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A chest tube (chest drain, thoracic catheter, tube thoracostomy, or intercostal drain) is a flexible plastic tube that is inserted

through the chest wall and into the pleural space or mediastinum. It is used to remove air (pneumothorax[2]) or fluid (pleural effusion, blood, chyle), or pus (empyema) from the intrathoracic space. It is also known as a Blau drain or an intercostal catheter.


Left-sided pneumothorax (right side of image) on CT scan of the chest with chest tube in place. Pneumothorax: accumulation of air or gas in the pleural space Pleural effusion: accumulation of fluid in the pleural space Chylothorax: a collection of lymphatic fluid in the pleural space Empyema: a pyogenic infection of the pleural space Hemothorax: accumulation of blood in the pleural space Hydrothorax: accumulation of serous fluid in the pleural space Postoperative: for example, thoracotomy, oesophagectomy, cardiac surg

Chest tube management Chest tubes should be kept free of dependent loops, kinks, and obstructions which may prevent drainage.[14] In general, chest tubes are not clamped except during insertion, removal, or when diagnosing air leaks. When a chest tube is inserted for whatever reason, maintaining patency is critical to avoid complications.[15] Manual manipulation, often called milking, stripping, fan folding, or tapping, of chest tubes is commonly performed to clear chest tube obstructions. No conclusive evidence has demonstrated that any of these techniques are more effective than the others, and no method has shown to improve chest tube drainage.[16] Furthermore, chest tube manipulation has proved to increase negative pressure, which may be detrimental, and painful to the patient.[16] For these reasons, many hospitals do not allow these types of manual tube manipulations.[17] Internal chest tube clearing can be performed to clear chest tube obstructions using an open or closed technique. Open chest tube clearing involves breaking the sterile environment separating the chest tube from the drainage canister tubing. The internal lumen may then be flushed with saline,[6] or a second catheter may be inserted inside the chest tube and suction used to clear the obstructions.[15] Closed chest tube clearing is performed using specially designed drainage systems. These systems use a magnetically driven wire loop to clear obstructions that form inside the chest tube.[18]

Endotracheal tube intubation

Indications Failure to obtain an airway by simple airway opening maneuvers (eg: OPA insertion) Airway protection (eg: from blood, broken teeth, vomitus) To provide a secure airway for transport To control ventilation in the unconscious/head injured patient

Endotracheal tubes

Uncuffed tubes are preferable in children up to eight years of age, to avoid oedema at the cricoid ring. Finding the right-sized tube is important, to avoid large leaks around the tube. Nasotracheal intubation whilst more secure is contra-indicated in patients with possible base of skull fracture Sizing:

Diameter Neonate - 3.0 mm 0-6 months -3.5mm 6-12 months -4.0 mm Then use (Age in years / 4) + 4 = size of endotracheal tube (ET) mm

Length of insertion at lips:

Visualise the tube passing through vocal cords avoiding endobronchial intubation:

ndotracheal tubes


10 cm

1 yr


2 yr

12 cm

3 yr

13 cm

4 yr

14 cm

6 yr

15 cm

8 yr

16 cm

10 yr

17 cm

12 yr

18 cm

Laryngoscopes 45. IntroductionA laryngoscope is an instrument used to view larynx and adjacent structures, most commonly for introducing tube into the trachea Laryngoscopes can be considered under two broad headings. Retractor type like the Macintosh laryngoscope.Fibreoptic Laryngoscope Two types : Rigid fibreoptic laryngoscope Flexible fibreoptic laryngoscope.

RIGID LARYNGOSCOPES:These are manufactured either as single piece or separate detachable blade and handle. For detachable handle & blade the light source is energized when blade & handle are locked in operating position. A single piece laryngoscope has a switch on handle that controls power to lamp. Rigid Laryngoscope has 2 parts 1. Handle 2. Blade.

1. Handle: The handle is the part that is held in the hand during use. It provides the power source for the light. Most often this is from disposable batteries.Fibreoptic illuminated laryngoscope may use a remote electrically operated light source.The handle is fitted with a hinge pin that fits a slot on the base of the blade.. 49. Handles are available in variable sizes & have rough surface for improved grip. 50. Although most blades form right angle with the handle when ready to use. The angle may also be acute or obtuse. An adapter may be fitted between the handle and the blade to allow angled to be altered. Howland lock is such an example.The patil-syracusehandle can be positioned and locked in four different positions (45, 90, 135 and 180). 51. Patil-syracuse handle 52. 2. BladeThe blade is a component that is inserted into the mouth. When a blade is available in more than one size, blades are numbered, with the number increasing with size. 53. The parts of the blade include base heel spatula/tongue flange web tip light source.

