume high pressure cuff:
They have a small diameter at rest and low residual
volume.
low volume , small , standard , conventional , low
compliance ,
high pressure
(Residual volume - the amount of air that can be
withdrawn from the cuff after it has been allowed to
assume its shape with the inflation tube exposed to
atmosphericpressure)
They have a small diameter at rest and low residual
volume.
low volume , small , standard , conventional , low
compliance ,
high pressure
(Residual volume - the amount of air that can be
withdrawn from the cuff after it has been allowed to
assume its shape with the inflation tube exposed to
atmosphericpressure)
Requires a high intracuff pressure to achieve a seal with
trachea.
Has a small area of contact with tracheal wall
Distends and deforms trachea to a circular shape
Pressure inside cuff is used to overcome cuff wall
compliance
Pressure exerted laterally on tracheal wall will be less than
intracuff pressure.
trachea.
Has a small area of contact with tracheal wall
Distends and deforms trachea to a circular shape
Pressure inside cuff is used to overcome cuff wall
compliance
Pressure exerted laterally on tracheal wall will be less than
intracuff pressure.
•
•
•
•
•
Advantages:
Usually reused (nondisposable silicon)
Less expensive
Offers better protection against aspiration
Better visibility during intubation than low pressure cuffs.
There is also low incidence of sore throat.
Disadvantages: The most serious risk associated with
these
cuff is ischemic damage to the trachea following
prolongeduse
•
•
•
•
Advantages:
Usually reused (nondisposable silicon)
Less expensive
Offers better protection against aspiration
Better visibility during intubation than low pressure cuffs.
There is also low incidence of sore throat.
Disadvantages: The most serious risk associated with
these
cuff is ischemic damage to the trachea following
prolongeduse
b) High volume low pressure cuff:
Large resting volume , high compliance , floppy , low pressure
They have a high residual volume,large diameter & a thin
competent wall.
Thin compliant wall seals trachea without stretching tracheal wall.
As cuff is inflated it first touches trachea at widest part of cuff or
narrowest point in trachea under cuff.
As cuff continues ti inflate , area of contact become larger and
cuff adapts itself to tracheal surface
Large resting volume , high compliance , floppy , low pressure
They have a high residual volume,large diameter & a thin
competent wall.
Thin compliant wall seals trachea without stretching tracheal wall.
As cuff is inflated it first touches trachea at widest part of cuff or
narrowest point in trachea under cuff.
As cuff continues ti inflate , area of contact become larger and
cuff adapts itself to tracheal surface
Advantage :
It is relatively easy to pass devices such as esophageal
stethoscope, temperature probes, nasogastric tubes
around low pressure cuffs.
Possible to measure and regulate the pressure exerted on
tracheal mucosa
Risk of cuff induced complications following prolonged
intubation is reduced.
It is relatively easy to pass devices such as esophageal
stethoscope, temperature probes, nasogastric tubes
around low pressure cuffs.
Possible to measure and regulate the pressure exerted on
tracheal mucosa
Risk of cuff induced complications following prolonged
intubation is reduced.
•
•
•
•
•
Disadvantage:
These tubes are more difficult to insert,
Obscure the view of the tube tip and larynx
The cuff is more friable and thus more likely to be torn
during
intubation.
Incidence of sore throats is greater with these tubes.
It may not effectively prevent fluid leakage into lower
airway
•
•
•
•
Disadvantage:
These tubes are more difficult to insert,
Obscure the view of the tube tip and larynx
The cuff is more friable and thus more likely to be torn
during
intubation.
Incidence of sore throats is greater with these tubes.
It may not effectively prevent fluid leakage into lower
airway
•
•
•
•
•
•
C)BIVONA FOAM CUFF
Has a large diameter, residual volume, surface area
It is filled with polyurethane foam that is covered with sheath,
applying suction to the inflation tube cause the foam to shrink.
when negative pressure is released the cuff expand
Before extubation cuff should be collapsed by aspirating and the
clamping the inflating tube
Pressure on the tracheal wall depend on relationship b/w cuff
diameter at residual volume and diameter of trachea
If too large cuff used , cuff:tracheal wall pressure ratio will be high
If too small cuff used there will not be seal.
