What was that device?

[Melbourne MICA]

Out of interest in a purely clinical sense, in the photograph of the late Michael Jackson when he arrived at hospital, he had a blue attachment to his ETT . Was this just a clamp to secure the tube or was it in fact part of another type of airway device like a combitube. We only secure our ETT's with a cloth tape tie. It works well enough as long as you keep a close eye on your tube so as to stop zealous EMT-B's or firies dislodging it in their haste to run up the hospital ramp or out the door of the pts residence.

Any help?

MM

 

[jtb_E10]

Out of interest in a purely clinical sense, in the photograph of the late Michael Jackson when he arrived at hospital, he had a blue attachment to his ETT . Was this just a clamp to secure the tube or was it in fact part of another type of airway device like a combitube. We only secure our ETT's with a cloth tape tie. It works well enough as long as you keep a close eye on your tube so as to stop zealous EMT-B's or firies dislodging it in their haste to run up the hospital ramp or out the door of the pts residence.

Any help?

MM

That was an endo-lock. They are devices to secure the ET tube in place on a patient.

 

[Melbourne MICA]

endo-lock

I take it they attach at the front in the oral cavity (?) with the ETT inserted through a central opening and a cloth tie or the like round the back of the neck to tie it off.

MM

 

[Ridryder911]

Actually, it looked more like a Thomas Brand.. same concept

Here is a link with all the different brands


http://online.boundtree.com/store/product_index.asp?keyword=et+tube+holder

 

[Melbourne MICA]

Ta

Actually, it looked more like a Thomas Brand.. same concept

Here is a link with all the different brands


http://online.boundtree.com/store/product_index.asp?keyword=et+tube+holder

Cheers Ryders - I'll scope them out. We peasants downunder have no such luxuries!!!!!

MM

 

[Ridryder911]

Try Boundtree, they are also International. The device is cheap enough to make it available to purchase and they really do work remarkably well. Much more effective than the traditional methods.

R/r911

 

[downunderwunda]

Melbourne,

they also fit LMA's, I believe the only reason they are not used here is cost.

 

[Scout]

They also lessen the chance of them using their teeth to bite on the tube.

 

[VentMedic]

The type they were using is probably one of the less secure devices I've seen used. The screw is either tightened too tight or too loose. The medic will use the marking at the screw as the proper number from what they learned which may be 2 - 3 cm too high and the tube becomes a supraglottic device. The hospital has to change out the device in the ED fairly quickly as it damages the soft tissue of the mouth after 2 - 4 hours. It is a pain when the patient vomits since the device covers the whole mouth area. We usually have to get it off on arrival to the ED just to get the vomit out of the mouth from the field. And of course, a cuffed ETT does not protect from aspiration.

There are several better devices on the page linked by Rid.

 

[boingo]

We use cotton trach tape, seems to do the trick. We carried the Thomas for a bit, no one seemed to care for it, especially the hospitals.

 

[AnthonyM83]

We usually have to get it off on arrival to the ED just to get the vomit out of the mouth from the field. And of course, a cuffed ETT does not protect from aspiration.

Happen to know stats on how well they (don't) protect from aspiration? Few minutes after my last intubation, patient vomited. Respiratory was handling him and they insisted that his airway was secure because of the inflated balloon. It still seemed wrong...
Why can't we have "VentMedics" at all the hospitals? I've seen some very shady RTs lately...

 

[ADKMedic]

It may take a little education on your part.

We use cotton trach tape, seems to do the trick. We carried the Thomas for a bit, no one seemed to care for it, especially the hospitals.

When we started using ET tube holders in our region the medics loved them and the hospital was pretty noncommittal. Then, the agencies were flooded with complaints from the hospital about their use. It seems that when patients were brought to the ED the holders were left in place when the patients were taken to ICU or the floor. Sometimes tissue would be squeezed between the tube holders and the bony structures of the mouth and tissue necrosis would result when they are left in place for a long period of time.

Please, if you are interested in using these devices educate your hospital that they are emergency use only and should be replaced by whatever means to secure the tube that the hospital respiratory techs feel comfortable using once the patient is under their care.