54. Types of Blades There are several types of blades which may be advantageous in particular situations. Macintosh BladeThe Macintosh blade is one of the most popular. The tongue has a smooth, gentle curve that extends from the base to the tip. In cross-section, the tongue, web. and flange form a reverse 'Z'. Cervical spine movement is greater compared to the Miller blade. 55. Left handed Macintosh BladeThe left handed Macintosh blade has the flange on the opposite side from the usual Macintosh blade. This blade may be useful for the abnormalities of right side of the face or oropharynx, left handed persons, intubating in the right lateral position, and positioning a tracheal tube directly on the left side of the mouth. 56. Improved Vision Macintosh BladeThe Improved Vision (IV) Macintosh blade is similar to the standard version except that the mid portion of the tongue is concave to allow greater visualization of the larynx 57. Polio BladeThe blade is offset from the handle at an obtuse angle to allow intubation of patients in iron lung respirators or body jackets Patients with obesity, breast hypertrophy, kyphosis with severe barrel chest deformity, short neck, or restricted neck mobility. Disadvantages of this blade are that little force can beapplied and control is minimal 58. Oxiport Macintosh (Mac/port)The Oxiport Macintosh blade a, conventional Macintosh blade with a tube added to deliver oxygen 59. Tull MacintoshThe Tull (suction) blade is a modified Macintosh that has a suction port near the tip. The suction channel extends next to the handle and has a finger controlled valves so that suction can be controlled by the laryngoscopist. 60. Fink BladeThe Fink blade is another modification of the Macintosh. The tongue is wider and has a sharper curve at the distal end. The height of the flange is reduced, especially at the proximal end. The light bulb is placed farther forward than on the Macintosh. 61. Bizarri-Guiffrida BladeThe Bizarri-Guiffrida blade is a modified Macintosh. The flange is removed, except for a small part that encases the light bulb. This was made to limit damage to the upper teeth. The blade is useful for patients with a limited mouth opening, prominent incisors, receding mandible, short & thick neck or anterior larynx 62. Miller BladeThe tongue is straight with a slight upward curve near the tip.In cross-section the flange, web, and tongue form a C with the top fattened.The lamp may be either on the right or left side of the blade. 63. Oxiport Miller BladeThe Oxiport Miller (also called Miller/port, oxyscope) blade has a built-in tube that allows delivery of oxygen or other gases during intubation. The tube also may be used for suction.Insufflation of oxygen during intubation using this blade has been found to decrease oxygen desaturation in spontaneously breathing anesthetized patients. 64. Tull Miller BladeTull (suction) Miller blade is a standard Miller blade with a suction tube whose port ends near the tip of the blade. Near the handle is a finger-controlled port that allows control of suction with a finger. 65. Mathews BladeThe Mathews blade is a straight blade with a wide and flattened petalloid configuration tip. It is designed for difficult nasotracheal intubations.

