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Интубационные ларингоскопы и маски

Intubation – Laryngoscopes – ETT – Laryngeal Masks
Mykonos – April 2012
Product Training
Carol Seroussi
November 2009
Anatomy - Reminder
Upper Airways
Anatomy - Reminder
Nose, Mouth, Pharynx
Upper Airways
Definition of Endotracheal Intubation
Endotracheal intubation is
the placement of a tube into
the trachea (windpipe) in
order to maintain an open
airway in patients who are
unconscious or unable to
breathe on their own.
other gaseous medications
can be delivered through the
Endotracheal Intubation
• Forms a safe airpassage down into the
trachea & prevents aspiration
• Makes ideal situation for ventilation as air
passes directly into the lower airways
• Can be oral or nasal
• Can be planned or unplanned
• Unconscious patients can be intubated w/o
• Conscious or semi-conscious patients need
sedation or relaxation medications
• The use of a laryngoscope allows direct
Indications for Endotracheal Intubation
It is of great importance to know how to evaluate &
address a patient who may require ventilatory support
• Inadequate ventilation can lead to brain injury or death
within minutes
• Causes can be
neuromuscular paralysis
obstructed or compromised airway
altered mentation
loss of consciousness
respiratory failure
Indications for Endotracheal Intubation
In the Operating Room
• the need to deliver ventilation = sedated patient
• most surgical procedures
– involving head and neck
– in non-supine positions that preclude manual airway
– involving neuromuscular paralysis
– involving cranium, thorax, or abdomen
– …etc
• protection of the respiratory tract from aspiration of
gastric contents
Indications for Endotracheal Intubation
Some Non-Operative Indications
• profound disturbance in consciousness with the inability to
protect the airway such as cardio-respiratory arrest or respiratory
• person in deep coma or unresponsive
• shallow or slow respirations (less than 8 per minute)
• severe pulmonary or multisystem injury associated with
respiratory failure such as: sepsis, hypoxemia and hypercarbia
• airway obstruction (no foreign object)
• need for prolonged ventilatory support
• large hemorrhage with poor perfusion
• protection from aspiration
• to prevent loss of airway at a later time, i.e.burn patient who
inhales hot gases may be intubated initially to prevent his airway
from swelling shut
Contra-Indications for Endotracheal Intubation
• Obstruction of the upper airway due to foreign
• Cervical fractures
• Following conditions require caution before
attempting to intubate
Esophageal disease
Ingestion of caustic substances
Mandibular fractures
Laryngeal edema
Thermal or chemical burns
Advantages/Drawbacks of Endotracheal Intubation
• Provides an unobstructed airway when properly placed
• Prevents aspiration of secretions (blood, mucous, stomach / bowel
contents) into the lungs
• Can be easily maintained for a lengthy period of time
• Facilitates positive pressure breathing without gastric inflation
• Facilitates body positioning and movement of the patient
• May be utilized to pass medications
• Need advanced training to properly perform procedure
• Bypasses the nares function of warming and filtering the air
• Increased incidence of trauma due to neck manipulation when spinal
cord injury is suspected
• May increase respiratory resistance
• Improper placement
Intubation Technique
Intubation Technique
Intubation Technique
Oral Axis
Pharyngeal Axis
Laryngeal Axis
Jackson-amended position
Intubation Grading Scale
• Determined by looking at the anatomy of the oral cavity
• Based on the visibility of the base of uvula, faucial pillars
(the arches in front of and behind the tonsils) and soft
• Used to predict the ease of intubation
• Scoring may be done with or without phonation
• Higher Mallampati Score (Class 4) is associated with
more difficult intubation
Intubation Grading Scale
Mallampati Score
• Class 1: full visibility of tonsils, uvula and soft palate
• Class 2: visibility of hard and soft palate, upper portion of tonsils
& uvula
• Class 3: soft and hard palate and base of the uvula are visible
• Class 4: only hard palate visible
Mallampati Classification
Grades 1-4
Equipment for Endotracheal Intubation
- Endotracheal tube
• Size of tube is dependent on size of patient
• 6,5 to 7 mm (female) & 7.5 to 8.0 (male) are the “universally accepted” size for
an unknown victim
- 10 cc Syringe – used to fill the cuff
- Stylet – a wire inserted into the ETT in order to stiffen it during passage
- Water soluble lubrication
- Stethoscope – to check for proper placement of the endotracheal tube
- Magill forceps – may be used to help guide an endotracheal tube from the pharynx
into the larynx
- Laryngoscope handle
- Laryngoscope blade
• Miller blade (straight blade)
• Macintosh blade (curved blade)
- Oropharyngeal airway (bite block) – to prevent the patient from biting down on the
endotracheal tube
- Tape – to secure the endotracheal tube in place
- Gloves
- Resuscitation bag – to facilitate positive pressure ventilation
- Suction Device – to clear the airway of debris (blood, mucous, saliva)
- Manometer – to ensure cuff pressure is adequate
• Insertion of a laryngoscope to lift the tongue and
the epiglottis
• Illumination of the pharyngeal room
• Free view to the glottis & vocal cords
Technique of Intubation
1.Place patient in supine position
2.Pre-oxygenate patient
3.Place pillow under head, flex the neck
4.Extension of the atlanto-occipital joint. (called "sniffing morning air")
5.Open mouth by separating lips & pulling on the upper jaw with index
6.Hold laryngoscope in the left hand
7.Insert laryngoscope into mouth with blade directed to the right tonsil
8.When tonsil in view, sweep blade to midline keeping the tongue on
the left; this brings the epiglottis into view. DO NOT LOSE SIGHT OF
9.Advance laryngoscope blade till it reaches the angle between the
base of the tongue and the epiglottis
10.Lift laryngoscope upwards and away from the nose - towards the
11.This manoeuvre should bring the vocal cords into view, but it may
be necessary for an assistant to press on the trachea to improve the
direct view of the larynx
12.Take the endotracheal tube in the right hand.
13.Keep the concavity of the tube facing the right side of the mouth
14.This causes least interruption to the view of the vocal cords
15.Watch the tube entering the larynx and insert it through the cords
only till the cuff is just below the cords.
16.Inflate the cuff to provide a minimal leak when the bag is squeezed
17.Monitor cuff pressure
18.Listen for air entry at both apices and both axillae to ensure correct
placement, using a stethoscope
Risks Associated with Endotracheal Intubation
Potential complications may include
Tracheal and esophageal perforation
Pneumothorax (collapsed lung)
Emphysema (obstructive pulmonary disease involving damage to
the alveoli)
Potential follow up signs and symptoms
Sore throat
Pain or swelling of the face and neck
Chest pain
Subcutaneous emphysema
Difficulty swallowing
Risks Associated with Endotracheal Intubation
Infections / VAP
• Mechanical ventilation (endotracheal intubation)
• Longer duration of mechanical ventilation
• Advanced age
• Depressed level of consciousness
• Preexisting lung disease
• Malnutrition
Product Training
Carol Seroussi
November 2009
Global description
Some history
The first laryngoscope was invented in
1854 by Manuel Patricio Rodríguez García.
