# ET Tubing question...



## highvelocity84 (Dec 6, 2008)

This is for all of you EMT-I and EMT-P who actually can perform this skill

(It sucks that us EMT-B have to read about it, but here in CA, its out of our scope to perform)

It says that you have to lubricate the stylet before inserting it into the ET Tube prior to inserting the ET tube going into the patient.

Since there is a hole at the end of the ET Tube, how do you know if the lubricant won't get aspirated into the lungs during ventilation?  Does that happen?

Please help me understand.  Thank you!


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## MSDeltaFlt (Dec 6, 2008)

I really don't mean to come off crass.  *However*, I have never seen or heard of a protocol stating that you *had* to lubricate the stylette.  You can consider it if you believe it would be beneficial.  But I find it a bit hard to fathom being told that I have absolutely no choice in a situation as mundane as that.

That being said, the amount of lubricant being used shouldn't even be a factor.  To be a risk for aspiration, it would have to be dripping off in buckets.  The odds of anyone using that much are extremely remote.

Now Vent might have some emperical data in support for or in support against this question.  She can reference anything (and usually does).  I'm more philosophical in my approach to learning, teaching, and practicing.


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## VentMedic (Dec 6, 2008)

You use a water soluble lube around the cuff to make passage through the cords less traumatic.

This same lube is used for inserting foleys, NGTs, trachs and NT suctioning. 

quote by highvelocity84 





> It sucks that us EMT-B have to read about it


 
Why does it "suck" you have to learn about a very important airway which you may see in the field? In CA, EMT-Bs are commonly used on CCTs with RNs.


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## highvelocity84 (Dec 6, 2008)

*RE: EMT Tubing question*

Ok.  I was just reading Brady's 10th edtion to Emergency Care and they talked about putting in the stylet, lubricated, into the ET tube before they put the ET tube into the patient.

But its good to know that its at minute amounts so that it doesn't really have an effect.

I wish I had a paramedic friend since I'm having to read about this stuff.

I mean, the CombiTubes look cool and all, but do you put the tube down the esophagus to inflate that esophageal cuff so that you're only ventilating the trachea??

It sucks how Brady doesn't even label which one is Tube 1 and Tube 2


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## WuLabsWuTecH (Dec 6, 2008)

lubricate the ETT, but i've never learned to lube the stylet.
for combitube: http://vam.anest.ufl.edu/airwaydevice/combitube/index.html


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## VentMedic (Dec 6, 2008)

MSDeltaFlt,

This one is for you.

http://www.cja-jca.org/cgi/content/full/54/suppl_1/44332


*EFFECTS OF LUBRICANTS ON THE STYLET REMOVAL FROM ENDOTRACHEAL TUBES*




> INTRODUCTION:
> Lubrication of a stylet is commonly employed to facilitate its removal following the placement of the endotracheal tube (ETT). However, presently there is no information about the effectiveness of these lubricants. The goal of this study is to determine the amount of effort required to remove a stylet from the ETT after the application of a variety of commonly used lubricants.
> 
> METHODS:
> ...


 
There are some that may want a quick exit with little effort. Too much lube will hinder safe securing of the tube since it easily gets on your gloves and the patient's face. 

I can only think of maybe a couple of situations I have used a lubricant on a stylet. 

For bronchoscopes, I use a silicone fluid.


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## MSDeltaFlt (Dec 6, 2008)

I rest my case.


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## tydek07 (Dec 6, 2008)

highvelocity84 said:


> This is for all of you EMT-I and EMT-P who actually can perform this skill
> 
> (It sucks that us EMT-B have to read about it, but here in CA, its out of our scope to perform)
> 
> ...



Hey,
I have never lubed the stylet... although, when I did my OR clinicals during medic school I saw a few that lubed the stylets up there. I guess it is a person preference, but I see no need to do this... the stylet is not that tight in there. But again, its mainly personal preference. Also, do not have to worry about it going into the lungs, as you don't use enough for that to happen.

Take Care,


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## MSDeltaFlt (Dec 6, 2008)

highvelocity84 said:


> Ok.  I was just reading Brady's 10th edtion to Emergency Care and they talked about putting in the stylet, lubricated, into the ET tube before they put the ET tube into the patient.
> 
> But its good to know that its at minute amounts so that it doesn't really have an effect.
> 
> ...