66. Alberts BladeIt has a cut-away flange to increase the visibility. There is recess to facilitate tracheal tube insertion. The blade forms a 67 angle with the handle. It is used for pediatric pt. 67. Double Angle BladeThe spatula of double angle blade has 2 angulations 20 & 30, to improve lifting of the epiglottis. The flange has been eliminated. The bulb is located at left edge of the blade between the 2 curvatures. The blade may be useful for the pt with anterior larynx. 68. Flexible tip bladeIt has a hinged tip that is controlled by lever attached to the proximal end of the bladeWhen the lever is pushed towards the handle,the tip of the blade is flexed.Eg: Mc-Coy, flipper,flex tip etc.It may improve the chances of successful intubation by elevating the epiglottis particularly in case of difficult intubation.Less force and less stress response. 69. Mc Coy blade 70. Techniques of use positioning the head :The head should be positioned so that the passage-way to the larynx is brought into a straight line for the best possible view of the vocal cords. The optimal position for most patients is flexion of 35 of the lower cervical spine and extension of the head of 8590 at the atlanto-occipital level, the so-called sniffing position. In children, it may be unnecessary to flex the lower cervical vertebrae, and in neonates it may be necessary to elevate the shoulders because the head is relatively larger. 71. The laryngoscope handle is held in the left hand. The fingers of the right hand are used to open the mouth and spread the lips apart. The blade is inserted at the right side of the mouth. This reduces the likelihood of incisor teeth damage and helps push the tongue to the left. The blade is advanced on the side of the tongue toward the right tonsillarfossa, so that the tongue lies on the left side of the blade. When the right tonsillarfossa is visualized, the tip of the blade is moved toward the midline. The blade is then advanced behind the base of the tongue, elevating it, until the epiglottis comes into view. 72. There are two methods for elevating the epiglottis, depending on whether a straight or curved blade is being used. Straight Blade TechniqueThe blade is made to scoop under the epiglottis and lift it anteriorly. The vocal cords should be identified.If the blade is advanced too far, it will result in elevation of the larynx as a whole rather than exposure of the vocal cords. The straight blade can also be inserted into the vallecula and used in the same manner as a curved blade. 73. Curved BladeAfter the epiglottis is seen, the blade is advanced until the tip fits into the valleculla. Traction is then applied along the handle, at right angles to the blade to carry the base of the tongue and the epiglottis forward. The glottis should come into view specially shaped to follow the contour of the oropharynx. Fibreoptic bundles for illumination & operatory viewing are housed in a sheath on the posterior aspect of blade. A viewing arm with eye-piece extends at a 45angle from the handle. A video camera can be attached to eyepiece for remote viewing.A working channel extends from the scope body to the point where the light bundles end at the tip. It can be used for suction, oxygen insufflations, administration of L.A/ Saline, or jet ventilation catheter. 76. 3 sizes are available :PediatricPediatric long for babies upto 8-10yrs of age.Adult version for children more than 10yrs & adults. Advantages :It causes less cervical spine movement than conventional laryngoscopy.Requires mouth opening of only 7mm.Rapidity of intubationLow risk of failed intubation or trauma to lips or teeth.

77. Disadvantages:Requires experience & Maintainence of skills & is somewhat expensive.Intubation with ETT >7.5mm may be more difficult.Certain ETT & Double lumen tubes will not fit the stylet 78. WuScopeDescription : It combines a rigid, tubular blade & a flexible fiberscope. Flexible Fiberscope portion.The fiberscope has short light & image transmitting fibreoptic bundles & tip deflection control.Blade portion It has 3 detachable metal parts - handle, main blade & bivalve element. 79. Handle- cone shaped tube that receives the fiberscope at the top & connects to the main blade at the base. The handle to blade angle is 110.Main blade & bivalve element are anatomically shaped. When positioned together, they form 2 passage ways- a larger 1 for suction catheter or ETT & a smaller 1 for fiberscope. An oxygen channel is alongside the slot for fiberscope. Different sizes of blades & bivalve element can be used with the handle. The adult blade can accommodate ETT upto 8.5mm 81. Advantages Can be used successfully to place both tracheal & double lumen bronchial tubes in difficult-to-intubate pts.No forceps or stylet is needed so risk of airway injury is low.Suctioning & oxygen administration can done simultaneously.Unlike flexible fibreoptic endoscopy, 1 can view ETT passing through glottis into trachea.There is no need for head extension or tongue lifting. 82. Disadvantages Requires experience or Maintainence of skills & high initial cost.Time required to assemble or disassemble the device is more.Application of cricoids pressure decreases the ease of intubation while using this device. 83. UpsherScope Description It consists of C-shaped metal blade, shaped to approximate curve of oropharynx. The distal part has an upward curve. To the lt are 2 tubes that carry fibreoptic bundles. Proximally the viewing bundle terminates in the eye piece while the light bundle makes contact with the light source at the handle.. It is presently available only in adult size. 84. Advantages It can be used with all size of adult ETT.Useful to intubate pts with difficult airways in a reasonable time. DisadvantagesNot suitable for naso-tracheal intubation.In routine intubation this scope has demonstrated no advantages over the conventional laryngoscopes 85. VIDEO LARYNGOSCOPE It can be created by attaching video system to a flexible laryngoscope or an optical stylet. It has many advantages The displayed anatomy is magnified & a larger viewing angle is provided.In addition to allowing laryngoscopy & intubation to be visualized, it can be used to observe vocal cord movements after thyroid surgery, verify tracheal tube position & aid in tracheal tube exchange.Results in less neck movement than conventional laryngoscopy.By projecting the image it makes a good teaching toolLimitations of these device is the need for a video endoscopy monitoring system. 86. VIDEO MACINTOSH INTUBATING LARYNGOSCOPEIt has macintosh blade attached to the handle. The image- light bundle is threaded through a small guide in the blade & advanced 2/3 of the length of the blade. Provides better view than traditional macintosh laryngoscope. 87. GLIDE SCOPEDescription :It has a miniature digital camera underside of a plastic blade. A light emitting device( LED) mounted beside the camera provides illumination. Blade has a 60 bend at the midpoint The Glide Scope is available in adult & pediatric size.Studies shows this scope yields a comparable or superior glottis view compared to direct laryngoscopy.It causes less cervical movements than macintosh blade

