Advanced Airway Consideration

[eric2068]

Ok, I am really serious about this subject.
This was a 3am bay talk after a call on night at the firehouse.
There had been a show on tv about conjoined twins, specifically the twin girls who share one body with two heads. Now these are two fully formed heads, each with a seperate upper airway, but it appears the share the same lower airway.
Ok, here is the question:
If you had to intubate this person(s), what would you with second airway? It has to be secured somehow because it has it's own set of cords, and any 02 would come out the other airway.
Please, take this seriously. I do not wish to offend anyone, but our profession is to take care off all persons, regardless. We need to be ready.
I am looking forward to your responses.
Thank you.

 

[VentMedic]

This sounds like a thoracopagus stiutation. I have been involved in conjoined twins on a few occasions, two of which were thoracopagus. We intubated both babies which isn't easy if they are facing each other. We do have a size 1 LMA that can be used in L&D until the babies are stabilized further in the NICU.

NOTE: LMAs are not in the NRP guidelines at this time. Conjoined twins will be picked up by diagnostics long before they are delivered and that delivery will be in a very controlled environment, probably by cesarean section.

Often the twins will have two sets of organs present. The issues come after the intubation because circulatory abnormalities and heart defects may require different treatments. Often we will have two totally different ventilators each running with different gases or medications hooked up to the twins.

 

[eric2068]

Then it would come to reason that you would need to vents, but cut the tidal volume in half on each vent, right?

 

[VentMedic]

Then it would come to reason that you would need to vents, but cut the tidal volume in half on each vent, right?

The lungs may be close to normal size. We do not do recipe VTs for babies. We do chest rise, color and aeration as our guides since most infant ventilators are pressure control and the VT will vary with compliance. A few ventilators have volume guarantee but that mode also has its purpose which may or may not be appropriate for every situation. Often in cases where we need lung protective protocols a HFOV will be used.

 

[marineman]

For field purposes (I will win the lottery twice before this happens anyway) with 2 uppers, 1 lower would to ETT one, then do a combi in the other so the two ETT's didn't interfere with eachother, then bag through the one ETT?

 

[eric2068]

I understand the infant/neo-nate side of it, but let me throw this into the mix. The conjoined twins on tv were about 16-17 years old. How would you do vent settings for them?

 

[VentMedic]

I understand the infant/neo-nate side of it, but let me throw this into the mix. The conjoined twins on tv were about 16-17 years old. How would you do vent settings for them?

If their lung conditions are unknown to us, again, chest rise or wiggle depending on ventilator, breath sounds/aeration, color and SpO2 depending on what cardiac annomalies they might have to form a baseline O2 Saturation. ABGs can also be done in 3 minutes. We may go by body length and predicted capacity or we may adjust VT according to the flow volume loops on the monitor (LTV if transport). We would then fine tune according to ABGs or CBG and monitor ETCO2 after we know the PaCO2/ETCO2 gradient.

Then, it would depend on why they are going on a ventilator and what protocol is decided on: ARDS, Sepsis, Cardiac defect based etc. These same things are considered in the hospital or if I was on a pedi transport picking up the child in the islands.

In the hospital the one child might be on HFOV with 10 Hz and a delta P or 8 with a MAP or 16. The other child might be on VAC with a rate of 16, VT of 350 and PEEP of 6. The gas mix will depend on each child's problems be it CHD, ARDS, Asthma, Pulmonary Hypertension etc. We can run CO2, NO, HeliOx, N2 as well as air and O2.

The same considerations are taken if they were 30 y/o. It also doesn't matter if they are conjoined or not, all patients are assessed for right machine, right mode and right gas. Before that someone may use the bag to determine the lung compliance and measure approximate pressures which will provide a decent starting VT. If it is determined the child needs HFOV and is too big for the transport HFV, the setting on the conventional transport ventilator (LTV series for peds) will be adjusted to whether oxygenation or ventilation is needed with lung sparing principles in mind.

We do not use ONE recipe for all nor do we use only one type of ventilator in one mode.

 

[eric2068]

Thank you for the info. I have learned alot.

 

[VentMedic]

I hope you understand that (and many other situations) the 10 ml/kg recipe does not always apply. One has to look at body stucture, spinal curves and chest cavity shape.

Here's some links for more reading about things I have mentioned:

Nitric Oxide - NO
http://www.inomax.com/

Nitrogen and CO2 gases for CHD
http://circ.ahajournals.org/cgi/content/full/104/suppl_1/I-159

Sensormedics HFOV 3100A - neo/pedi

http://www.sensormedics.com/prod_serv/prodDetail.aspx?config=ps_prodDtl&prodID=61

Sensormedics HFOV 3100B pedi/adult
http://www.sensormedics.com/prod_serv/prodDetail.aspx?config=ps_prodDtl&prodID=62

Bunnell Jet Ventilator - HFJV (at one time was rigged for transport)

http://www.bunl.com/jet.html

How to set up: (yes, it says 460 breaths per minute - not a typo)
http://www.sh.lsuhsc.edu/cps/pandp/17.30.pdf

Transport HFV - Bronchotron
http://www14.inetba.com/percussionaire/filecabinet/part5.pdf

http://www.int-bio.com/userfiles/file/VentworkshopBronchotron.pdf


This might be interesting to you and definitely something you should be aware of as you will now see these patients more frequently.
Congenital heart doctors play catch-up with patients

http://www.bcm.edu/findings/vol5/is2/07feb_n2.html
[FONT=Verdana, Arial, Helvetica][/FONT]
[FONT=Verdana, Arial, Helvetica]Congenital Heart Disease in Adults [/FONT]

http://www.rjmatthewsmd.com/Definitions/congenital_heart_disease.htm

Learn about these diseases and you will be able to do a great hx about their surgical repairs, maintenance, "normal" SpO2 and medications. Many that do live into adulthood may become candidates for heart (and lung) transplants and/or frequent fliers for CHF and pulmonary hypertension.

 

[yanagster]

Kind of funny, but I asked the same question to a paramedic adjunct teacher in my class not but two days ago after watching that program on discovery health. We were working with Combitubes that day. Fun and exciting stuff.

 

[VentMedic]

Kind of funny, but I asked the same question to a paramedic adjunct teacher in my class not but two days ago after watching that program on discovery health. We were working with Combitubes that day. Fun and exciting stuff.

So does your instructor think he is going to get a Combitube into a 30 week gestation baby?

 

[VentMedic]

Also, before thinking about airways for conjoined twins, you must first be able to do a cesarean section as a Paramedic on a living patient.

 

[medic417]

Also, before thinking about airways for conjoined twins, you must first be able to do a cesarean section as a Paramedic on a living patient.

Well when that building collapsed and she was dieing and told me save the baby and so i ........o wait that was on TV sorry disregard.