Modern day laryngoscope systems initially
began in early 1940s by Foregger, USA
From a catalogue of surgical equipment
published in London in 1930
Global description
How to use a laryngoscope
•Place patient’s head in Jackson-amended
•Hold laryngoscope in the left hand
•Insert laryngoscope into mouth with blade
directed to the right tonsil
•When tonsil is in view, sweep blade to
midline keeping the tongue on the left; this
brings the epiglottis into view.
•Advance blade till it reaches the angle
between the base of the tongue and the
•Lift laryngoscope upwards and away from the
nose - towards the chest
•This manoeuvre should bring the vocal cords
into view, but it may be necessary for an
assistant to press on the trachea to improve
the direct view of the larynx
Global description
Types of laryngoscopes
Warm light
• Distal light bulb on the tip of the
 Krypton Bulb
Cold light
• Integrated light bulb in the
laryngoscope handle
 Halogen Bulb
 Xenon Bulb
 LED Bulb
Global description
Types of laryngoscopes
Cold light handle
Warm light handles
Cold light blades
Warm light blades
Global description
Different types of blades
The 2 major types of blades
Miller – Straight
The tip of the straight
laryngoscope blade picks
up the glottis.
Mc Intosh – Curved
The epiglottis remains
below the tip of the blade
Global description
Other blade types
There are uncountable and various other special blades in the
• Foregger
• Patil-Syracuse
Henderson = large Miller
• Seward
Dörges = 3 sizes in 1
• Robertshaw
• Mc Coy
• Bizzari-Giuffrida
• Wisconsin-Forreger
• Henderson...
Most of them were developed
before flexible FO was established
Global description
Market specification
Special blades
Global description
Since 1943
For standard intubation of
patient with normal anatomy
Size 5
Size 4
Size 3
Size 2
Size 1
Global description
Krypton light
Different Types of Lights
Warm light
Halogen light
Xenon light
Cold light
LED light
Laryngoscopes by Teleflex
Cold Light
• Reusable metallic blades all types
• Disposable plastic blades Mac & Mill.
• X-LITE Take-A-Part
• Reusable metallic blade Mac only
• Replaceable light holder
• SafeView
• Plastic disposable blades Mac & Mill.
• Metallic disposable blades Mac & Mill.
• All include a protection sheath
Warm Light
• Metallic reusable blades
• Plastic disposable blades
• Mac & Mill.
Mixed System
•Reusable metallic blades Mac & Mill
•Can be used with a standard (warm
light) handle as bulb is positioned at
the rear of the blade not on the handle
Laryngoscopes by Teleflex
Safeview - LED handle
cold light with battery
container (non
X-Lite - Xenon handle
(cold light) with battery
container (non
FOCS - Standard
handle warm light with
battery container (non
Laryngoscopes by Teleflex
Disposable blades: Out of a survey
At the university hospital
12 of the 25 handles (48%)
1 of the 25 blades (4%)
At the community hospital
7 of the 13 handles (54%)
3 of the 13 blades (23%)
tested positive for occult blood contamination after cleaning and
disinfection (the surfaces of laryngoscope handles and blades are
irregular and contain potential repositories for infectious material)
Laryngoscopes by Teleflex
Disposable blades X-LITE
Ideally suited for emergency and ambulant care!
Single packed, ready for immediate use
Sizes: 2/3/4
Fibreglass light holder
The fibreglass light holder makes it possible to use
fibreoptic handles
Xenon or LED light
(depending on type of handle used)
Sizes: 0/1
Laryngoscopes by Teleflex
Disposable blades SafeView – Plastic & Metallic
Ideally suited for emergency and
ambulant care
Curved blade, can be used with
small mouth opening, easy insertion
Protection Sheath
secure fixation
medical grade
stainless steel
Single packed, blade already
inserted in protection sheath ready
for immediate use
No risk of handle contamination
Fibreglass light holder
The fibreglass light holder makes it
possible to use fibreoptic handles
reduced height
to fit all patients
Laryngoscopes by Teleflex
Disposable blades SafeView – Plastic & Metallic
Xenon or LED Light
(depending on type of handle used)
Plastic Metal
1 to 4
0 to 4
0 to 2
00 to 4
Laryngoscopes by Teleflex
Disposable blades SafeView – Plastic & Metallic
How to use the protection sheath
Connect the blade in its protection sheath onto the
handle. Maintain sheath at connection side and tear
out the pre-cut tip of the sheath.
Protect the handle by sliding the sheath over it.
Once intubation is successful, slide the sheath
back onto the blade and dispose blade & sheath.
Laryngoscopes by Teleflex
Disposable Laryngoscopes – Metallic
LED Light
Mac Intosh
1 to 4
00 to 2
Laryngoscopes by Teleflex
Cleaning and sterilisation
Please always
take a close look
at directions for
 Always comply with local regulations as they may differ
 When using any disinfectant or sterilization solutions be sure to
follow the manufacturers instructions.
 Be sure that bulbs are in place before any type of cleaning - Do not
remove bulbs
 Immediately after using instruments should be rinsed in clean tap
water to remove any residue. External surfaces should be gently
scrubbed in soapy water with a soft brush.
Laryngoscopes by Teleflex
Cleaning and sterilisation
General sterilisation procedures for blades
Gas sterilisation i. e. Formaldehyd, Ethylenoxid
Plasma sterilisation i. e. STERRAD
Chemical sterilisation i. e. STERIS
Autoclave sterilisation at up to 134ºC for 18min
(WHO/CDS PH/92.104)
Sterilisation of laryngoscope handles
Please note that not every technique of sterilisation is usable.
The right procedure depends on the type of handle.
Laryngoscopes by Teleflex
Handles and sterilisation
• Handles in general are not to be sterilised with batteries in them
• Standard handles should not be immersed in any liquid rather wipe
clean and dry  oxydation due to aggressive materials used for
cleaning which have seeped inside the handle can affect contact
between spring and bottom
• X-LITE handles can be immersed in cleaning/disinfectant solution
and can be sterilised using chemical or plasma or gas-sterilisation
Not suitable for autoclave because of too high temperature
• The Dolphin handle is absolutely fluid-proof! Therefore, the batteries
do not need to be removed during cleaning nor during chemical
sterilisation. However the batteries must be removed if the handle is
sterilised in autoclave
Laryngoscopes by Teleflex
Replacement parts
Teleflex offers replacement parts as shown in the catalogue
Lid for handle casing
Battery container (without light and without battery)
Rechargeable battery
Actuator for handle small/large
For any other case please note that it is inexpedient to send the
instrument back to be repaired because this is more expensive than to
buy a new one!