88. FLEXIBLE FIBEROPTIC LARYNGOSCOPEIntroduction:The 1st use of flexible fibreoptic technology in the airway management can be credited to Dr P Murphy, who in 1967 invented Choledochoscope for intubation of trachea.The flexibility of these devices means that they can be made to follow virtually any anatomical space to return an image of the objective. The technique of flexible fibreoptic intubation has become a gold standard for management of difficult laryngoscopy. This has tended to create the impression that the technique is solution to all difficult airways, but this is patently not so. 89. Principles & DesignThe pathway through which the illumination & the image pass consists of thousands of very fine glass fibers, each typically of 10m in diameter.Each fiber consists of a central glass core surrounded by a thin cladding of another type of glass with different refractive index. As a result of difference in refractive indices, light entering the glass fiber undergoes total internal reflection along the length of the fiber to emerge at the other end.For image transmission, the arrangement of fibers relative to one another must be identical at either end of the bundle, as each fiber carries tiny portion of the overall image. This is called a COHERENT BUNDLE. 91. Parts It is composed of several parts, a light source, handle & flexible insertion portion.The handle is the part to be held in hand during use. It includes the eyepiece, focusing ring, working channel port & the tip control lever. The insertion tube carries 2 light bundles 1 image bundle 1 working or biopsy channel 2 angulation wires, which control the more flexible tip of device 92. These are held together with a stainless steel spiral wrap followed by a stainless steel braid & covered by waterproof material, to give a rigid cross section while allowing overall flexibility. The fiberscope is axially rigid to twisting forces thus rotation of the control handle results in similar rotation of the tip. The fiberscope uses a powerful external cold light source so that the tissues are not damaged by radiant heat. 93. Usage The intubatingfiberscopes are available with insertion tubes ranging in size from 2.5mm ext diameter to over 6mm with proportionately larger working channels. A device with ext diameter of 3.5mm is optimal for use in adults. The advent of the miniature video camera has revolutionized fibreoptic endoscopy. 94. Fibreoptic IntubationIt can be performed via oral or nasal route.The fiberscope is inserted & advanced behind the tongue & into the larynx. Once in the trachea, a tracheal tube which has been previously loaded onto the fiberscope is advanced off the scope into the trachea & then the fiberscope is removed.Oral intubation is considered more difficult than nasal intubation 95. Advantages Reliable approach to the difficult airway management.Facility to record images for review & documentation.Improvements in teaching techniques.DisadvantagesMore expensive & fragile & difficult to use than rigid laryngoscope.Requires more time than rigid laryngoscopy.Requires considerable experience & skill MaintainenceLaryngeal trauma may occur. 96. Complications of laryngoscopy1. Dental injury2. damage to soft tissue and nerves3. Injury to cervical spinal cord4. Circulatory changes5. Swallowing or aspiration of foreign body.6. Shock or Burns 7. Laryngoscope malfunctions8. Disease transmission9. TMJ Dislocation. 97. Endotracheal tubes 98. HISTORY In 1667 Robert Hook kept a dog alive for over an hour by ventilating its lungs with a pair of bellows tied into the trachea. In 1871, Friedrich Trendelenburg developed a cuffed catheter for insertion through a tracheostomy to prevent soiling of the lungs during operation of the upper airway. In 1878,