•
•
•
•
•
C)BIVONA FOAM CUFF
Has a large diameter, residual volume, surface area
It is filled with polyurethane foam that is covered with sheath,
applying suction to the inflation tube cause the foam to shrink.
when negative pressure is released the cuff expand
Before extubation cuff should be collapsed by aspirating and the
clamping the inflating tube
Pressure on the tracheal wall depend on relationship b/w cuff
diameter at residual volume and diameter of trachea
If too large cuff used , cuff:tracheal wall pressure ratio will be high
If too small cuff used there will not be seal.
•
•
•
Diffusion of anaesthetic agent
occurs into cuff but pressure does not
increase if the inflating channel is open.
There is no need of pressure monitoring
It can provide seal at a low tracheal wall pressure.
•
•
Diffusion of anaesthetic agent
occurs into cuff but pressure does not
increase if the inflating channel is open.
There is no need of pressure monitoring
It can provide seal at a low tracheal wall pressure.
•
•
D)MALLINCKRODT LANZ CUFF
It consists of a very compliant latex pilot balloon inside a
transparent plastic sheath with an automatic pressure regulating
valve b/w balloon & cuff
Pilot balloon has three functions:
1.An indication of cuff inflation
2.An external reservoir for cuff
3.Pressure limiting device
Designed to maintain intracuff
pressure of 20-25 torr at end
expiration.
•
D)MALLINCKRODT LANZ CUFF
It consists of a very compliant latex pilot balloon inside a
transparent plastic sheath with an automatic pressure regulating
valve b/w balloon & cuff
Pilot balloon has three functions:
1.An indication of cuff inflation
2.An external reservoir for cuff
3.Pressure limiting device
Designed to maintain intracuff
pressure of 20-25 torr at end
expiration.
•
•
•
A pressure regulating valve present between pilot balloon
and cuff.
Pressure regulating valve permit rapid gas flow from the
balloon to cuff but only slow flow from the cuff to balloon,
this prevents the gas from being squeezed back in to the
balloon when airway pressure rises rapidly, so there is no
gas leaks during PPV.
Also prevents increase in cuff pressure & volume due
to nitrous oxide and other gases into cuff.
•
•
A pressure regulating valve present between pilot balloon
and cuff.
Pressure regulating valve permit rapid gas flow from the
balloon to cuff but only slow flow from the cuff to balloon,
this prevents the gas from being squeezed back in to the
balloon when airway pressure rises rapidly, so there is no
gas leaks during PPV.
Also prevents increase in cuff pressure & volume due
to nitrous oxide and other gases into cuff.
•
•
•
•
As air is injected cuff and balloon are inflated in parallel.
when balloon has stretched appearance a pressure of
approximately 26 to 33 cmH2O will be present in cuff.
the intraballoon pressure remains constant.
The pressure regulating valve protects against rapid loss
of cuff volume into balloon during inspiration.
•
•
•
As air is injected cuff and balloon are inflated in parallel.
when balloon has stretched appearance a pressure of
approximately 26 to 33 cmH2O will be present in cuff.
the intraballoon pressure remains constant.
The pressure regulating valve protects against rapid loss
of cuff volume into balloon during inspiration.
CUFF PRESSURES
•
•
Intracuff pressure and pressure on tracheal wall:
It is desirable that cuff seals the airway without extending
so much pressure on the trachea so that its circulation is
not compromised.
So it is recommended that the pressure on the lateral
tracheal wall should be kept between 25-34cm of H20.
•
•
Intracuff pressure and pressure on tracheal wall:
It is desirable that cuff seals the airway without extending
so much pressure on the trachea so that its circulation is
not compromised.