You definitely need to hang around others who have higher training, more experience, and/or are considered "elders" in their field: other basics, medics, RN's, RT's, MD's, DO's.  Pick their brains.  Wisdom rubs off.

Brady doesn't have to label which one is Tube 1 and Tube 2.  The combitube does it for you already.


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## MSDeltaFlt (Dec 6, 2008)

highvelocity84 said:


> Ok.  I was just reading Brady's 10th edtion to Emergency Care and they talked about putting in the stylet, lubricated, into the ET tube before they put the ET tube into the patient.
> 
> But its good to know that its at minute amounts so that it doesn't really have an effect.
> 
> ...



Oh, almost forgot.  It doesn't matter where the combitube ends up.  You inflate both bulbs with the amount of air listed on each pilot cuff.  Which ever one gives you lung sounds, use that one.

Just bare in mind that the combitube is "idiot resistent" not "idiot proof".  The teeth or, in my neck of the woods, the gums go *between* the black rings.  If not, you will not be able to maintain an adequate seal.  This is the voice of experience talking.


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## WuLabsWuTecH (Dec 7, 2008)

um...  correct me if i'm wrong, but doesn't the stylet come out seconds after insertion and not hours?  How can yo uventilate a pt while the stylet is still in there?


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## marineman (Dec 7, 2008)

umm. Nobody has said that you ventilate the patient with a stylet in. Personally I don't have a whole lot of tubing experience only 1 on an actual patient so far but in class I never even used a stylet and we were never told about lubing it.


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## VentMedic (Dec 7, 2008)

WuLabsWuTecH said:


> um... correct me if i'm wrong, but doesn't the stylet come out seconds after insertion and not hours? How can yo uventilate a pt while the stylet is still in there?


 
The study I posted was done with ICU or OR situations. We use many different types of ETTs in different applications with several different manipulations. 

Like I mentioned previously in another airway thread, there are over 300 different airways and that also includes many different ETTs.

The stylet, especially in adults, may be very necessary for the success of your intubation. It doesn't mean it is impossible to intubate without it but it can delay your intubation time and even be more traumatic if you can not adequately guide the tube through the cords.

Some Paramedics get offended if they see MDs or RTs changing their tubes in the ED but what they don't understand is we (RTs and Intensivists) already have a plan in action for special ventilation or long term management based on the injury or disease process. If at all possible, nasally intubated patients will be reintubated orally within the first couple of hours.


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## marineman (Dec 8, 2008)

Vent just because you mentioned nasal intubation, we were taught that was good for COPD patients but we never got a straight answer as to why. Do you have any input on that?


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## VentMedic (Dec 8, 2008)

marineman said:


> Vent just because you mentioned nasal intubation, we were taught that was good for COPD patients but we never got a straight answer as to why. Do you have any input on that?


 
COPD patients may be fatiguing but still are still very much awake when the decision to intubate is made.     

It does come with its share of complications and is rarely done in hospitals that consider themselves progressive or those that are aware the hospital will eat the cost of an acquired complication or infection occurring within their walls.   In EMS, you may not have a choice. 

The hospital will probably change the tube because of the smaller diameter, resistance created in the nasal passage and some COPD patients already having increased difficult exhaling. It makes for a vey difficult wean even with the modern ventilators.   Of course the other reason for the change is infection or complications from bleeding.  Sometimes the nare must be packed  once the tube is removed.  If the person is immediately orally intubated at soon at possible upon arrival to a hospital, the nose can hopefully heal before the patient is extubated.


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## bonedog (Dec 8, 2008)

The stylet's my service uses are coated in a polymer that makes them easy to with draw. Some of the ones I have seen in hospital stick terribly, making withdrawl a pain.

The only time I might lube a tube is if I was forced to use a gumboogie as you have to rotate the tube to get the bevel at the right angle for the cords, otherwise I was told the lube can for a cast in the trachea which can result in necrosis and sloughing.


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## VentMedic (Dec 8, 2008)

bonedog said:


> otherwise I was told the lube can for a cast in the trachea which can result in necrosis and sloughing.


 
That can happen with some petroleum based lubes which are NOT advisable.  

There are some research projects to see if coating the tube with certain lubricants can be useful in preventing VAP (vent associated PNA).


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## bonedog (Dec 8, 2008)

Thanks VM, we use lido jel, not sure if it is in a petroleum base.