For field use, I think these devices are great. They do not crush the tube, they provide a bite block, and (the ones I have used like the Thomas) provide ample space to suction around. Most important, they do exactly what they are designed to do, they can quickly be applied and hold the ET tube securely in place.

 

[VentMedic]

Happen to know stats on how well they (don't) protect from aspiration? Few minutes after my last intubation, patient vomited. Respiratory was handling him and they insisted that his airway was secure because of the inflated balloon. It still seemed wrong...

Stats? Let me just give you a basic anatomy lesson. The cuff is located below the cords. Whatever gets through the cords is considered aspirated. The tube just makes it easier to suction out. The best way is to prevent aspiration by correct use of a BMV or an OG/NG tube.

By understanding this is why we don't have the issues in Peds and Neo with the cuffless tubes. Unfortunately, due to the larger VTs required for adults, a cuff is necessary. So, ensuring the patient is adequately ventilately without much volume loss is the ONLY purpose of a cuff. However, we do have some modes of ventilation and ventilators where we do not use a cuff even for adults.

BTW, the cuff is also not meant to "hold the tube in place and keep it from falling out" as some are also led to believe.

Why can't we have "VentMedics" at all the hospitals? I've seen some very shady RTs lately...

That is because you are in California. CA has a long history of RT mills just like your medic mills. There are still quite a few "techs" in that state who do suck. But, have you met any RRTs from Loma Linda or Long Beach?

As least even (and especially) CA has been doing its best to get rid of the RTs that don't belong in the profession. The increased education standards is helping as well. The profession in CA can not afford to have another Efren Saldivar. The RTs in that state will be paying for his mess for years to come with the mandatory CEUs that essentially is "How thou shalt not kill your patients".

 

[AnthonyM83]

Gotcha.
And yes, I've met one RT from Long Beach. He was a wealth of knowledge. Him and one other RT from Centinela (who was a contrast to the other ones at that hospital) were the only ones who fit the profile of an RT that I've gotten from my interactions with you. Of course, similar thing has happened with finding paramedics who fit my idea of what one was from posting here since I was in EMT school.

 

[VentMedic]

Anthony,
This might also be of interest to you.
http://www.zapvap.com/_pdfs/inservice_poster.pdf

For the last 5 - 10 years, depending on teaching or otherwise, hospitals have been using ETTs with subglottic suction ports to reduce VAP. Some may already have seen RRTs and/or MDs switching out the tubes in the ED or at least in the ICU if it is suspected the patient will be intubated for over 48 hours.

Secretions from the oral cavity (and sinuses) will drain to the cuff when the patient is sedated and especially if a paralytic is used.

 

[wyoskibum]

Also, the 2005 AHA ACLS guidelines advocate the use of a commercial endotracheal tube holder.

 

[VentMedic]

Also, the 2005 AHA ACLS guidelines advocate the use of a commercial endotracheal tube holder.

And there are many, many to choose from. We don't use the same method of securing a child as we do an adult nor a burn patient. We also have to use a device that works with the injuries and care of the patient as well as the shape of the person's face for which allowances for deformities must be made. That is also why hospitals have many different ETTs to choose from.

While many things may work emergently, some providers get focused on just the one device they have or have "grown up with" and know no other way to secure a tube. I have even seen tubes come in unsecured "with the cuff inflated real big so the tube won't fall out" because they didn't know how else they could secure the tube.

 

[Melbourne MICA]

Dohh!!!!

Stats? Let me just give you a basic anatomy lesson. The cuff is located below the cords. Whatever gets through the cords is considered aspirated. The tube just makes it easier to suction out. The best way is to prevent aspiration by correct use of a BMV or an OG/NG tube.

By understanding this is why we don't have the issues in Peds and Neo with the cuffless tubes. Unfortunately, due to the larger VTs required for adults, a cuff is necessary. So, ensuring the patient is adequately ventilately without much volume loss is the ONLY purpose of a cuff. However, we do have some modes of ventilation and ventilators where we do not use a cuff even for adults.

BTW, the cuff is also not meant to "hold the tube in place and keep it from falling out" as some are also led to believe.

