# Placing Two ET Tubes?



## EMSrush (Mar 10, 2011)

Question about intubation:

I knew of a medic who, if he tubed the goose, would leave the ET tube in, and place a second ET tube, which (he claimed) would always go into the trachea. He would leave both tubes in, even as he rolled up into the ED, but would plug up the first tube. I haven't tried this yet, and I'm not sure how the ED would look at it. It sounds like it could cause trauma. 

Has anyone tried this before? I would love thoughts and feedback, positive or negative.

Thanks!


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## Shishkabob (Mar 10, 2011)

Yes, you could do it, yes people do do it, and it's not necessarily bad because it when you go for the second tube you just have to tell yourself "Dont go where a tube already is"

You could then place a gastric tube down the ET placed in the coprophagous.



Make sure if you DO leave both in, you clearly mark which one is NOT to be used.  Tape the crap out of it, tell the receiving doc, whatever.... just make sure it doesn't get used.


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## usafmedic45 (Mar 10, 2011)

For massive hemoptysis, one of the standard procedures is "lung isolation" (also called "selective intubation" and several other things) which can be done with two ETTs or a specialized tube (which most hospitals don't stock in readily accessible places...).  It's a very interesting technique.


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## EMSrush (Mar 10, 2011)

Other than the obviously pre-existing tube, I am wondering how the insertion process of the second ET tube differs from an initial insertion. Is it normally done blind...?


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## medicstudent101 (Mar 10, 2011)

Can't say I've ever heard of something like this being done before. Although it makes tons of sense. Another interesting thing I've seen done in the ICU, is pts with ARDS and a few other Resp. conditions with two ETT's placed in each mainstem of the right and left, respectivly. Pretty awesome stuff


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## MediMike (Mar 11, 2011)

I work with a fella who swears by this technique, unfortunately when you consider the amount of time the pt. is going without ventilation its a rather poor choice in my opinion. Last ditch effort? Maybe. I'd rather rely on good bagging technique if I was unable to get the tube.


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## firetender (Mar 11, 2011)

*Help me out here...*

You're talking if you mis-place the first tube, just leave it in, right?

...because that makes it "easier" to place the next tube in because the esophagus is all blocked up?

What happened to the part where you visualize the vocal cords and get it right the first time? And I don't recall it being easier to visualize the vocal cords while working around another tube.


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## Smash (Mar 11, 2011)

I'm with firetender.  Just don't suck the first time.  If it looks like a tough tube consider adjuncts like a bougie or video laryngoscopy.  If it looks really bad, consider whether you really want to intubate at all.


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## Handsome Robb (Mar 11, 2011)

I'm with smash. They invented BIADs for a reason. Always have a backup plan for a failed attempt is what I was always taught. Also, with the failed tube still in place I don't see how you could visualize with a laryngoscope for the second attempt. A blind insertion with an ETT sounds like a high risk for trauma to the cords and other parts of the airway which can make your life even harder, introducing bleeding into an already compromised airway, unless your talking a digital intubation?


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## truetiger (Mar 11, 2011)

The mechanics behind this sound good but how long is it going to take to miss with one tube and then correctly place another? You should take no longer than 30 seconds to intubate your patient, seems it might be kinda hard to reoxygenate a pt with an et tube sticking out of their mouth.


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## reaper (Mar 11, 2011)

This is an old school thought. The thought process was one hole was blocked, so you will only go in the other. Problem is, You can fit more then one tube in the esophagus and it has been done before. This is why it is not taught any more.


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## Melbourne MICA (Mar 11, 2011)

*On the money*



reaper said:


> This is an old school thought. The thought process was one hole was blocked, so you will only go in the other. Problem is, You can fit more then one tube in the esophagus and it has been done before. This is why it is not taught any more.



Spot on reaper. There should be no reason for any Para to be doing this in this day and age. How many aids do you need to find the right hole for goodness sake.

Ambulance mythology stuff -  someone thought he was being clever then everyone thinks the same thing because why? The funny thing is you can never find out who started it all.

Bad practice.

MM


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## volparamedic (Mar 12, 2011)

I have used this technique before but it's few and far between. Depending on this every time isn't advisable. If you have to do this then you need retrained. I know on anterior patients or patients with a lot of bodily fluids that would cause you to miss easily it works great.  I truly miss the salem sump tubes we use to carry. I always remove the missed tube. Once the airway is secured there is no reason to leave the other tube...it just complicates matters.  It gives you an additional land line and let me tell you...if you've never intubated an anterior patient before....your time is coming.


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## usalsfyre (Mar 12, 2011)

volparamedic said:


> ...if you've never intubated an anterior patient before....your time is coming.


Never tubed an anterior patient, but I've had a few who had thyromental distances that weren't conducive to direct laryngoscopy...


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## 8jimi8 (Mar 12, 2011)

usalsfyre said:


> Never tubed an anterior patient, but I've had a few who had thyromental distances that weren't conducive to direct laryngoscopy...