We are also using the evac tubes which has resulted in decrease of VAP.


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## MasterIntubator (Dec 9, 2008)

Ahhhh.... a breath of fresh air... as I loooove the tube.

To lube or not to lube...... this is where my 100 intubation a month average comes from.... I have time to study and play, and do it again an hour later to see the effects

The key to lubing the stylet is to put only a thin film on it, just enough to make it slide.  ( I am not advocating that everyone do that.... it just what I do ). 

Why lube?  I use the grey teflon coated stylets, although much better than the 1970/80 bare copper wires, sometimes the stylus still sticks to the inner tube wall.  Most cases this is not a problem, but get a hairy.... that 1/2" of retraction is enough to dislodge the tube from position ( the trachea ).  i.e.  a 3.0mm tube.

What happens?  Sometimes the stylus gets a few extra bends in it.  Some of us like to pre form that tube in some crazy ways ( I sometimes do a 90 degree bend at the 26 mark so I can gently rotate the distal tube flange to help get past some non-agreeing cords )

.... anyway, the stylus sometimes gets hooked or a little 'clingy' to the inner wall of the tube.  When it does, it sometimes creates enough friction to grab the tube, and could potentially back the distal end out and you will not even know.... even though you are holding the proximal end without moving an inch!!
I have watched ( thru fibrevision ) the tip of the tube come out while retracting the stylus. There is enough curvature along the dorsal side of the tube that it gladly bends with ease.

Why do we field providers miss that sometimes?  Well, we shove the scope in, get a vis on the chords... pass the tube... pull the scope out... then shove our meaty hand over the face to hold the tube and most everything from the 20 mile marker down is in the dark. You won't get to see the slight grab.

Soooooooo... the lube just assists in preventing that.
In the field... I just put a pea sized amount of Kentucky jelly on the distal end of the stylus and spread with my fingers ( it'll fit )
In the OR... we don't use it much.  Sterile Surgilube on a sterile 4x4 and wipe.

The bad side.... but rare.  Some Surgilube buffs will almost dunk the entire tube in lube.  What has happened, the lube can and will gel and thicken further, almost to a rubber like consistancy.... after a while on a vent, and cause problems.
But dang.... that is more lube than anyone needs. 

Aspiration from lube should not even be an issue.  Especially in the field.  

I hope you understood most of that.  Lube is a tool, and is a beautiful tool in the right settings.  You just need to know when and where to use them... and WHY.

Ohh... that side hole near the end of the tube, is the murphy eye.  And it serves a wonderful and very important job. ( and another chapter )


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## VentMedic (Dec 9, 2008)

MasterIntubator said:


> Aspiration from lube should not even be an issue. Especially in the field.


 
Lipoid pneumonia is not totally unheard of especially by those that use oil based products. However, a person doesn't have to be intubated to experience that. There are still many people that use Vaseline to prevent their nares and lips from drying from O2 use.

The draw back by some who lube the stylet is it slip sliding out of position and bouncing on the floor at the more inopportune moment.


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## MasterIntubator (Dec 9, 2008)

I think I worded that wrong..... it should be taken as.... we shouldn't worry to much from aspiration in the field, not that it can't happen.  ( looking in the light of field folks kinda intubate the soon to be dead  vs elective routine intubation ).

I hear you on that the pneumonias, Vent.  More chapters of info.....


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## VentMedic (Dec 9, 2008)

MasterIntubator said:


> I think I worded that wrong..... it should be taken as.... we shouldn't worry to much from aspiration in the field, not that it can't happen. ( looking in the light of field folks kinda intubate the soon to be dead vs elective routine intubation ).


 
There are several things I learned when I went to RT school after several years of being a master intubator in the field. Even though I had an excellent success rate intubating, I now know there were several things in my technique that I could have done better to prevent many complications later, some of which are deadly. It now takes just a few seconds extra to get things done more correctly when I'm intubating outside of the hospital but it may improve the patient's chance of survival. It is a bummer to save a patient only to have them die of complications which may easily have been prevented with a little more education and improved technique.


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## MasterIntubator (Dec 10, 2008)

I agree with you 100%.  I re-read what I wrote.... I just can't word what I really meant.... it still reads like I downplay propper technique in any scenario.

Guess my retinas are burnt tonight.

Bedtime....


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