Blow me away why don't you Venty. Their is a eons old mythological belief amongst the ALS types, (even here) about ETT providing the "best" level of protection from aspiration. It is typically called "securing the airway". If what you are saying is on the mark (and it usually is) I must humbly put up my hand bend over and prepare to take it where it hurts because I have gone along with this concept for ever. I understand the ventilation issues and of course we see them most obviously in arrested pts where the soft bag will fill up very quickly necessitating some weening.

But even today our education still talks about BVM, LMA and ETT in terms of both airway "protection" and of course relative efficiencies for ventilation worst to best. Seems like the old timers who routinely emphasize basic airway protection measures like side position, drainage, suction etc are right on the money and always have been.

I promise I will never look at a nasogsatric tube the same way again.

Stone the crows and call me a platypus!!!!

To be investigated further.



MM

 

[VentMedic]

A lot of changes in attitudes have had to take place when we started examining our ventilator associated PNA rates. We do not allow NT intubation in the hospital except when there is absolutely no other choice, which in our hospital that should not be the case. Of course in the OR for facial surgery NTI is acceptable (RAE tubes) but if the tube has a chance of staying for more than 72 hours a trach is preferred method of securing the airway. There are two reasons for that: 1. if the tube falls out inadvertently the patient will get an emergent trach. 2. it will reduce the chance of sinus infections leading to bigger badder things.

We also no longer use nasogastric tubes on ventilator patients but go OG for long term placement. An NG is acceptable in the rescue phase but it had better be gone when the CCM doctors round.

We are still not using the subglottic suction ports with the trachs yet although that hear those expensive trachs are available more so in Europe. We do postural drainage and if on a vent, cuff deflation with a trendelenburg manuver to clear secretions above the trach.

I am always amazed at how many secretions can be drained by the subglottic suction port. It has also increased patient comfort as they don't feel like they have to cough or be frequently suctioned from the draining secretions.

An ETT is still the definitive method for securing the airway and while the tube can slow the flow of vomit through the cords, it also keeps the cords open for secretions to pass through. They have no other choice but to hang out on the cuff and slowly contaminate the lung fields. The pressure around the cuff also changes with each breath when on a ventilator which can allow for secretions to be introduced. We attach a spring loaded device that attempts to keep consistent pressure in the cuff.

When I was looking for the link to that device I came across this artilce from the ERS. Defeating VAP is global since it is costly for healthcare.

http://erj.ersjournals.com/cgi/reprint/20/4/1010.pdf


Managing an airway is both a science and an art. As I have also stated before, there are over 300 different airway devices and now just as many accessories.

 

[VentMedic]

Here's a couple of links to view some of the many different tubes we work with in a hospital.

This article is 10 years old so some of the new tubes and theories are not listed.

http://www.aarc.org/marketplace/reference_articles/06.99.0661.pdf

Some of these tubes you may see in people at their homes or on the street for a variety of reasons. Some of them do not have a standard 15 mm connector so you may have to get creative. Before pulling any device, make sure it does not have large internal phlanges that will rip the trachea.

http://www.bosmed.com/metanavigation/about-us.html

http://www.bosmed.com/airway-management.html

http://www.bosmed.com/safe-t-tubestm.html

All about trachs
http://www.rcjournal.com/contents/04.05/04.05.0497.pdf

Metal/silver trach tubes (aka Jackson trachs in the U.S. and are now stainless)
http://www.kapitex.com/tracheostomy/negustubes

Shiley trachs (other good respiratory links on that page also)
http://www.dhmc.org/webpage.cfm?site_id=2&org_id=116&morg_id=0&sec_id=0&gsec_id=3103&item_id=8169

Portex trachs
http://www.smiths-medical.com/catalog/portex-tracheostomy-tubes/

Bivona trachs
http://www.smiths-medical.com/catalog/bivona-tracheostomy-tubes/

Portex ETT for selective lung ventilation
http://www.smiths-medical.com/catalog/endobronchial-tubes/blue-line-endobronchial-tubes-1.html

Various special purpose ETTs
http://www.smiths-medical.com/catalog/endotracheal-tubes/