So it is recommended that the pressure on the lateral
tracheal wall should be kept between 25-34cm of H20.
•
•
•
Intracuff pressure and Nitrous oxide :
The resting intracuff pressure and volume of the cuff
inflated with air rise during nitrous oxide anesthesia,
which results in ischaemia of the tracheal mucosa or
compression of the tube, and increase in volume may
lead to cuff herniation.
The increase varies directly with partial pressure of N2O ,
the permeability of cuff wall and time.
When N2O is stopped,pressure in the cuff decreases
rapidly.
•
•
Intracuff pressure and Nitrous oxide :
The resting intracuff pressure and volume of the cuff
inflated with air rise during nitrous oxide anesthesia,
which results in ischaemia of the tracheal mucosa or
compression of the tube, and increase in volume may
lead to cuff herniation.
The increase varies directly with partial pressure of N2O ,
the permeability of cuff wall and time.
When N2O is stopped,pressure in the cuff decreases
rapidly.
Changes in cuff pressure
•
•
Lower during hypothermic bypass
Rise due to pressure from nearby surgical procedures
increase in altitude
diffusion of oxygen into cuff
change in head positions
coughing ,straining , changes in muscle tone.
•
•
Lower during hypothermic bypass
Rise due to pressure from nearby surgical procedures
increase in altitude
diffusion of oxygen into cuff
change in head positions
coughing ,straining , changes in muscle tone.
Steps to prevent the increasing pressure includes the
following:
a) Filling the cuff with gas mixture to be used
for anesthesia or saline
b) Fitting the cuff system with pressure relief valve or
pressure
regulating devices e.g.Lanz pressure regulating valve,
sponge cuff
c) Monitoring cuff pressure
and deflating the cuff as
needed.
following:
a) Filling the cuff with gas mixture to be used
for anesthesia or saline
b) Fitting the cuff system with pressure relief valve or
pressure
regulating devices e.g.Lanz pressure regulating valve,
sponge cuff
c) Monitoring cuff pressure
and deflating the cuff as
needed.
INFLATION SYSTEM
•Inflation lumen
Connects inflation tube to cuff
Located within wall of tracheal tube
Must not encroach on tracheal tube lumen.
Does not bulge outward
•Inflation lumen
Connects inflation tube to cuff
Located within wall of tracheal tube
Must not encroach on tracheal tube lumen.
Does not bulge outward
•External inflation tube
Cuff tube , pilot tube or line , pilot balloon line , inflating
tube ,
tail.
Its external diameter does not exceed 2.5mm and
attached to
tube at a small angle.
The distance from tip of the tube to where the inflation
tube is
attached is atleast 3cm between machine end of inflation
tube
Cuff tube , pilot tube or line , pilot balloon line , inflating
tube ,
tail.
Its external diameter does not exceed 2.5mm and
attached to
tube at a small angle.
The distance from tip of the tube to where the inflation
tube is
attached is atleast 3cm between machine end of inflation
tube
•
•
Pilot balloon
Located near midpoint of inflating tube or adjacent to
inflation
valve.
To indicate cuff inflation
Inflation valve
When the tip of a syringe is inserted a plunger is
displaced
from its seat and gas can be injected into cuff.Upon
removing
the syringe the valve seals so gas cannot escape.
•
Pilot balloon
Located near midpoint of inflating tube or adjacent to
inflation
valve.
To indicate cuff inflation
Inflation valve
When the tip of a syringe is inserted a plunger is
displaced
from its seat and gas can be injected into cuff.Upon
removing
the syringe the valve seals so gas cannot escape.
•Tracheal tube connector
Attach tube to breathing system.
Made of plastic or metal
Size of connector is designated by ID of patient end in
mm.
Machine end has a 15mm male fitting.
Connector should be same size of tube.
Most commonly used connectors are straight and 90
degree
curved
Curved or flexible connector facilitate positioning but
increase
Attach tube to breathing system.