the Glasgow surgeon William MacEven placed a metal tube by manual palpation through the mouth into the trachea & administered chloroform anaesthesia. In 1950s, the use of cuffed ETT became standard anesthetic practice. 99. DESCRIPTION: An endotracheal tube is one through which anesthetic gases and respiratory gases are conveyed into and out of the trachea. It has tracheal & machine endThe bevel is defined as the slanted part of the tube at the tracheal end. When, an opening in the tube is present on the opposite side of the bevel, it is designated as Murphy's tip endotracheal tube. 100. REQUIREMENTS OF IDEAL ET TUBE 1) Inertness 2) Smoothness of outer surface to avoid damage to mucosa 3) Inner surface should be smoothed and non-wettable to prevent building of secretions. 4) Non-inflammable 5) Transparent 6) Easily sterilized 7) Non kinking 101. 8) Sufficient strength to allow thin wall construction 9) Thermoplasticity to confirm to anatomic passage and to be self centering within the trachea.10) Non reactive with lubricants or anesthetic agents11) Latex free12) Non injurious catheter tip Currently used tubes are manufactured from synthetic rubber, plastic materials and silicone. 102. GENERAL PRINCIPLES RESISTANCE AND WORK OF BREATHING A tracheal tube places a mechanical burden on spontaneously breathing patient. It is a source of more resistance and is an important factor in determining the work of breathing. The factors determining the resistance include: 1) Internal diameter: The tube with thick wall decreases the ID and thereby increases the resistance and vice-versa. 2) Length: Decreasing the length of the tube decreases the resistance. 3) Configuration: Abrupt change in the diameter and direction increases the resistance. Gentle curve connectors offer less resistance than right-angled ones as there will be increased resistance because of turbulent flow of gases. 103. DEAD SPACE The volume of tracheal tube and connector is usually less than that of the natural passage. Dead space is normally reduced by intubation. In pediatric patients long tubes and connectors may increase the dead space considerably. 104. STANDARD MARKING OF ETTThe markings are situated on the bevel side above the cuff & are read from pt end to machine end Type of the tube: Oral or nasal or oral/nasal Size: ID in mm External diameter may also be indicated. Manufacturer's name or trade mark 105. Tube has Graduated markings, showing the distance in cms from the patient end. Precautions are usually noted: Disposable/Do Not ReuseImplantation tests (IT) or Z-79 indicating the tube has been tested for tissue toxicity & accomplish ANSI standard. Opaque lines may also be included at the patient end or along full length. 106. CUFF SYSTEM A Cuff system consists of the cuff & inflation system.The purpose of cuff system is to provide a seal between tube & tracheal wall to prevent passage of pharyngeal contents into the trachea & ensure no gas leaks past the cuff. The cuff also serves to center the tube in trachea. 107. INFLATION SYSTEM 1) Inflation valve: When a syringe tip is inserted, a plunger is displaced from its seat & gas can be injected into the cuff. Upon removal of the syringe the valve seals and gas cannot escape. 2)Pilot balloon: Its function is to give an indication of inflation or deflation of the cuff and a rough idea of the cuff pressure. 108. 3) External inflation tube: The standard specifies , a)The external diameter should not exceed 2.5mm b) The inflation tube should be attached to the ETT at asmall angle. c) The tube should extend at

least 3cm beyond the machine end of the ETT before a pilot balloon or inflation valve is incorporated. 4) Inflation lumen: This connects the inflation tube to the cuff. It is located within the wall of the tracheal tube. 109. CUFF:The cuff is a inflatable sleeve near the patient end of ETT. The cuff material should be strong and tear resistant but thin, soft and pliable. Cuffs are usually made of the same material as the ETT. 110. CUFF PRESSUREIntracuff pressure and pressure on tracheal wall:It is desirable that cuff seals the airway without extending so much pressure on the trachea so that its circulation is not compromised or trachea is dilated. When cuff is inflated in the trachea, there is a linear decrease in the perfusion. It is reduced when the lateral pressure on the tracheal wall attains 30cm of H20 (22mmHg) and ceases completely at 50cm of H20 (42mmHg). So it is recommended that the pressure on the lateral tracheal wall should be kept between 25-34cm of H20. 111. Intracuff pressure and use of nitrous oxide:The resting intracuff pressure and volume of the cuff inflated with air rise during nitrous oxide anesthesia, which results in ischaemia of the tracheal mucosa or compression of the tube, and increase in volume may lead to cuff herniation. 112. Steps to prevent the increasing pressure includes the following: a) Filling the cuff with gas mixture to be used for anesthesia or saline b) Fitting the cuff system with pressure relief valve or pressure regulating devices. c) Use of special system e.g. Lanz pressure regulating valve, sponge cuff and special tubes like Brandt tubes. d) Monitoring cuff pressure and deflating the cuff as needed. 113. Types of cuffs: a) Low volume high pressure b) High volume low pressure a) Low volume high pressure cuff: They have a small diameter at rest and low residual volume. It requires a high intra-cuff pressure to achieve a seal with the trachea. It has a small area of contact with the trachea and distends and deforms the trachea to a circular shape. . 114. The intra-cuff pressure and lateral pressure on the tracheal wall increase sharply as increments of air are added to the cuff. For this reason use of largest ETT has been advised, so that the cuff will be minimally inflated when a seal is created 115. Advantages:Usually reused,Less expensive Offers better protection against aspirationBetter visibility during intubation than low pressure cuffs.There is also low incidence of sore throat. Disadvantages; The most serious risk associated with these cuffs is ischemic damage to the trachea following prolonged use. 116. b) High volume low pressure cuffs:They have a high resting volume, large diameter and a thin competent wall. As it is inflated, it first touches the trachea at its narrow point. As cuff inflation continues the area of contact become larger and the cuff adopts itself to irregular tracheal surface. If the cuff inflation is continued the area in contact will be subjected to increasing pressure and trachea will be distorted to a circular cross section similar to high pressure cuff. 118. Advantage :It is relatively easy to pass devices such as esophageal stethoscope, temperature probes, nasogastric tubes around a low pressure cuffs. Disadvantage: These tubes are more difficult to insert,Obscure the view of the tube tip and larynxThe cuff is more friable and thus more likely to be torn during intubation. Incidence of sore throats is greater with these tubes.It may not effectively prevent fluid leakage into lower airway.

