endo trachial tube

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Slide 1 : Endo tracheal tube Dr Sourav
Slide 2 : The tracheal tube is a device that is inserted through the larynx into the trachea to convey gases and vapors to and from the lungs. General Principles Resistance and Work of Breathing: A tracheal tube places a mechanical burden on the spontaneously breathing patient. It adds resistance and is usually a more important factor in determining the work of breathing than the breathing system. This is particularly important in pediatric patients. Several factors help to determine the resistance to gas flow imposed by a tracheal tube.
Slide 3 : Internal Diameter The single most important factor in determining the resistance to gas flow is the internal diameter (ID) of the tube and its connector. A tube with a thick wall will offer more resistance than a thin-walled tube with the same outer diameter (OD). Resistance will be increased if a suction catheter, fiberscope, or other device is passed through the tube or if secretions line the inner wall b) Length Decreasing tube length lowers its resistance
Slide 4 : c) Configuration Curves in the tube or connector increase resistance, but if the curve is gentle, the increase is small. Kinking increases resistance d) Dead Space The tracheal tube and connector constitute mechanical dead space. Because the volume of a tracheal tube and its connector is usually less than that of the natural passages, dead space is normally reduced by intubation. In pediatric patients, however, long tubes and connectors may increase the dead space
Slide 5 : Tracheal Tube System Tube Materials: The material from which a tracheal tube is manufactured should have the following characteristics. Low cost Lack of tissue toxicity Transparency Easy sterilization and durability with repeated sterilizations (unless disposable) Nonflammability A smooth, nonwettable surface inside and outside to prevent secretion buildup, allow easy passage of a suction catheter or bronchoscope, and prevent trauma Sufficient body to maintain its shape during insertion and to prevent occlusion by torsion, kinking, or compression by the cuff or external pressure Sufficient strength to allow thin wall construction Thermoplasticity to conform to the patient's anatomy when in place Lack of reaction with lubricants and anesthetic agents Latex-free
Slide 6 : Polyvinyl chloride (PVC) is the substance most widely used in disposable tracheal tubes. It is relatively inexpensive and is compatible with tissues. Tubes made from PVC are less likely to kink than rubber tubes. They are stiff enough for intubation at room temperature but soften at body temperature, so they tend to conform to the patient's upper airway. PVC tubes have a smooth surface that facilitates passage of a suction catheter or bronchoscope. Their transparency permits observation of the tidal movement of respiratory moisture as well as materials in the lumen.
Slide 7 : Tube Design The international/U.S. Standard contains requirements and recommendations for tracheal tubes, including the material from which the tube is constructed, the inside diameter, length, inflation system, cuff, radius of curvature, markings, packaging, and labeling A typical tracheal tube’s internal and external walls should be circular. A tube whose lumen is oval or elliptical in shape is more prone to kinking than one that is round
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Slide 9 : SIZE & LENGTH Internal diameter is marked on the outer side of the tube in millimeters. Usually a size of 8.5-9.0mm ID tube is selected for an average adult male & a size of 7.5-8.0 ID tube is selected for an average adult female. Paediatric size are determined on the basis of the age & weight.
Slide 10 : Oral Intubation Length in centimeters = age/2 + 12 cm Length in centimeters = weight in kg/5 + 12 cm. Length in centimeters = height in centimeters/10 + 5 cm. Rule of 7-8-9: infants weighing 1 kg are intubated to a depth of 7 cm at the lips, 2-kg infants to a depth of 8 cm, and 3-kg infants to a length of 9 cm. Equations based on the crown-rump and crown-heel length have been developed . Nasotracheal Intubation L = (S × 3) + 2, where L is the length in centimeters, and S is the ID of the tube in millimeters Multiplying crown-heel length by 0.21. For total tube length, 0.16 × height in centimeters + 4.5 cm, then leave 2 cm of tube outside the nostril of an infant and 3 cm outside for an older child
Slide 11 : The Bevel It is left facing and oval in shape. The angle of the bevel is the acute angle between the bevel and the longitudinal axis of the tracheal tube .Most commonly, the opening of the bevel faces to the left when viewing the tube from its concave aspect. This is because the tube is usually introduced from the right, and the larynx is easier to visualize with the bevel facing to the left. A hole through the tube wall on the side opposite to the bevel. This is known as a Murphy eye, and a tube with this feature is called a Murphy or Murphy-type tube.