Product Training
Carol Seroussi
November 2009
Endotracheal Tubes
Features of the Tube
Wall Thickness = ID/OD ratio
Size: mm ID
Cuff: Design, Material
Position Indicator
Tip: Magill or Murphy
Inflation Line
Pilot Balloon
Connector: 15 mm Female ISO
The Cuff
• Seals the airway
• Avoids aspiration
• Avoids gas leaks
Various forms of trachea
• Cuffed tubes are generally used in adults,
uncuffed in peds although this is
• Modern trach tube cuffs have a large
resting volume & diameter and a thin wall
which allow seal without stretching the
cuff wall
• Cuff size is important
Cuff Pressure
• Lateral wall pressure =
points of contact of the cuff
onto the trachea
• Intracuff pressure reflects
the lateral wall pressure
• Optimal cuff is sufficiently
large to effect a seal before
being inflated to its residual
volume = a cuff with a
resting circumference
higher than tracheal
• Ordinary the cuff pressure
should not exceed 25cmH2O
Cuff Pressure
Over inflation induces
high lateral wall
pressure and can
result in :
Mucosal inflammation
• Tracheal stenosis
• Cuff rupture with
subsequent deflation
• Cuff distortion which
may lead to airway
Cuff Pressure
Low Volume - High
Pressure Cuff
• Cuff resting diameter <
tracheal diameter
• Cuff pressure monitored is
often > 30 cm H2O to seal
• Perfusion in the tracheal
mucosa is reduced or
Cuff Pressure
High Volume - Low
Pressure Cuff
• Cuff resting diameter > tracheal
• Cuff pressure is adjustable
under a level of 30 cm H2O
• Perfusion in the tracheal
mucosa is reduced but sufficient
for the nutrition of the tissues
Cuff in a D-Shaped Trachea
Too much pressure leads to necrosis
Dilation of the trachea
No seal  leaks
Herniation of the cuff
Too much pressure
on the wall of the
Cuff Sealing
High Pressure
Deflated Cuff
Low Pressure
Deflated Cuff
High Pressure
Inflated Cuff
Low Pressure
Inflated Cuff
Cuff Sealing & Aspiration Discussion
Consensus about pressure/volume
• All cuffs are High Volume – Low Pressure
Discussion is about design & material
Until 2007 Manufacturers’ claims were mainly about
tracheal wall pressure to ensure lowest patient trauma =
battle around cuff thickness
PVC Barrel Cuff
Covidien Hi-Lo
Teleflex Rusch
PVC Tapered Cuff
Teleflex Sheridan HVT
Portex Soft Seal
Cuff Sealing & Aspiration Discussion
Consensus about pressure/volume
• All cuffs are High Volume – Low Pressure
Discussion is about design & material
Since 2007 – Manufacturers’ claims are mainly about
sealing to avoid silent aspiration & reduce VAP occurence
Claim: reduces
microaspiration by at
least 95% compared to
the Mallinckrodt™ HiLo™ basic, barrelshaped, PVC cuff
PU Barrel Cuff
KC Microcuff
Claim: reduces
microaspiration by at
least 81% compared to
the Mallinckrodt™ HiLo™ basic, barrelshaped, PVC cuff
PU Tapered Cuff
Covidien SealGuard
PVC Tapered Cuff
Covidien TaperGuard
Cuff Sealing & Aspiration Discussion
Claim1: Covidien SealGuard reduces microaspiration by at least 95% compared to
the Mallinckrodt™ Hi-Lo™ basic, barrel-shaped, PVC cuff
Claim2: Covidien TaperGuard reduces microaspiration by at least 90% compared
to the Mallinckrodt™ Hi-Lo™ basic, barrel-shaped, PVC cuff
• Mostly in vitro or bench studies comparing
Sealguard/ TaperGuard to Hi-Lo
• Patient studies are mostly non-conclusive due to
• Number of patients
• Patient population
• Ventilation time
• …etc
• Study from Lorente in CCM 2007
• Conclusive about
•PU cuff
• Not conclusive about cuff design
Main types of tubes
Uncuffed tubes
• Mainly used for children as the cricoid ring in children is
circular and constitutes the smaller part of the larynx.
• An ETT of the right size will provide good seal
• In adults, the proximal part of the larynx is barely circular, thus
seal cannot be done by the tube only.
• Usually uncuffed ETT has a black distal tip (15 to 40 mm
according to size) to help position it behind the vocal cords and
graduation markings through the whole length.
Main types of tubes
Cuffed tubes
• Most used
• Used when leakage control is
• Cuff presence decreases the ID of
the tube (inflation channel) thus
increasing the respiratory
• Inflation of the cuff must be
ckecked periodically
• Use in children developing
Main types of tubes
Armoured tube
• Armoured tubes have a better resistance to kinking or
• Mainly used in situations when a compression or kinking risk
exists (trauma, larynx compression…)
• Available with or without cuff
Special tubes
• Preformed tubes
Nasal or oral
Mainly used in oral & maxillo-facial surgery
No bulky connections near the operating site
Difficult aspiration
Oral ETT are usually shorter than nasal ones
• Laser tube
– Used for ENT surgery
– Non flammable
• Microlaryngeal
Standard Tubes
• Suitable for anesthesia (short- & medium-term)
• Suitable for long-term ventilation in ICU
• Made of
• Thermo-sensitive PVC (Rüschelit® - latex free - disposable)
• Soft Silicone (latex-free - reusable)
• Red Rubber (with latex - reusable)
• Tubes can be used nasally or orally (except Red Rubber)
• Black position indicator (except Red Rubber)
• Murphy Eye optional for most tubes
• Cuffed or uncuffed versions for most tubes
Standard Tubes – Cuffed or Uncuffed
• Silicone
• Rubber
Standard Tubes Disposable - PVC
• SafetyClear
• Uncuffed
• Magill 100380
• Murphy 100382
• Sizes (ID) 2 to10 mm
• Super SafetyClear
• Low-Pressure Cuff
• Magill 112480
• Murphy 112482
• Sizes (ID) 2,5 to10 mm
• 112481 Murphy w/Flexislip
• Indications: short & medium term intubation;
anesthesia or emergency
Standard Tubes Disposable - PVC
• Main Competitors
• Main advantages over competition
• Tyco/Mallinckrodt
• Cuff enables more resting
• Lo-Contour Cuffed &
• Less pressure on tracheal wall
• Portex
• Less trauma
