Placing Two ET Tubes?

[Smash]

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!

 

[waffleiron]

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.

 

[sihi]

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.

 

[Melbourne MICA]

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.

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

 

[jwk]

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.

 

[usafmedic45]

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.

 

[8jimi8]

USAF VS Ventmedic part DEUX

 

[ffemt8978]

USAF VS Ventmedic part DEUX

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

 

[usafmedic45]

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.