Slide 12 : Cont….. The purpose of the eye is to provide an alternate pathway for gas flow if the bevel becomes occluded. Forceps, tube changers, and fiberscopes may inadvertently advance through a Murphy eye and become caught. Using a tube with a Murphy eye will reduce trauma during nasal intubation. Disadvantage is that secretions may accumulate in the eye. Some tubes have an additional eye above the bevel. This may provide an additional measure of safety if the tube accidentally advances into a mainstem bronchus.
Slide 13 : Cuff System : A cuff system consists of the cuff plus an inflation system, which includes an inflation tube, a pilot balloon, and an inflation valve. The purpose of the cuff system is to provide a seal between the tube and tracheal wall to prevent passage of pharyngeal contents into the trachea and ensure that no gas leaks past the cuff during positive-pressure ventilation. Cuff connected to the pilot balloon which has a self sealing valve for injecting air.the pilot balloon also indicate whether cuff is inflated or not. After intubation cuff is inflated till there is no air leak can be hard during IPPV The narrowest point in the adult’s airway is Glottis (which is hexagonal) The narrowest point in the child’s airway is sub-glotic
Slide 14 : Cuff Types: Low-volume, High-pressure Cuff & B. High-volume, Low-pressure Cuff Low-volume, High-pressure Cuff Description: The low-volume, high-pressure cuff has a small diameter at rest and a low residual volume . It requires a high intracuff pressure to achieve a seal with the trachea. It has a small area of contact with the tracheal wall and distends and deforms the trachea to a circular shape The pressure exerted laterally on the tracheal wall will be less than the intracuff pressure
Slide 15 : Advantages These cuffs offer better protection against aspiration better visibility during intubation than low-pressure cuffs. They may be associated with a lower incidence of sore throat. Because they are usually reusable, they are less expensive. They have been recommended for use in adolescent patients
Slide 16 : Disadvantages Ischemic damage to the tracheal wall mucosa following prolonged use. The pressure on the tracheal wall exerted by such a cuff is difficult to determine High-volume, Low-pressure Cuff Description : A high-volume, low-pressure cuff has a large resting volume and diameter. A thin compliant wall allows a seal with the trachea to be achieved without stretching the tracheal wall. As the cuff is inflated, it first touches the trachea at the widest part of the cuff or the narrowest point in the trachea under the cuff. As the cuff continues to inflate, the area of contact becomes larger and the cuff adapts itself to the tracheal surface.If cuff inflation is continued, the area in contact with the cuff will be subject to increasing pressure, and the trachea will be distorted.
Slide 17 : Advantages Provided the cuff wall is not stretched, the intracuff pressure closely approximates the pressure on the tracheal wall. It is possible to measure and regulate the pressure exerted on the tracheal mucosa. Disadvantages: I. More difficult to insert, as the cuff may obscure the view of the tube tip and larynx II. The cuff is more likely to be torn during intubation, especially if forceps are used. III. Incidence of sore throat may be greater with low-pressure. IV. It may not effectively prevent fluid from leaking into the lower airway even at cuff pressures as high as 60 cm H2O V. Fluid leakage is increased with spontaneous respiration and is reduced with continuous positive airway pressure, positive end-expiratory pressure (PEEP), and pressure-supported ventilation.Intermittent positive-pressure ventilation adds some protection. Lubrication with a water-soluble gel will reduce fluid leak for a limited period of time
Slide 18 :
Slide 19 : Changes in Intracuff Pressure The intracuff pressure and volume of a cuff inflated with air rise when nitrous oxide is administered . The increase varies directly with the partial pressure of the nitrous oxide, the permeability of the cuff wall, and time. Heated humidification slows diffusion of nitrous oxide into the cuff.When nitrous oxide administration is discontinued, the pressure in the cuff decreases rapidly. Increases in cuff pressure may result from pressure from nearby surgical procedures Diffusion of oxygen into the cuff . Changes in head position away from the neutral position Cuff pressure will also be affected by coughing, straining, and changes in the muscle tone