Lol...


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## TomB (Mar 12, 2011)

reaper said:


> This is an old school thought. The thought process was one hole was blocked, so you will only go in the other. Problem is, You can fit more then one tube in the esophagus and it has been done before. This is why it is not taught any more.



True that. Not to mention that when the patient vomits the additional pressure created by the relatively small diameter and orifice of the tube extends the reach of the vomit which can come out with astonishing speed and force. Or, sometimes it just falls nicely into the patient's orbits. Not cool when the patient is dead and staring at you with vomit in his/her eyes. A tube in the esophagus also reduces the effectiveness of cricoid pressure. Just not a good idea.


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## usalsfyre (Mar 12, 2011)

TomB said:


> True that. Not to mention that when the patient vomits the additional pressure created by the relatively small diameter and orifice of the tube extends the reach of the vomit which can come out with astonishing speed and force. Or, sometimes it just falls nicely into the patient's orbits. Not cool when the patient is dead and staring at you with vomit in his/her eyes. A tube in the esophagus also reduces the effectiveness of cricoid pressure. Just not a good idea.



I've also seen it cascade off the ceiling through an esophogeal ETT, especially if it was ventilated a few times before the wrong placement was realized. Vomit in the eyes is one thing, vomit on every surface in the truck is a new level of suckage. 

As for cric pressure, it's effectiveness period is pretty well in question from what I understand.


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## WTEngel (Mar 12, 2011)

I'm with most on here. This is an old school technique and not generally taught anymore AFAIK. 

Also, it opens you up to liability in my opinion, as there isn't any clinical research I have seen to back up this technique.

Also, as had been mentioned, it is very easy to fit two, maybe even three ET tubes into the esophagus. All it really accomplishes is making your field of view smaller, gives you false sense of security that your next attempt will be easier, and makes you look like a joker when you walk into an ER.

Leave dual ET tubes for the patient that needs dual intubation and the professionals who know how to do it...


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## EMSrush (Mar 12, 2011)

MediMike said:


> I work with a fella who swears by this technique, unfortunately when you consider the amount of time the pt. is going without ventilation its a rather poor choice in my opinion. Last ditch effort? Maybe. I'd rather rely on good bagging technique if I was unable to get the tube.



I hope it's a back up technique that he swears by, and not an initial technique.


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## MediMike (Mar 13, 2011)

volparamedic said:


> let me tell you...if you've never intubated an anterior patient before....your time is coming.



(flips through AnP book)...Trachea is anterior on everybody...right?! 

It was a backup technique, still don't like it. Way too much downtime on the ventilation end of things.


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## Smash (Mar 13, 2011)

All my patients I intubate are anterior. Just lying there right in front of me. I think having them behind me would make it a bit difficult to work on them!


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## waffleiron (Mar 19, 2011)

This is an interesting discussion! As a new medic I have no experience with this scenario, but if I was presented with a difficult airway like this I would simply either use a bougie for the second attempt or go for the back-up airway. 

Delaying ventilation for this long does not sound advisable. Also, with an endotracheal tube placed in the esophagus, ventilation using a BVM with basic adjuncts is impossible, so if you still can't get tracheal placement on the second attempt, now both tubes have to come out in order to be able to form a seal and resume ventilation on the patient. The same applies if you wish to place a supraglottic airway. I forsee this wasting a lot of time in which the patient is without oxygen, or worse, without chest compressions.

Also, with the current research and updated AHA guidelines emphasizing uninterrupted chest compressions over securing the airway, supraglottic airways are gaining much more acceptance in cardiac arrests. The most progressive service in my area actually uses a King LTD as the primary airway in a cardiac arrest, completely skipping ETI. In this context, intubation of the esophagus followed by the trachea requires too much time and effort when you could be spending that time doing other things that could benefit the patient more (chest compressions, defibrillation, med adminstration, etc).

That being said, I think esophageal access does have its place in the EMS world. Placing an OG tube or even an endotracheal tube in the esophagus AFTER the airway has been secured allows you to have much more control over what is presumably an overly inflated stomach and it's ensuing gastric contents, which also helps to alleviate/reduce the air pressure inside the GI tract. Reductions in thoracoabdominal pressure such as this make chest compressions more effective by allowing the the heart to refill more effectively during the recoil period in CPR. I believe resQpods work in a similar fashion except on the respiratory system. I'd be curious to see some research comparing the effectiveness of chest compressions with both of these interventions in place versus without one or either of them.

Basically what I was taught about this in school (which was a few months ago, by the way ) was that gastric access is something that is nice to do in a cardiac arrest for the reasons mentioned above, but nobody does it because there are other parts of a cardiac arrest that have a much higher priority (chest compressions, meds, defibrillation, etc) so it tends to not happen. I will make an honest effort to try to place an OG tube on my arrests as a new medic, but due to the  relatively short transport times here in Massachusetts, only time will tell if I am able to follow through on this statement.