119. THE GUIDELINES TO DETERMINE THE SIZE OF ETT:Ideal tube in average Adult male 8.5mm ID Ideal tube in an average Adult female - 7.5mm ID. Age is recognized as the most reliable indicator of appropriate ETT size for children.3 months & less ------ 3 mm ID3 - 9 months -----3.5 mm IDOlder than 1 year -----ID in mm = (16 + age in years)/4 120. Younger than 6 years ---3.5 + age in years/3 = ID in mmOlder than 6years ---4.5 + age in years / 4 = ID in mmInfants below 1kg ----2.5mm Infants 1-2 kg -----3.0 mm Infants 2-3 kg ----3.5 mm Infants 3 kg -----4.0 mm Choosing a tube whose external diameter is same width as the patient's distal little finger 121. Other recommendations for size of ET tubes 122. DEPTH OF INSERTION The tube should be in the middle third of the trachea with the head in neutral position. The following calculations can be used. 1) Length in cm = age/2 + 12 2) Length in cm = weight in kg/5 + 12 3) Length in cm = height in cms/10 + 5 4) Length in cm = 3 ID (mm) 123. In adults, the tube should be passed until the cuff is 2.25 to 2.5cm below the vocal cordIn average size adult patients, securing the tube at the anterior incisor at 23cm in males and 21cm in females will usually avoid endobronchial intubation. For nasal intubation 5cm should be added to these length for positioning at the nares. 124. SPECIFIC ET TUBES Cole tube: It is uncuffed ETT, designed for pediatric patients. The patient end is smaller in diameter than the rest of the tube They are sized according to the internal diameter of the tracheal portion. It ranges from 2mm to 5mm..It is recommended for neonatal resuscitation but not for long term intubation.Disadvantage of this tube is that it cannot be used nasally 125. Spiral embedded tubes:Also known as Armored tube.These tubes have a metal or nylon spiral woven reinforcing wire covered both internally and externally by rubber, PVC or silicone. A stylet is often needed for intubation. These tubes are esp useful in situations where the tube is likely to be bent or compressed as in head & neck surgery 126. Advantages: Primary advantage of tube is resistance to kinking and compression. The portion of the tube outside the patient can be easily angled away from the surgical field without kinking Can be used for patients with Tracheostomies Disadvantages:Tube may rotate on the stylet during intubation. Insertion through nose & intubating LMA is difficult. Fixation of these tubes are more difficult. If the patient bites the tube it will cause permanent deformity resulting in obstruction of the tube. 127. Preformed tubes/Ring-Adair-Elwyn (RAE): It is preformed to facilitate the head & neck surgeries.The tubes are available in cuffed, uncuffed ,nasal and oral version. There is apreformed bend in the tube that may be temporarily straightened for suctioning. Each tube has a rectangular mark at the center of the bend. Distance from this mark to the distal tip is printed on each tube. 128. Oral RAE tubes are shorter than the nasal ones. The external portion is bent at an acute angle so that when in place it rests on patients chin & the connector over the pts chest. Nasal RAE has a curve opposite to the curvature of the oral tube, so that when in place the outer portion of the tube is directed towards patient's forehead 129. Advantages: Easy to secure and reduce the risk of unintended extubation. Breathing system remains away from surgical field Disadvantages: It offers more resistance than conventional tubes.Suctioning is difficult

