Dr S Parthasarathy MD DA DNB Dip Diab DCA Dip Software statistics PhD physiology IDRA FICA History As early as 1542 Vesalius recorded intermittently blowing into a reed ID: 1014394
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1. Endotracheal intubation – tubes Dr. S. Parthasarathy MD., DA., DNB, Dip. Diab., DCA, Dip. Software statistics- PhD ( physiology) , IDRA, FICA
2. History As early as 1542, Vesalius recorded intermittently blowing into a reed that was passed into the aspera arteria of an animal whose thorax had been opened.
3. Pugh, a Chelmsford surgeon, constructed an "air pipe" which was made from a coiled wire covered with soft leather--
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5. In 1667, Robert Hooke, at the Royal Society in London, similarly kept a dog alive for over an hour by ventilating its lungs with a pair of bellows tied into the trachea which had been severed below the epiglottis.
6. I.W. Magill and E.S. RowbothamBritish army unit Passed a red rubber tube through the nose blindly– uncuffed tubes – plastic surgeries and head and neck surgeries Inhalational anesthesia instead of insufflation anesthesiaLater became !!
7. 1910 - Kirstein, a Berlin physician, had advocated direct laryngoscopic intubation with the Kirstein Autoscope,1920 – chevaliar Jackson introduced laryngoscope
8. Minutes !! In 1941, Gillespie, writing in Endotracheal Anaesthesia, stated: ‘An experienced worker should be able to intubate all but the most difficult cases in ten minutes. The beginner will often require thirty.’
9. In 1542 – vesalius
10. THE TRACHEAL (ENDOTRACHEAL, INTRATRACHEAL) TUBE is a device that is inserted through the larynx into the trachea to convey gases and vapors between the breathing system and the lungs. It may also be inserted through a tracheostoma as a temporary measure.
11. Tracheal tubes were made of red rubber not transparent, can become hardened sticky with age, have poor resistance to kinking, become clogged by dried secretions more easily than plastic tubes, do not soften much at body temperature. Latex allergy is one more possible problem usually have high-pressure cuffs.
12. Original nasotracheal tubes Bevel angle different Longer Thinner More luminous Radius of curvature is less
13. PVC
14. Other than this what does a PVC tube have ? Prior to use, a PVC tube may be cooled to make it more firm during intubationwarmed to facilitate placement over a fiberscope. smooth surface that facilitates passage of a suction catheter or bronchoscope
15. Material Silicone tubes more expensive than PVC, soft and can be sterilized and reused.Chemicals called plasticizers may be added to PVC during manufacture to produce a softer product. The most widely used plasticizers are a group of chemicals called phthalatesPolyurethane has been used for tracheal tube cuffs in recent years.
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18. Why bevel ? the tube is usually introduced from the right, and it is easier to visualize the larynx with the bevel facing to the left.More opening Entry point space of tube – less
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20. Murphy eye a hole through the tube wall on the side opposite the bevel. This is known as a Murphy eye.provide an alternate pathway for gas flow if the bevel becomes occluded.A forceps, tube changer, or fiberscope may inadvertently advance through a Murphy eye and become caught.
21. Easier for nasotracheal intubationSecretions can accumulate If there is no murphy eye , the cuff can be placed distally and there is more chance of better placement of tube without endo bronchial migration A big murphy eye will weaken the tip
22. Additional murphy eye in rare tubes
23. Blunt tip and soft
24. Characters of tubes Inertness Rat implantation testSurface – smooth , no rough edges Microscopy reveals so irregular surfaces still with colonizing bacteria Is it the reason for nosocomial pneumonia ?
25. Rigidity : Dual properties Rigid to prevent kinking But still flexible to cause less damage Posterior larynx affected ? By pressure Can you make S tubes ? Z 79 standards
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27. Lumen integrity: If we inflate the cuff the lumen should not collapse Water bath test 40 degrees 24 hours
28. Cuff pressuresLow volume high pressure cuffs2 – 3 ml in adults – no leak means may be upto 100 mm Hg But high volume low pressure cuffs – may be less than 25 Tracheal wall is not circular -
29. Keep it below 25 mmHg
30. Nitrous oxide (N2O) diffuses into tracheal tube cuffs filled with air. This applies also to cuffs on supraglottic airways.The rate at which diffusion occurs depends on:• the permeability of the material from which the cuff is constructed (rubber being more permeable than plastic)• the surface area of the cuff exposed to N2O• the partial pressure of N2O in the respiratory gas.Can go up to 90 mm Hg in 20 minutes
31. The Bivona ‘Fome-Cuf’ uses a piece of shaped foam to replace the air within the cuff. Prior to insertion the cuff is evacuated to collapse the foam and after insertion the pilot tube is opened to the atmosphere to allow the foam to expand, to ‘inflate’ the cuffBecause the pilot tube is left open, diffusion of nitrous oxide does not further inflate the cuff.
32. ASTM testing for rigidity American society for testing and materials American national standards institute Z79 committee that develops standards for anesthetic and ventilatory equipment. The label Z79” signifies that a device meets the established standard.
33. Inflation system Balloon cuff Inflating lumen Should not bulge , should not compromise the lumen Inflation valve with a luer lock tip At least 3 cm the tube should come outside the machine end Testing the leaking is inflation upto 150% of its diameter and water bath
34. Position of vocal cords Black line showing where the position of vocal cord and insertion distance
35. Pediatrics
36. Length of the tube Markings 6 mm tube means internal diameter – 6 mm 20 mm diameter trachea not even a 10 mm tube will go !! Why ?
37. Size of the larynx
38. 6 mm internal diameter - 28 cm approx 0.5 mm increase 2 cm increase in length
39. endotracheal tube used to ventilate elephants. This particular tube has an internal diameter of 45 mm ! imagine the length of the tube as Bob is six feet (183 centimeters) tall !
40. Radio opaque line Optical density equal to a piece of aluminium1 * 1*10 mm - Entire length of the tube or tip
41. Summary Size
42. Thank you all