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## sihi (Mar 26, 2011)

I have intubated with a two tubes. It was resuscitation and my first intubation. --> stressful situation and when in laryngoscopy I saw the 1st hole - I put tube (oesophagus:huh

I didnt removed it, I put 2nd tube in right hole.

Problem can appear. Intubated oesophagus can compress larynx and you dont see  vocal chords.


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## Melbourne MICA (Mar 26, 2011)

waffleiron said:


> This is an interesting discussion! As a new medic I have no experience with this scenario, but if I was presented with a difficult airway like this I would simply either use a bougie for the second attempt or go for the back-up airway.
> 
> Delaying ventilation for this long does not sound advisable. Also, with an endotracheal tube placed in the esophagus, ventilation using a BVM with basic adjuncts is impossible, so if you still can't get tracheal placement on the second attempt, now both tubes have to come out in order to be able to form a seal and resume ventilation on the patient. The same applies if you wish to place a supraglottic airway. I forsee this wasting a lot of time in which the patient is without oxygen, or worse, without chest compressions.
> 
> ...



Interesting choice of avatar! Your points are spot on particularly about an OG or NG tube. Evacuation of the stomach is a sorely underestimated component of airway management and has particular relevance in the patient with a hyper-inflated chest such as the asthmatic.

With the emphasis on attaining good SPO2 readings and controlled ETCO2 we are inclined to overlook the importance of unrestricted mechanical action during ventilation aside from passive or ECC generated regurgitation and aspiration risk also being mitigated by successful OG/NG placement. I.e. it's seen as a "nice to have" option rather than an absolutely necessary component.

And there are other considerations. 

Posture. 

The ideal position for ventilation is upright - we all understand this when we position our asthmatic patients in a seated or semi-recumbent position to maximise chest wall expansion and passive relaxation. This also facilitates maximum  diaphragmatic movement. If you posture the patient supine - as we all do for assisted or controlled ventilation you now create the ideal conditions for the splinted abdomen with the chest wall/thorax now opposed by gravity.

The patient. 

Many of the patients likely to require ventilation will have some level of obesity mainly due to obesity being a risk factor for many serious pathologies including stroke, heart disease, diabetes etc - all pathologies where unconsciousness or cardiac arrest may occur with progression or acute exacerbation of the condition. This not only occurs with or adds to risk of these pathologies but is reflected in the general health and physical fitness of the population - we all know our lifestyle habits have generated an enormous rise in obesity problems. In other words, many of our patients have large weighty slabs of fat weighing down on the abdomen whenever they try to breath. 

Therefore we will see more and more patients where we need to consider the impact of abdominal splinting relative to ventilation management and of course the degree of obesity will have a directly proportional relationship on the level of splinting of the abdomen particularly in the supine position.

So as you quite correctly point out: our training is wrong if we are underestimating the importance of the OG/NG tube and when we ventilate we must look holistically at the situation and weigh all elements, including free mechanical action into the equation for best results.

We are creatures of habit and products of our time - all the answers aren't necessarily on the screen in front of you.

Cheers. Great comments.

MM


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## jwk (Apr 17, 2011)

usafmedic45 said:


> For massive hemoptysis, one of the standard procedures is "lung isolation" (also called "selective intubation" and several other things) which can be done with two ETTs or a specialized tube (which most hospitals don't stock in readily accessible places...).  It's a very interesting technique.



Lung isolation is done with either 1) an endobronchial tube, which is a funky double-lumen endotracheal tube allowing independent lung ventilation, or 2) using an endobronchial blocking baloon which only allows one lung to be ventilated.  The endobronchial tubes have two standard airway connectors at the proximal end.  Both devices are used frequently in thoracic cases.  I've never heard of placing two ETT's, and can't imagine anyone doing it.  The trachea is round, not oval.  Trying to place two ETT's through the cords would be horribly traumatic to the airway.  And if you did it with smaller ETT's, then your gas flows will be compromised.


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## usafmedic45 (Apr 17, 2011)

> Both devices are used frequently in thoracic cases. I've never heard of placing two ETT's, and can't imagine anyone doing it.



It was originally done with two ETTs when the procedure was first attempted (Magill in the 1930s) and I said it can be done.  It doesn't mean it should be used as a standard procedure but it has been also described as an option in austere environments.  It simply is a matter of what is more important: risking damaging the vocal cords or having a dead patient.  Not a common decision, but one that does occasionally come up.


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## 8jimi8 (Apr 17, 2011)

USAF VS Ventmedic part DEUX


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## ffemt8978 (Apr 17, 2011)

8jimi8 said:


> USAF VS Ventmedic part DEUX



If you don't have the proof, don't make the accusation.


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## usafmedic45 (Apr 17, 2011)

8jimi8 said:


> USAF VS Ventmedic part DEUX



That was my thought as well.  The moderators are apparently on the lookout for her return so they are watching several accounts rather closely to make sure she does not creep back into our midst again.


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