130. Laryngectomy tube:Designed for insertion into a tracheostomy site. The tube is preformed in a J configuration at the pt end. This allows the part of the tube external to the patient to be directed away from the surgical field. The tip may be short and/or without a bevel to avoid inadvertent advancement into a bronchus. 131. Injectoflex:It is used for laryngeal microsurgery.It is a short cuffed silicone tube designed to be placed below the vocal cords. The tube has an embedded wire spiral to prevent kinking and compression. The cuff inflation lumen and the inflation tube are integrally joined in a sheath with a malleable introducer. 132. Microlaryngeal tracheal surgery tube :Is available with an ID of 4, 5or 6mm, each of which has the same length and cuff diameter as a standard 8mm ID tube.Designed for microlaryngeal tracheal surgery.The small diameter provides better surgical access The problems with this tube are incomplete exhalation & occlusion. 133. Endotrol tubes:A tip control system is incorporated in this tracheal tube to change the direction of the tip.This tube has ring loop at the machine end that is connected to the tip with a cablePulling the ring causes the tip of the tube to move anteriorly. This is useful when laryngoscopy is difficult and only epiglottis is seen. 134. Tubes with extra lumens: Tubes are available with one or more separate lumens terminating near the tip. They are useful for respiratory gas sampling, airway pressure monitoring, injection of fluids and drugs & jet ventilation. 135. The LITA (Laryngotracheal Instillation of Topical anaesthesia) Has additional small bore channel within the concave surface of the tube.10 small holes at the distal 13cm of the tube allows the injected medication to be spread both above & below the cuffs. This can provide a smooth emergence from anesthesia without coughing in most cases. 136. EMG Reinforced TubeThis tube is designed to monitor recurrent laryngeal nerve electromyogram activity during surgery.The tube is wire-reinforced & has 4 stainless steel electrodes above the cuff. The electrodes are connected to a monitor. 137. Laser-shield II Tracheal Tube:It is designed for use with CO2 and KTP lasers. Made from silicone with an inner aluminium wrap and a smooth Teflon outer coating. The cuff is not laser resistant & contains methylene blue crystals. It should be inflated with water or saline solution. . 138. Cottonoids for wrapping around the cuff are supplied with each tube.These must be moistened and kept moist during the entire procedure Disadvantage :Exposure of unprotected parts of the tube proximal & distal to cuff can result in rapid combustion.The methylene blue crystals may not fully dissolve & may obstruct the pilot tube, making it impossible to deflate. 139. Laser-Flex Tubes:Laser flex tube is a flexible stainless steel tube with a smooth surface designed for used with C02 and KTP (potassium-titanylphosphate) lasers.Adult version has two PVC cuffs and PVC tips with Murphy eye.The tube cuffs are inflated by two separate inflation tubes. The distal cuff can be used if proximal one is damage by laser. 140. The cuff should be filled with saline. The distal cuff should be filled first until sealing occurs, then the proximal cuff is filled with saline coloured with methylene blue.Problems with the laser flex tube

include stiffness, roughness, cannot be trimmed. The double cuff adds to the time of intubation and extubation. 141. Lasertubus:This is made of white rubber & has a cuff-within-a cuff design. If the outer cuff is perforated by a laser beam, the trachea will still be sealed by inner cuff. The inner cuff is filled with air & outer with water or saline. The shaft above the cuff is covered by a corrugated silver foil, which is covered by merocel sponge that should be moistened with saline before use.It is recommended for use with argon, NdYAG, CO2 lasers. 142. Hi-Lo Evac TubeIt incorporates dedicated channel which can be used to clear secretions below the vocal cords but above the cuff. The lumen may be blocked by secretions. 143. Hi-Lo Jet Tube It is an uncuffed tube with additional lumen that can be used for Jet ventilation, monitoring airway pressure, sampling respiratory gases or administering local anesthetics. 144. REFERENCES Understanding Anaesthesia Equipment, 5th Edition, Jerry A. Dorsh and Susan E. DorshAnaesthetic Equipment, 5th Edition, CS Ward Clinical Anaesthesiology, 4Ih Edition, GE MorganBenumoff s - Airway managementUnderstanding paediatricanaesthesia Rebecca Jacob 145. Thank you