• Blue Line Cuffed & Uncuffed
• Comparable to Hi-Lo from Tyco
• Sheridan
at a better price
• CF Close Fitting
Blue Line
Standard Tubes Reusable – Silicone & Rubber
• SilkoClear 105102
• Silicone tube w/ preformed cuff
• Nasal/oral Murphy eye
• Sizes (ID) 5 to 9 mm
• Soft Red Rubber Tube 102000
• Red Rubber tube w/ Silkolatex cuff
• Coated with Silkolatex
• Nasal/oral Magill type
• Sizes (ID) 2.5 to 11 mm
• Indication : short/medium term intubation during
surgery in anesthesia or emergency
• Competition
• Phoenix Medical
Intensive Care – Emergency
Longer term intubation
• Safety Clear Plus
• Super Safety Silk
Intensive Care – Emergency Disposable
• SafetyClear Plus
• Clear PVC
• Magill 112080
• Murphy 112082
• High-Volume Low-Pressure Cuff
• Sizes (ID) 5 to10 mm
• Indication: long term intubation nasal/oral
in ICU & Emergency
• Main Competitors
• Tyco/Mallinckrodt
• Hi-Lo Cuffed & Uncuffed (HVLP
• Sheridan
• HVT – High Volume Tapered
(HVLP Cuff)
• Portex
• Blue Line® with HVLP Soft-Seal
Profile cuff
Tyco Hi-Lo Cuff
Blue Line
Intensive Care – Emergency Disposable
• Super SafetySilk 112680 + 112682
• Extremely soft & highly thermosensitive PVC
• Velvet-like surface but not completely
smooth inside & outside tube for improved
sliding properties
• High-volume/low-pressure cuff
• Sizes (ID) 5 to10 mm
• Hooded soft tip: atraumatic intubation
• Indication: long-term intubation, nasal and
• 112682
• Murphy eye & softer material
• Sizes (ID) 3 to10 mm
• Fits perfectly for nasal intubation in ICU,
ENT surgery or paediatric ICU
• Soon to be: DEHP-Free version
Intensive Care – Emergency Disposable
Competition Portex Ivory
• Main Claims
• PROFILE SOFT SEAL cuff made from velvet soft PVC
• Larger cuff resting diameter
“PROFILE SOFT SEAL cuff combines the benefits of the
PROFILE cuff design with a larger cuff resting diameter“
Main advantages 112682 over Ivory
• Less traumatic bevel
• Inflation channel situated near proximal end of the tube
and not in the middle
• More sizes available 5 to10 as compared to 5 to 9 +
pediatric sizes 3 to 5
• Less expensive
• Soon to be: DEHP-Free
Intensive Care – Emergency Disposable
• Competition Tyco/Mallinckrodt SatinSoft
– Hi-Lo™ cuff for added sealing
– Soft atraumatic tip
– Murphy eye
– Oral & nasal intubation
• Competition Sheridan Naz-Al
– Special PVC blend for
added softness
– Soft atraumatic tip
– Cuff inflation line positioned
high reduces nasal trauma
Intensive Care – Emergency Disposable
• EDGAR tube 111480 (w/ cuff) 111380 (w/o cuff)
• Endotracheal Drug and Gas Application during
• PVC Magill tube w/ low-press cuff & additional
instillation channel with luer-lock adapter
• Sizes (ID)
• 6.5 mm to 10 mm with cuff
• 2.5 mm to 6 mm without cuff (black tip)
• Indication: endobronchial application of drugs
during cardiopulmonary resuscitation
• Emergency, ICU
Intensive Care – Emergency Disposable
• Competition Sheridan Stat-Med
• Cuffed tube with secondary lumen
positioned at tip for rapid drug delivery to
• May be used to monitor pressure, endtidal CO2 or for tracheal lavage
• HVT cuff
• Competition Sheridan LITA Laryngotracheal
Instillation of Topical Anesthesia
• Distribution of lidocaine at the end of an
operation so that there is no bucking and
coughing during extubation.
• 8 holes (6 above the cuff and 2 below)
where the lidocaine is sprayed
Intensive Care – Emergency Disposable
• Aid Instillation Kit 111100
• Instillation catheter + angled plastic connector
• Indications
• Endotracheal drug application during resuscitation
• Application of surfactant in neonatology
• Emergency, NICU
• Competition
• none
Intensive Care – VAP Prevention / Intervention
Intervention to prevent VAP should start BEFORE
• What decisions can be made prior to intubation?
–Type of ETT that will be utilized
–Has OR staff been educated on VAP and how to prevent it?
– Intubate orally rather than nasally
– Intubate with a “long-term” ETT if the patient is at risk of ICU stay
– Use an ETT that allows subglottic suctioning
Once Intubated….
Intensive Care – VAP Prevention / Intervention
Subglottic Secretion Suctioning (SGS)
• Secretions accumulate above the ET tube cuff
• Secretions can seep past the cuff into the
lower tract, causing pneumonia1
• Drainage of the subglottic secretions is an
effective strategy in preventing VAP2
American Thoracic Society. Consensus Statement: Hospital Acquired Pneumonia in Adults: diagnosis, assessment of severity, initial
antimicrobial therapy, and preventative strategies. Am J Respir Crit Care Med. 1996;151:1711-1725.
Dezfulian C, Shojania K, Collard HR, Kim HM, Matthay MA, Saint S. Subglottic secretion drainage for preventing ventilator-associated
pneumonia: a meta-analysis. Am J Med 2005; 118:11-18.
Intensive Care – VAP Prevention / Intervention
The Clinical Challenge
– Hospitals find existing solutions cost prohibitive to apply to all patients
– 7x more expensive to utilize 100% Evac tubes versus standard
– Anesthesiologists are not a stakeholder in VAP prevention
– 80% of all hospital-based intubations take place in the Operating Room
– Patients that need access to SGS often are not intubated with the appropriate
– ~ 20% of intubation require long-term ventilation
– Difficult to predict who will be long-term versus short-term
– If a subglottic secretion suctioning ET tube is not used at initial intubation
– Patient must be extubated and re-intubated –
– not advised in VAP-Prevention guidelines  most clinicians are reluctant
– It’s a classic Catch 22: ETT is available to help prevent VAP but clinicians
don’t have widespread access to it because of cost. When they decide they
need it, they can’t use it because of patient safety concerns.