Slide 20 : Means to Limit Cuff Pressure Cuff pressure can be measured continuously or at frequent intervals and altered by inflating or deflating the cuff as needed. This is the only way to ensure adequate protection from the threats of aspiration and tracheal ischemia. Measurement is easy, and cuff monitors are inexpensive The cuff can be filled with a gas mixture containing oxygen and nitrous oxide or nitrous oxide alone .This is awkward to perform. A cuff inflated with nitrous oxide will lose volume and may allow a leak when nitrous oxide administration is discontinued. The cuff can be filled with water or saline.This results in a more stable pressure. However, the initial adjustment of cuff pressure is more difficult. Fluid-filled cuffs cannot be deflated rapidly. Using a cuff designed to reduce diffusion of nitrous oxide, a cuff with a high compliance, or a cuff with a large thin-walled pilot balloon has been recommended
Slide 21 : CONT….. 5. Pressure may be assessed by manual palpation and pinching the pilot balloon. These methods do not give consistently accurate assessments of cuff pressur. Inflation System Inflation Lumen: The inflation lumen, which connects the inflation tube to the cuff, is located within the wall of the tracheal tube. Pilot Balloon: The pilot balloon (bulb, external reservoir, external balloon) may be located near the midpoint of the inflating tube or adjacent to the inflation valve. Its function is to indicate cuff inflation. Inflation Valve: The inflation valve is designed so that when the tip of a syringe is inserted, a plunger is displaced from its seat and gas can be injected into the cuff. Upon removing the syringe, the valve seals so that gas cannot escape from the cuff. Some tubes may lack an inflation valve. If a valve is not present, cuff inflation is maintained by applying a clamp to the external inflation tube or by placing a plug in its free end.
Slide 22 : Tracheal Tube Connector The tracheal tube connector (union) serves to attach the tube to the breathing system. It may be made of plastic or metal The end that fits into the tube is called the patient end, and the size of the connector is designated by the ID of this end in millimeters. The end that connects to the breathing system is called the machine end and has a 15-mm male fitting. The most commonly used connectors are the straight and 90° curved Acute angle connectors with less than a 90° curve and flexible connectors are available. A curved or flexible connector may facilitate positioning the breathing system away from the surgical field but increases resistance and must be removed from the tube when it is desired to insert a stylet or suction catheter.
Slide 23 : Route Of Insertion Tube can be inserted orally or nasally. Oral Intubation Oral intubation is generally preferred for general anesthesia and in emergencies because it can be performed more quickly and easily than nasal intubation. It allows use of a wider and shorter tube than can be used for nasal intubation. Obstruction from biting can occur with oral intubation. A bite block, rolled gauze, or oral airway should be placed between the teeth to prevent the patient from biting the tube and occluding the lumen.
Slide 24 : Nasal Intubation The nasal route is commonly used for surgical procedures involving the oral cavity, oropharynx, and face where an oral tube would hinder the surgeon's access to the operative field Other indications may include a fractured mandible, limitation of movement at the temporomandibular joints, a patient with a neck injury or cervical spine disease, intra-oral pathology including mechanical obstruction, and patients who will not tolerate direct laryngoscopy. A tracheal tube one size smaller than would be considered optimal for oral intubation is preferable to minimize trauma. It should be thoroughly lubricated along its entire length with a sterile, water-soluble lubricant. The cuff should be fully deflated
Slide 25 : Advantages Securing the tube is easier. The nasal route eliminates the possibility of the tube being occluded by biting. Nasal intubation may cause less cervical spine movement than oral intubation . Disadvantages a smaller tube must be used, resulting in increased resistance and difficulty in suctioning or endoscopy. Intubation usually takes longer. Severe bleeding may occur Nasal intubation has been shown to result in a high incidence of bacteremia, sinusitis, and otitis Child with adenoid hypertrophy
Slide 26 : Contraindications Coagulopathy Nasal polyps, abscesses, foreign bodies Possibly epiglottitis A fracture at the base of the skull
Slide 27 : Perioperative Complications Oesophagial or Bronchial intubation Obstruction: by kinking , biting , herniation of cuff, occlusion by secretion,foreign body, bevel lying against the wall of the trachea. Trauma and injury to the various tissue and structure during or after intubating
Slide 28 : Use of the Tracheal Tube Cuffed tubes are routinely used in adults Traditionally, uncuffed tracheal tubes were routinely used in young children, with the practice of adding a cuff beginning at 6 to 10 years of age. In recent years, cuffed tracheal tubes have been used more often in small children.