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Nasogastric Tubes Naso-gastric tube; as the name implies a tube (available in different sizes and types) pases through the nostrils (sometimes through oral cavity!) to the stomach, to the doudenum or even jujunum [i.e. nasoenteric; here by the action or peristalsis]. The ordinary NG tube mesurment: Extend the tube from the nasal orifices to the ear (lateral face) to the xiphi sternum..! insertion; enquire about any previous nasal surgery, or trauma or difficulty in breathing through a particular nostril check for nostrils patency, ask the patient to blow his/her nose, During the insertion the tube has to point downlward toward the xiphoid process, once reach the nasopharynx, twist it to 180 degrees this minimizes the risk of tube coiling at the back or the pharynx, lubricate the proximal end of the tube with lidocain jelly, insert the tube through the nostril (sometimes one is wider than the other) , insert till u reach the nasopharynx, here u will face some resistance twist the tube (as we said 180) and push, ask the patient to swallow, the tube is now in the stomach.. 45. Nasogastric Tubes Indications: Aspiration: to provide samples of gastric contents for lab analysis; to keep stomach free of gastric contents and air; post operation Feeding Lavage: in cases of poisoning or overdose Medication Contrast study introduced into tube for UGI or SBS


A rectal tube, also called a rectal catheter, is a long slender tube which is inserted into the rectum in order to relieve flatulence which has been chronic and which has not been alleviated by other methods. The term rectal tube is also frequently used to describe a rectal balloon catheter, although they are not exactly the same thing. Both are inserted into the rectum, some as far as the inner colon, and help to collect or draw out gas or feces.

The use of a rectal tube to help remove flatus from the digestive tract is needed primarily in patients who have had a recent surgery on the bowel or anus, or who have another condition which causes the sphincter muscles not to work appropriately enough for gas to pass on its own. It helps to open the rectum and is inserted into the colon to allow gas to move downward and out of the body. This procedure is generally only used once other methods have failed, or when other methods are not recommended due to the patients condition.

In some cases, a rectal tube refers to a balloon catheter, which is commonly used to help reduce soiling due to chronic diarrhea. This is a plastic tube inserted into the rectum, which is connected at the other end to a bag used to collect stools. It is only to be used when necessary, as the safety of routine usage has not been established. Serious complications have also been noted, and include rectal perforation and reduced sphincter muscle tone.

Use of a rectal tube and drainage bag does have some benefits for patients who are critically ill, and may include protection for the perineal area and greater safety for health care workers. These are not great enough to warrant use for most patients, but those with prolonged diarrhea or weakened sphincter muscles may benefit. Use of the rectal catheter should be closely monitored and removed as soon as feasible.

Insertion of a rectal tube must be done by a trained professional and it should be completed very carefully using a well-lubricated tube. Patients should be taken to a private area and relaxed for maximum benefits. The nurse or doctor will raise one cheek of the buttocks and carefully insert the tube into the colon. After a few moments, flatus may have exited through the tube, but if not, the procedure may have to be repeated at a later time.

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Nasogastric Feeding Tube Doctors use a nasogastric tube (NG tube) when the need for gastrointestinal intubation will take place for less than four to six weeks, per Merck. Medical personnel insert the NG tube in the nostril of either

conscious or unconscious patients. This tube passes down the esophagus and into the stomach. Once inserted, placement verification by x-ray and the aspiration (drawing up a substance) of gastric (stomach) content ensures proper function, states Williams and Hopper. Only trained professionals like doctors and nurses prove qualified to place an NG tube.

advertisement Gastrostomy Feeding Tube Placed in the stomach either surgically, endoscopically,or radiologically, the gastrotomy feeding tube (G tude) is a permanent device, according to Merck. G tube placement happens when the estimated need goes beyond four to six weeks. The National Library of Medicine states, the physician inserts a balloon or special tipped tube into the stomach through a small incision made on the left side of the stomach and sutures the opening closed around the tube. Jejunostomy Feeding Tube A jejunostomy feeding tube (J tube) is a permanent feeding tube placed in the small intestine. Physicians implace the J tube surgically nto the small intestine in order to deliver the required nutrition and medications to the affected person. When they cannot use a G tube and a bowel obstruction exists above the small intestine, physicians will opt to use a J tube instead, says Merck. Physicians can easily pull this tube out during in an inpatient setting. Administration of diluted feedings through this tube in smaller volumes remains the protocol. Esophagostomy Feeding Tube Although the use of an esophagostomy feeding tube proves more practical in the use of animals, human patients affected with malnutrition can also benefit from this device, according to Williams and Hopper. The esophagostomy tube can be placed, with minor equipment, directly into the esophagus. This tube can be used for people or animals that need gastrointestional intubation for a short period. The esophagostomy tube is beneficial to a person when damage to the nasal cavity or jaw prevents nasogastric placement.

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