Made of plastic or metal
Size of connector is designated by ID of patient end in
mm.
Machine end has a 15mm male fitting.
Connector should be same size of tube.
Most commonly used connectors are straight and 90
degree
curved
Curved or flexible connector facilitate positioning but
increase
Method of securing a
nasotracheal tube. A: A
skull cap is placed
around the head. An
acute-
angle connector is
used and taped so that
it does not exert
pressure on the nasal
ala. B: Foam padding is
used to keep the
breathing system from
exerting pull on the
tracheal tube. C: Tape
is added to keep the
breathing system
firmly in place.
nasotracheal tube. A: A
skull cap is placed
around the head. An
acute-
angle connector is
used and taped so that
it does not exert
pressure on the nasal
ala. B: Foam padding is
used to keep the
breathing system from
exerting pull on the
tracheal tube. C: Tape
is added to keep the
breathing system
firmly in place.
Common probles with use of tracheal tubes
•
•
•
•
Disconnection of the tube from the 15 mm ISO connector
or of the connector from the catheter.Most likely during
positioning
Leak. In uncuffed tubes excessive leak indicates a larger
tube is required. With cuffed tubes a leak may arise if the
cuff is at the cords.
Kinking external and inside patient.
Foreign bodies have been found within airway devices
causing blockage
•
•
•
•
Disconnection of the tube from the 15 mm ISO connector
or of the connector from the catheter.Most likely during
positioning
Leak. In uncuffed tubes excessive leak indicates a larger
tube is required. With cuffed tubes a leak may arise if the
cuff is at the cords.
Kinking external and inside patient.
Foreign bodies have been found within airway devices
causing blockage
•
•
Short, uncuffed and preshaped tubes (a combination of
which is commonly used in children) are particularly
prone to inadvertent extubation
(Endo) bronchial placement.extension of the head and
neck tends to advance the tube.
•
Short, uncuffed and preshaped tubes (a combination of
which is commonly used in children) are particularly
prone to inadvertent extubation
(Endo) bronchial placement.extension of the head and
neck tends to advance the tube.
•
•
•
THE GUIDELINES TO DETERMINE THE SIZE OF ETT:
Designated by ID (mm). ISO standard requires Tube size
to be marked b/w cuff and the take off point of the
inflation tube for cuffed tubes.
For uncuffed tube size marking should be towards the
patient end
Ideal tube in average Adult male – 8.5 & Adult female -
7.5mm ID.
•
•
THE GUIDELINES TO DETERMINE THE SIZE OF ETT:
Designated by ID (mm). ISO standard requires Tube size
to be marked b/w cuff and the take off point of the
inflation tube for cuffed tubes.
For uncuffed tube size marking should be towards the
patient end
Ideal tube in average Adult male – 8.5 & Adult female -
7.5mm ID.
Age is recognized as the most reliable indicator of
appropriate ETT size.
Cuffed tube in children , following formula used
ID in mm = age / 4 + 3
appropriate ETT size.
Cuffed tube in children , following formula used
ID in mm = age / 4 + 3
•Proper size selection
1. For children below 6 years: age in years/3 + 3.75
For children older than 6 years: age in years/4 + 4.5
2. ID = 3 mm for those 3 months of age and younger
= 3.5 mm for those from 3 to 9 months of age
= (age in years + 16)/4 over 9 months of age
3.Older than 1 year ------ID in mm = (16 + age in years)/4
4. Use of a measure based on body length
5. Choosing a tube whose external diameter is the same width as
the distal
phalanx of the little or index finger.
7. ID = 2.44 + (age × 0.1) + (height in cm × 0.02) + (weight in kg x
0016)
1. For children below 6 years: age in years/3 + 3.75
For children older than 6 years: age in years/4 + 4.5
2. ID = 3 mm for those 3 months of age and younger
= 3.5 mm for those from 3 to 9 months of age
= (age in years + 16)/4 over 9 months of age
3.Older than 1 year ------ID in mm = (16 + age in years)/4
4. Use of a measure based on body length
5. Choosing a tube whose external diameter is the same width as
the distal
phalanx of the little or index finger.