Intervention to prevent VAP has to start BEFORE intubation
Intensive Care – VAP Prevention / Intervention
Predicting which patient will remain on long-term ventilation
and need a special ETT is not always easy
Hospitals find existing solutions cost prohibitive to apply to all
Physicians are reluctant to disturb a patent airway
The First Convertible Endotracheal Tube
Eliminates selectivity
• Convertible endotracheal tube with integrated
suction port
– Ideal choice for both short and long term
– Simplifies tube selection and consolidates
• Separate suction line allows for subglottic
secretion removal, on demand
– Increases the number of patients that can be
viable candidates for subglottic suctioning, a
clinically proven strategy for VAP reduction
The First Convertible Endotracheal Tube
High Volume Low Pressure Cuff
• Effective seal at low pressures
• Design reduces pressure on the tracheal
Placement ring
• Provides visual depth
marking for tracheal
Suction Lumen
• Allows removal of accumulated
• Custom design reduces likelihood of
mucus obstruction
* Does not replace cuff pressure monitoring
Pilot Balloon
• Tactile feedback allows for
optimal gauge of cuff
• Convenient size printing
Integrated suction port
• Easy connection to the suction line
• Strategically positioned for
placement out of patient’s mouth
• Cap seals suction port when not in
The First Convertible Endotracheal Tube
Suction line with integrated sealing caps
• Design allows for easy connection to the suction port
• Caps protect environment & suction line when line not
in use
Easy to hold connector
• Custom design connector
• Enables easy handling when
connecting/ disconnecting
suction tubing
• No extra force applied on
patient’s ET
Integrated suction port
• Easy connection to the suction line
• Strategically positioned for placement
out of patient’s mouth
• Cap seals suction port when not in
The Teleflex ISIS is designed to
be the right product, every time
• Eliminates the need to choose which type
of tube to use
Distinct features and benefits are
targeted at separate audiences
• Anesthesiology
• Intensive Care
High Volume Low Pressure Cuff
Placement Ring
Pilot Balloon with tactile feedback
Soft, molded tip
Ability to remove secretions after an
extended surgical procedure
• Integrated suction port on the ETT
• Custom Suction Lumen for Subglottic
Secretion Suctioning
• Separate suction line with ergonomically
designed connector
• If clogged, suction line can be changed
without reintubating patient
• Hight Vomume Low Pressure Cuff
• Pilot Balloon with tactile feedback
First product on the market with
subglottic secretion suctioning
• Secretions enter the evacuation port near the
cuff and are removed through the suction lumen,
which is connected to wall suction
Three different variations available
• Hi-Lo EVAC
– Hi-volume low pressure barrel cuff design
• TaperGuard Evac
– PVC tapered cuff design
• SealGuard Evac
– Polyurethane tapered rather than PVC
SealGuard Evac
• Polyurethane
• New design “pear-shape”
• Designed to adhere closely to the walls of the
trachea to prevent subglottic secretion slippage
into the lungs
• Similar cuff material to Kimberly Clark MicroCuff
TaperGuard Evac
• New design “pear-shape”
• Reduces leakage past the cuff by at least 81%,
compared with the Mallinckrodt Hi-Lo™
endotracheal tube
Example of Mallinckrodt Cuff
Left Side Tapered –
Right Side Barrel
Portex Blue Line SACETT
• Unique blue inflation line
• Actual Ivory tube with Soft Seal cuff
• Suctioning capabilities are a direct knock-off of the Hi-Lo Evac tube
Special Tubes – Preformed
• Preformed
• Nasal Safety Silk
• Others
• Laser
• Microlaryngeal
• BronchoFlex
Special Tubes – Preformed
AGT/Oxford Tubes Characteristics
• Anatomically shaped preformed tubes
• Used for surgery in the head, neck and throat
• Allow placement of the breathing circuit away from the
surgery field
• Avoid tube kinking
• Thermo-sensitive PVC (Rüschelit®) for better adaptation to
patient’s morphology
Special Tubes – Preformed
AGT Oral
AGT tracheal tube
Anatomically shaped preformed tubes made of PVC
Low-pressure cuff; radiopaque line
Unique design helps protect against kinking and disconnections
Curve can be temporarily straightened to allow easy passage of
suction catheter.
Available cuffed/uncuffed, oral/nasal
Cuffed: hooded Murphy tip with eye; Uncuffed: 2 eyes for peds
Indications : short/medium term for head, ENT, neuro- & maxillofacial surgeries when it is necessary to direct breathing circuits
away from the operative field
AGT cuffed oral 111780 3.5 to 9 mm; nasal 111781 3.5 to 8 mm
AGT uncuffed oral 100180 3 to 7 mm; nasal 100181 3 to 6.5 mm
NEW Nasal Safety Silk preformed, Murphy with cuff 111782 sizes
3.5 to 8 mm = softer material
AGT Nasal
Special Tubes – Preformed
Nasal Safety Silk
Nasal Safety Silk
• Softer PVC
• All dimension as per existing 111781 except
– Tube OD one size up to improve kinking resistance
– Proximal tip longer to avoid trauma to patient forehead
• Increased curvature/elbow radius in order to have a better kinking
• All sizes come with light blue x-ray line
• PA white connector bonded to the shaft
• Connector vertical to main axis of tube to be less traumatic on
patient’s face
Main advantages over competition
• As soft as silk for nasal or pediatric intubations
• Extremely smooth and gliding surface
• Atraumatic tip
• Optimaldistal length to avoid selective intubation
• Available in all sizes and half sizes
• Black ring for easy positioning
• Pediatric sizes
RAE Tracheal Tubes
RAE stands for:
*and occasionally, Ring, Adair, and Eldwin
Portex PDT & Polar
Special Tubes – Preformed
• Competition Portex® Directional
Endotracheal Tube (PDT)
• Pediatric and adult sizes
• Cuffed or uncuffed
• Oral/nasal configurations
• THE reference in nasal preformed
• Nellcor Nasal & Oral RAE®
• Available in cuffed and uncuffed