Slide 29 : Advantages of cuffed tubes Improved accuracy of monitoring end-tidal gases, tidal volume, compliance, and oxygen consumption; Decreased risk of aspiration less operating room (OR) pollution; decreased risk of fire Ability to use high inflation pressures and low fresh gas flows
Slide 30 : Various type of tracheal tube Cole Tube: It is an uncuffed tube. The patient end has a smaller diameter than the rest of the shaft. This tube is used for neonatal resuscitation but not for long-term intubation. Disadvantage is that it cannot be inserted through the nose.
Slide 31 : Some tracheal tubes are preformed to facilitate surgery about the head and neck.One of these is the Ring-Adair-Elwin (RAE) tube,which has a preformed bend that may be temporarily straightened during insertion. Frequently, there is a mark at the bend. The external portion of the oral version is bent at an acute angle so that when in place, it rests on the patient's chin with the connector over the patient's chest. The nasal version has an opposite curve from the oral tube so that when in place the outer portion of the tube is directed over the patient's forehead. This helps to reduce pressure on the nares. The oral tubes are shorter than nasal tubes. b) Preformed Tubes
Slide 32 : Spiral Embedded Tubes: The spiral embedded (flexometallic, armored, reinforced, anode, metal spiral, woven, wire-reinforced) tube has a metal or nylon spiral-wound reinforcing wire covered internally and externally by rubber, PVC, or silicone.The spiral may not extend into the distal and proximal ends. The connector is frequently bonded to the tube. Advantage resistance to kinking and compression. The portion of the tube outside the patient can be angled away from the surgical field without kinking This makes them useful for insertion into the patient with a tracheostomy for submental intubation ,and retromolar positioning.A spiral embedded tube may pass more easily over a fiberscope than a conventional tube
Slide 33 : A forceps and/or a stylet will often be needed for intubation. The tube may rotate on the stylet during insertion The elastic recoil force may increase the tendency to unintentional extubation They are difficult to insert through the intubating laryngeal mask airway Disadvantage
Slide 34 : The Hunsaker tube (Fig. 19.5) is laser-resistant and designed for subglottic jet ventilation. It is compatible with carbon dioxide, neodymium-yttrium aluminum-garnet (Nd-YAG), and argon lasers. The OD is 3 mm, and it has an integral lumen for monitoring airway pressure and respiratory gases. The patient end has a basket-shaped distal extension designed to center the tube. This tube has been used to administer one-lung ventilation C) Hunsaker Mon-Jet Ventilation Tube
Slide 35 : Laryngectomy tubes have a “J” configuration at the patient end They are designed to be inserted into a tracheotomy. 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 advancement into a bronchus. D) Laryngectomy Tube
Slide 36 : The microlaryngeal tracheal surgery (LTS or MLT) tracheal tube is available with an ID of 4, 5, or 6 mm.The large cuff diameter is the same as that found on a standard 8-mm-ID tube. This helps to keep the tube centered in the trachea. One version has a yellow-colored cuff. This tube is designed for microlaryngeal surgery or for patients whose airway has been narrowed to such an extent that a normal-sized tracheal tube cannot be inserted. The small tube diameter provides better visibility and access to the surgical field E)Microlaryngeal Tracheal Surgery Tube
Slide 37 : F) Endotrol Tube
Slide 38 : The Laser-Shield II (Fig. 19.12) is made from silicone with an inner aluminum wrap and an outer Teflon coating (94). It is designed for use with CO2 and potassium-titanyl-phosphate (KTP) lasers. The cuff is not laser-resistant and contains methylene-blue crystals. It should be inflated with water or a saline solution. There is 1 cm of unprotected silicone tubing above the cuff G) Laser-Shield II Tube
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Slide 42 : Hi-Lo Evac Tube The Hi-Lo Evac tube incorporates a dedicated channel that can be used to clear secretions below the vocal cords but above the cuff. Results were mixed when using this tube to prevent or delay pneumonia. The lumen may become blocked by secretions
Slide 43 : Thank you….

 


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