7. ID = 2.44 + (age × 0.1) + (height in cm × 0.02) + (weight in kg x
0016)
•
•
•
CHECKING OF TUBE
Tube should be examined to defect such as splitting,
holes & missing sections.
Tube should be checked for obstruction, looking into
both ends or by inserting a stylet
Cuff should remain inflated for 1 min to check for any
leaks
•
•
CHECKING OF TUBE
Tube should be examined to defect such as splitting,
holes & missing sections.
Tube should be checked for obstruction, looking into
both ends or by inserting a stylet
Cuff should remain inflated for 1 min to check for any
leaks
DEPTH OF INSERTION
•
•
•
The tube should be in the middle third of the trachea with the head
in neutral position. The formulas based on subject’s height, age &
weight may be used in children for oral intubation..…
1) Length in cm = age/2 + 12
2) Length in cm = weight in kg/5 + 12
3) Length in cm = height in cms/10 + 5
4) Rule of 7-8-9 for
1 kg infant-depth of 7 cm at the lips
2 kg infant-8cm
3 kg infant-9 cm
Naso tracheal intubation -Multiplying crown heel length by 0.21
•
•
•
The tube should be in the middle third of the trachea with the head
in neutral position. The formulas based on subject’s height, age &
weight may be used in children for oral intubation..…
1) Length in cm = age/2 + 12
2) Length in cm = weight in kg/5 + 12
3) Length in cm = height in cms/10 + 5
4) Rule of 7-8-9 for
1 kg infant-depth of 7 cm at the lips
2 kg infant-8cm
3 kg infant-9 cm
Naso tracheal intubation -Multiplying crown heel length by 0.21
•
•
•
•
In adults, the tube should be passed until the cuff is 2.25 to 2.5cm
below the vocal cords
In uncuffed tubes, tube tip should not be inserted more than
1cm past the cords <6months
2cm past the cords up to 1yr
3-4cm past the cords > 1yr
In average size adult patients, securing the tube at the anterior
incisor at 23cm in males and 21cm in females will usually avoid
endobronchial intubation.
For nasal intubation 5cm should be added to these lengths for
positioning at the nares.
•
•
•
In adults, the tube should be passed until the cuff is 2.25 to 2.5cm
below the vocal cords
In uncuffed tubes, tube tip should not be inserted more than
1cm past the cords <6months
2cm past the cords up to 1yr
3-4cm past the cords > 1yr
In average size adult patients, securing the tube at the anterior
incisor at 23cm in males and 21cm in females will usually avoid
endobronchial intubation.
For nasal intubation 5cm should be added to these lengths for
positioning at the nares.
CONFIRMATION OF ET TUBE POSITION
•
•
•
•
•
•
•
•
Visualize the tube passing through vocal cords
Feel the compliance of reservoir bag
Observe the chest wall rise with inspiration
5 point Auscultation
Movement of respiratory mist in ETT
Cuff Palpation over the suprasternal notch
EtCO2 detectors,Capnography(gold standard)
Chest x –ray
•
•
•
•
•
•
•
•
Visualize the tube passing through vocal cords
Feel the compliance of reservoir bag
Observe the chest wall rise with inspiration
5 point Auscultation
Movement of respiratory mist in ETT
Cuff Palpation over the suprasternal notch
EtCO2 detectors,Capnography(gold standard)
Chest x –ray
•
•
•
•
•
Fibreoptic laryngoscope /bronchoscope
Esophageal detector device
(rely on aspiration of air rapidly through ETT)
Sonomatic confirmation
Pulse oximeter value
Good pt. color & Vocal silence after
awake intubation
•
•
•
•
Fibreoptic laryngoscope /bronchoscope
Esophageal detector device
(rely on aspiration of air rapidly through ETT)
Sonomatic confirmation
Pulse oximeter value
Good pt. color & Vocal silence after
awake intubation
INFLATION OF CUFF:
•
•
•
After checking tube position cuff is inflated with
minimum amount of gas that will cause it to seal against
the trachea at peak inspiratory pressure.