• Oral/nasal configurations
• Tip-To-Tip® radiopaque line
• Sheridan
• Available cuffed and uncuffed
• Oral/nasal configurations
• Sheridan’s original design with
Dr.'s Ring, Adair, Elwin (RAE)
• HVT cuff
Tyco RAE
Special Tubes – Preformed
Oxford tube 112880
Anatomically shaped tube
Non kinking PVC
Low-pressure cuff
Sizes = 7 to 10 mm
Indications : oral intubation
Anesthesia, emergency
Special Tubes – Laser
• Laser tube 102004
• Laser resistant tracheal tube made of white soft rubber
• Material: laser-guard foil 17 cm long consisting of
Merocel® foam and corrugated silver foil
• Special double cuff design with double pilot balloons
• Non-kinking design
• Sizes 4 to 8 mm
• Indications : ENT & mouth laser surgery
• Competition Tyco Laser-Flex®
• Stainless steel laser-resistant body
• Smooth surface and Magill curve minimize
trauma during intubation
• Patented double cuff design
Special Tubes – Laser
• Competition Sheridan Laser-Trach
•Red rubber design
•Embossed copper foil diffuses laser energy
minimizing unintended laser damage to tissue
•Covered with absorbent polyester knit for
fume by-products of combustion
•For CO2 and KTP laser surgery
• Competition Medtronic-Xomed Laser-Shield® II
• Tested for use with CO2 and KTP lasers
• Reflective aluminum wrap with smooth fluoroplastic
overwrap for atraumatic intubation
• Methylene blue is present in the inflation valve to provide
immediate detection of inadvertent cuff rupture
• All tubes are cuffed
Special Tubes – Microlaryngeal
• Microlaryngeal tube 112460
• Smaller OD allows easier intubation of airway narrowed by
tumor or abnormality & optimal access to the operating field
• Made of PVC with low-pressure cuff
• Cuff size and tube length like an 8,5 mm classic tube
• Sizes (ID) 4 to 6 mm
• Indications : surgery in the laryngeal space
• Competition
Tyco - MLT
Sheridan LTS
Armoured Tubes
• Procedures where patient’s head will
be flexed, extended or repositioned
during surgery; head, neck & throat
surgery, maxillofacial, reconstructive,
cranial..etc for prevention of tube
• When bronchoscopic intubation is
performed to remove the breathing
circuit from the surgery field
• Thermo-sensitive PVC (Rüschelit®) or
silicone or latex
Armoured Tubes - Disposable
• Rüschflex 104201, 104202, 104203
• Made of soft PVC able to keep
perfectly the curved form
• Fixed white connector
• Soft and frosty balloon
• Soft and atraumatic formed tip
Frost cuff &
hooded tip
Armoured Tubes - Disposable
Four types to offer the right solution
• 104201 Magill, from 3.5 to 10mm
• 104202 Murphy eye, 3.5 to 10mm
• 104203 Magill with Flexi Slip stylet
• 104203 Murphy with Flexi Slip stylet
Mainly for facial, ENT and neuro-surgery
Armoured Tubes - Disposable
• Competition Tyco
• Milky tube
• No radiopaque detection below cuff
• Clinician cannot determine tip placement
on X-ray,
• Higher pressure
• Thinner wall
• Less kinking resistance
• Cuffed 5 to 9,5 mm
• Uncuffed 3 to 5
• Competition Portex
• Difficult to insert due to straight shape
• Competition Sheridan Spiral-Flex
• Oral ref with preloaded stylet and bite
guard available
• Less kinking resistant
Armoured Tubes - Disposable
• Bronchoflex set 104100
• Tracheal tube for oxygen insufflation during fiberoptic
or rigid bronchoscopy
• Double lumen ID 7,5 mm & 3 mm
• Uncuffed
• ICU, endoscopic departments
• Set composed of armoured tube, oxygen tube,
plastic bite block with fixation flange & neck band
Armoured Tubes - Disposable
• Silkolatex tube with cuff 103040
• Removable connector to allow fiberoptic intubation
• Sizes 3 to 10.5 mm
• SilkoClear Flex with flexible thin-wall cuff 105702
• Fixed connector
• Sizes 3.5 to 10 mm
• Short/middle-term anesthesia
• Competition
• Bivona Fome-Cuf® Wire Reinforced
Fome-Cuf material automatically
adjusts to trachea and helps protect
from aspiration.
Pediatric Tubes
• Usually tubes w/o cuff due to difference
between anatomical structures & ped
airway fragility
• Increased demand for cuffed tubes since
high pressure low volume cuffs on the
• Disposable and reusable tubes
• With & w/o spiral
• Made of PVC, Latex, Silicone, Rubber
Pediatric Tubes
Uncuffed tracheal tubes for infants and children
100280 – SilkoClear, silicone, oral/nasal, Magill, 2 to 4.5 mm
100380 – SafetyClear, PVC, oral/nasal, Magill, 2 to 6.5 mm
100382 – SafetyClear, PVC, oral/nasal, Murphy, 2 to 6.5 mm
100480 – SafetyClear Soft, PVC, oral/nasal, Magill, 2 to 5.5 mm
100780 – AGT preformed, PVC, oral, 2 eyes, 2 to 6.5 mm
100181 – AGT preformed, PVC, nasal, 2 eyes, 2 to 6.5 mm
103600 – Armoured, PVC, nasal/oral, Magill, 2,5 to 6.5 mm
105400 – Armoured, silicone, nasal/oral, Magill, 2 to 6.5 mm
Pediatric Tubes
Cuffed tracheal tubes for infants and children
102000 – Soft red rubber, oral/nasal, Magill, 2,5 to 6 mm
112480 – Super SafetyClear, PVC, oral/nasal, Magill, 2,5 to 6 mm
112482 – Super SafetyClear, PVC, oral/nasal, Murphy, 2,5 to 6 mm
111780 – AGT preformed, PVC, oral, 1 eye, 3,5 to 6 mm
111781 – AGT preformed, PVC, nasal, 1 eye, 3,5 to 6 mm
104201 – Rüschflex, PVC, nasal/oral, Magill, 3,5 to 6.5 mm
104202 – Rüschflex, PVC, nasal/oral, Murphy, 3,5 to 6.5 mm
112682 – Safety Silk, soft PVC, nasal, Murphy, sizes 3.5 to 4.5 mm
Teleflex Laryngeal Masks
It provides an “oval seal
around the laryngeal inlet”
once it is inserted and the
cuff inflated
Once in place, it lies at the
crossroads of the digestive
& respiratory tracts
Indications of the Laryngeal Mask
• Laryngeal masks are indicated for use as an alternative to the
face mask for achieving and maintaining control of the airway
• Laryngeal masks are not indicated as a replacement for the
endotracheal tube
• Laryngeal masks are indicated for use in
• Routine and emergency anesthetic procedures
• Known or unexpected difficult airways
• Establishing an airway during resuscitation in the profoundly unconscious
patient with absent glossopharyngeal and laryngeal reflexes when tracheal