Cuff pressure adjusted so there is no leak at PIP.
Leak can be detected by
1.Palpation or auscultation of pretracheal area
2.Difference b/w inhaled and exhaled volumes
3.Monitoring for CO2 in upper airway
•
•
•
After checking tube position cuff is inflated with
minimum amount of gas that will cause it to seal against
the trachea at peak inspiratory pressure.
Cuff pressure adjusted so there is no leak at PIP.
Leak can be detected by
1.Palpation or auscultation of pretracheal area
2.Difference b/w inhaled and exhaled volumes
3.Monitoring for CO2 in upper airway
INDICATIONS OF ET TUBE
1) DURING SURGERY-
- To secure & maintain a free airway
- To protect against aspiration of gastric/ oral contents
- To provide positive pressure ventilation
2) NON SURGICAL CONDITIONS
- as a life saving measure
- CPR
- Protection of airway in unconscious or semiconscious patient
- --
- When patient needs mechanical ventilation.
- Respiratory obstruction
- Tracheobronchial toileting in severe sputum retention
1) DURING SURGERY-
- To secure & maintain a free airway
- To protect against aspiration of gastric/ oral contents
- To provide positive pressure ventilation
2) NON SURGICAL CONDITIONS
- as a life saving measure
- CPR
- Protection of airway in unconscious or semiconscious patient
- --
- When patient needs mechanical ventilation.
- Respiratory obstruction
- Tracheobronchial toileting in severe sputum retention
PERIOPERATIVE /POSTOPERATIVE
COMPLICATIONS OF ET
•
•
•
•
•
•
•
•
•
Failure to pass over an Intubating Device
Trauma
Esophageal Intubation
Inadvertent Bronchial Intubation
Swallowed Tracheal Tube
Foreign Body Aspiration
Leaks
Intubating Device Trapped inside the Tracheal Tube
Tracheal Tube Fires
COMPLICATIONS OF ET
•
•
•
•
•
•
•
•
•
Failure to pass over an Intubating Device
Trauma
Esophageal Intubation
Inadvertent Bronchial Intubation
Swallowed Tracheal Tube
Foreign Body Aspiration
Leaks
Intubating Device Trapped inside the Tracheal Tube
Tracheal Tube Fires
•
•
•
•
•
•
Tracheal Tube Obstruction
Aspirating Fluid from above the Cuff
Misplacement of Equipment into the Trachea(temp probe,
NG tube)
Ulcerations
Latex Allergy
Tracheal Stenosis
•
•
•
•
•
Tracheal Tube Obstruction
Aspirating Fluid from above the Cuff
Misplacement of Equipment into the Trachea(temp probe,
NG tube)
Ulcerations
Latex Allergy
Tracheal Stenosis
•
•
•
•
•
•
•
•
•
•
•
Scan Artifact
Unintended Extubation
Infection
Difficult Extubation
Emergence Phenomena
Postoperative sore throat
Hoarseness
Neurologic Injuries
Upper Airway Edema
Vocal Cord Dysfunction
Vocal Cord Granuloma
•
•
•
•
•
•
•
•
•
•
Scan Artifact
Unintended Extubation
Infection
Difficult Extubation
Emergence Phenomena
Postoperative sore throat
Hoarseness
Neurologic Injuries
Upper Airway Edema
Vocal Cord Dysfunction
Vocal Cord Granuloma
•Reference
Ward’s Anesthetic equipments
Anesthetic equipments Dorsch
Ward’s Anesthetic equipments
Anesthetic equipments Dorsch
THANK YOU
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