intubation is not possible
• May be used as a fiberoptic conduit when intubation is difficult, hazardous
or unsuccessful
• Can be used for bronchoscopy in the awake or asleep patient
Contraindications of the Laryngeal Mask
• As a routine airway, laryngeal mask is contraindicated in patients who
Are not fasted or where fasting cannot be confirmed
May have retained gastric contents
Greater than 14 to 16 weeks pregnant
Have multiple or massive injury
Have massive thoracic injury
Have massive maxillofacial trauma
Are at risk of aspiration
Morbidly obese patients
Obstructive or abnormal lesions of the oropharynx
NOTE: Not all contraindications are absolute
• As an emergency airway, it is contraindicated in patients who
Are not fasted
Are not profoundly unconscious
May resist insertion
Side-Effects of the Laryngeal Mask
• Throat soreness
• Dryness of the throat and/or mucosa
• Side effects due to
• Improper placement
• Overinflation of the cuff
Teleflex Laryngeal Masks
Insertion Technique
Laryngeal Mask - Preparation for Insertion
ID (mm)
Description & weight capacity*
Standard Single Use and Reusable
Neonates/Infants up to 5 kg
< 4ml
Infants 5-10 kg
< 7ml
Infants/Children 10-20 kg
<10 ml
Children 20-30 kg
<14 ml
Step 1: Size Selection
Children 30-50 kg
<20 ml
Verify that the size of the
laryngeal mask is correct for
the patient
Adults 50-70 kg
<30 ml
Adults 70-100 kg
<40 ml
Adults >100 kg
<50 ml
Flexible Single Use and Reusable
*Patient weight is a guide only, clinical judgement is key
Neonates/Infants up to 5 kg
< 4ml
Infants 5-10 kg
< 7ml
Infants/Children 10-20 kg
<10 ml
Children 20-30 kg
<14 ml
Children 30-50 kg
<20 ml
Adults 50-70 kg
<30 ml
Adults 70-100 kg
<40 ml
Adults >100 kg
<50 ml
Laryngeal Mask - Preparation for Insertion
Step 1: Size Selection
• Size 4 is the normal adult size for male & female
• Many adults will comfortably take a size 5
• Size 3 is mostly a pediatric size
• Or small adults for whom size 4 does not stay
• When in doubt –> use a larger size with small inflation volumes
rather than a smaller size excessively inflated
• If the mask is too small
• The aperture may be below the level of the glottis, causing
• Overinflation may be needed to obtain a seal
*Patient weight is a guide only, clinical judgement is key
Laryngeal Mask - Preparation for Insertion
Step 2: Examination of the Laryngeal Mask
• Visually inspect the laryngeal mask cuff for tears
or other abnormalities
• Inspect the tube to ensure that it is free of
blockage or loose particles
Step 3: Deflation & Inflation of the
Laryngeal Mask
• Deflate the cuff to ensure that it will maintain a
vacuum & form a smooth flat wedge shape
which will pass easily around the back of the
tongue and behind the epiglottis. This can be
performed by pushing down the mask on a flat
surface, with 2 fingers pushing the tip
• Inflate the cuff to ensure that it does not leak maximum air in cuff should not exceed the
recommended guidelines
Laryngeal Mask - Preparation for Insertion
Step 4: Lubrication of the Laryngeal Mask
Use a water soluble lubricant
Only lubricate just prior to insertion
Lubricate the back of the mask thoroughly
Avoid excessive amounts of lubricant on the anterior surface of the cuff or in
the bowl of the mask as inhalation of the lubricant following placement may
result in coughing or obstruction
Step 5: Positioning of the airway
Open the mouth
Extend the head and flex the neck
Pull the lower jaw downwards
Visualize the posterior oral airway
Ensure that the laryngeal mask is not folding over in the oral cavity as it is inserted
Laryngeal Mask – Insertion Technique
Insertion Video - Intersurgical
Insertion Video - LMA
Laryngeal Mask Insertion
Grasp the laryngeal mask by
the tube, holding it like a pen
as near as possible to the
mask end
Place the tip of the laryngeal
mask against the inner
surface of the patient’s upper
Step 1
Laryngeal Mask Insertion
Under direct vision, press the
mask tip upwards against the
hard palate to flatten it out
Using the index finger, keep
pressing upwards as you
advance the mask into the
pharynx to ensure the tip
remains flattened and avoids
the tongue
Step 2
Laryngeal Mask Insertion
Keep the neck flexed and
head extended
Press the mask into the
posterior pharyngeal wall
using the index finger
Keep mouth open for
better visualization by
pushing lower jaw
Step 3
Laryngeal Mask Insertion
Continue pushing
with your index finger
Guide the mask
downward into
Push the mask into
the hypopharynx until
resistance is felt
Step 4
Laryngeal Mask Insertion
Grasp the tube firmly with the
other hand
Withdraw your index finger
from the pharynx
Press gently downward with
your other hand to ensure the
mask is fully inserted
Step 5
Laryngeal Mask Insertion
• Inflate the mask with the
recommended volume of
air to obtain a “just-seal”
• Maximum recommended
pressure is 60 cmH2O
• Do not touch the laryngeal
mask tube while it is being
inflated unless the
position is obviously
• Make sure the black line
remains aligned with nasal
septum & upper lip at all
• Normally the mask will rise
up slightly out of the
hypopharynx as it is
inflated, to find its correct
Step 6
Verify & Secure Placement
Step 7
• Inflate the cuff
• Connect the laryngeal mask to
a Bag-Valve Mask device or low
pressure ventilator (20 cmH2O
for correct seal)
• Check for leaks: ventilate the
patient while confirming equal
breath sounds over both lungs
in all fields and the absence of
ventilatory sounds over the
• Insert a bite block or roll gauze
• Affix the laryngeal mask
Removal of the Laryngeal Mask
• Mask should be left in place until
• patient recovers his reflexes
• patient can spontaneously open his mouth upon verbal request
• Patient may remove the mask as soon as protective reflexes are
back – this occurs with the cuff inflated…
• Should the cuff be deflated prior to removal of the mask?
• If the cuff is fully inflated
– Secretions will be removed
– High risk of patient trauma
• If the cuff is fully deflated
– Secretions will fall past the cuff into the bronchus
– Risk of laryngospasm
– Suctioning can be necessary
• If the cuff is moderately inflated
– Secretions will be removed
– Suctioning should not be necessary
Issues with Laryngeal Mask Insertion
Failure to press the
deflated mask up
palate or inadequate
lubrication or deflation
can cause the mask
tip to fold back on
Once the mask tip has
started to fold over, this may
epiglottis into its down-folded
position causing mechanical
If the mask tip is
deflated it can
push down the
epiglottis causing
If the mask is inadequately deflated it may either
push down the epiglottis
penetrate the glottis
Teleflex Laryngeal Masks
Product Information
• A laryngeal mask consists of
• A mask or cuff (with or without epiglottis bars)
• A tube with an inflation line
• A 15 mm connector
• A pilot balloon
Teleflex Sure Seal Laryngeal Mask
Product Information
Black Line
Cuff Pilot
(or Standard
Pilot Balloon)
Laryngeal Masks – RUSCH Crystal Airway Mask
Laryngeal Masks – RUSCH Crystal Airway Mask
Item Code
Rüsch CAM,
Size 1.0
10 / Case
Rüsch CAM,
Size 1.5
10 / Case
Rüsch CAM,
Size 2.0
10 / Case
Rüsch CAM,
Size 2.5
Light Purple
10 / Case
Rüsch CAM,
Size 3.0
10 / Case
Rüsch CAM,
Size 4.0
10 / Case
Rüsch CAM,
Size 5.0
10 / Case
Laryngeal Masks – RUSCH Crystal Airway Mask
Key Features
Rotationally-moulded laryngeal cuff
• Produces a cuff with stronger yet thinner wall
• Posterior aspect of cuff (top) is reinforced
–Reduces possibility of distal portion of cuff folding back on
itself upon insertion
• Support wedge between cuff and tube
–Prevents cuff from pushing back against the tube
–Prevents leaks around epiglottis and base of tongue
• Smooth transition from tube to cuff
• No risk of a “disconnect” of the cuff from the tube
Laryngeal Masks – RUSCH Crystal Airway Mask
Key Features
Location of pilot balloon line attachment
• Attaches to ventilation tube just below the 15 mm connector
–Integrated through the wall of the tube
• Produces a stronger connection to inflation lumen
• Protects the point of connection
• Angles out at a 450 angle to keep out of patient’s face
Latex Free Cuff
• Safety for both clinician and patient
• Prevents any kind of anaphylactic reaction
Single Use
• Ease of use; prevents cross contamination
Seven Sizes Available
• To accommodate a wide range of patients
Color Coded
• To help easily identify different sizes
Laryngeal Masks – Sure Seal Product Range
Product design as per customer’s preference
Anatomical shape of the cuff – proven & trusted, best seal
Atraumatic & thin tip – better seal, less trauma
Silicone cuff for all products – best proven seal, less trauma
Epiglottis bars – a plus compared to no bars
Rigid yet smooth enough tube – easy insertion
Smooth transition from tube to cuff – no trauma
Inflation line attached to the cuff – better ID/OD tube
15 mm ISO connector
A full offering to cover most needs
• Reusable range
standard & reinforced
8 sizes available – to fit all patients including obese
• Disposable range
standard & reinforced
w/ Standard Pilot Balloon (SPB) or Cuff PilotTM (CP)
8 sizes available – to fit all patients including obese
Laryngeal Masks – Sure Seal Product Range
Reusable products – Standard & Reinforced
• Supplied with a standard pilot balloon
Cuff PilotTM cannot be re-sterilized
• Autoclavable pilot balloon color differentiated = blue
• Transparent connector
• Non sterile: same as competition, before use, hospital will sterilize
• Single-packed 10 in a cardboard box
• No color code for packaging – no need, will be discarded at
• 3 years shelf-life
• Each reusable mask is supplied with a unique serial number & a
card with this serial number stamped on it
• Each time the mask is sterilized the sterilization staff dates & signs
the card
– To confirm it has been sterilized
– To track the number of uses of each mask
Laryngeal Masks – Sure Seal Product Range
Disposable products – Standard & Reinforced
• Disposable masks are available
– 100% silicone
with Cuff Pilot
– PVC/Silicone
with Standard Pilot Balloon
– PVC does not contain DEHP – DBP – BBP  DEHP-Free PVC
– It is not phthalate-free as it contains DINP
• Disposable masks are supplied
– Sterile ready to use
– Single-packed 10 in a flat pack
– With a clear standard pilot balloon – non autoclavable
– Or with a Cuff Pilot – non autoclavable
– 2 years shelf-life
– Packaging is color coded for sizes
– Blue connector with & without Cuff Pilot
Laryngeal Masks – Sure Seal Product Range
Features & Benefits
Unique Cuff Pilot
Constant pressure monitoring ; tenders
lockout by differentiating feature
Comprehensive range of products
Fulfill most tender requests
Single use sterile mask Prevents cross infection; ready to use;
convenience; time gain
Reusable mask Fully autoclavable at 138°C - guaranteed for
40 uses
Reinforced flexible masks Prevents occlusion of the airway tube;
suitable for use in head and neck
procedures; airway tube may be positioned
as required
Design as per market leader
200M uses; proven clinical performance
Epiglottis Bars Avoids epiglottis to fall & obstruct the airway
Straight tube construction Allows easy access of suction catheter, ETT
or flexible fibre optic devices
Tube Pliability Designed to facilitate insertion & minimize
mucosal pressure
Silicone extra-soft cuff Soft & atraumatic to patient's laryngeal
space; ensures the best possible consistent
seal with the least possible mucosal
pressure; smoother insertion and quicker
sealing time
Cuff wedge shape Designed for anatomical fit in the
hypopharynx & easy placement
Tapered anatomical cuff tip Resists folding over during insertion and
plugs the upper esophageal sphincter &
reduces gastric insufflation
Laryngeal Masks – Sure Seal Product Range
Features & Benefits
Disposable units available as 100%
Disposable units available with PVC
tube & Silicone Cuff
All units (except reinforced) contain no
metal parts
Available in 8 clearly marked sizes
Cuff inflation volume and patient weight
clearly marked on tube
Mask size conveniently located at
proximal tip of tube
Convenient depth marks
Inflation line separate from the tube
Soft pilot balloon
Clearly marked radio opaque black line
Individually numbered reusable masks
Color coded packaging
Touch & Feel of reusable product
Cost effective solution; clear view in case of
Allows use in MRI scans
Fits all patients
Easy replacement
Easier identification of correct size
Monitoring of correct position
Risk of inflation line being bitten is reduced
Provides precise tactile indication of degree
of inflation
Easy insertion
Product identification and traceability
Easy size identification
Laryngeal Masks – Sure Seal Product Range
How does Cuff PilotTM work?
• Safe cuff inflation is about pressure not volume – optimal maximum cuff
pressure in laryngeal masks is
– 60 cm of water pressure in adults
– 40 to 50 cm of water pressure in infants
• Cuff Pilot constantly monitors pressure in the cuff detecting changes due to
temperature, nitrous oxide levels & movements within the airway
• The integrated device provides at-a-glance feedback, alerting physician
instantly to changes before they affect patient safety
Laryngeal Masks – Sure Seal Product Range
How does Cuff PilotTM work?
The integrated device has a valve for
inflation and contains 3 coloured
zones & 1 clear zone
• Green Zone indicates optimal cuff
pressure (40 to 60 cmH2O)
• Yellow Zone indicates possible under
inflation (<40) or decreased cuff
• Clear Zone between Green & Red
indicates pressure between 60 & 70 –
serves to optimize pressure by
alerting of pressure deviation &
informing of slight deflation need
• Red Zone indicates possible over
inflation or increased cuff pressure
Sure Seal USP – Cuff Pilot
Why should we promote Cuff PilotTM?
LMA Cuff Pressure – An audit – ASA 2009 – Haldar & Immanuel Anaesthetic Department, Queen's Hospital, Burton-on-Trent, UK
“The LMA has many advantages over the face mask and the endotracheal tube. But it
can also be associated with morbidities like sore throat, malposition, nerve damage if it is
not used correctly. Thus it is important to avoid over inflation of the laryngeal mask cuff
at any given time. If the cuff is under inflated, on the other hand, it can produce an
inadequate seal making positive pressure ventilation and airway protection from above
the cuff ineffective (…) Although cuff pressure monitoring is recommended by the
manufacturers, little evidence exists for this in clinical practice. Better awareness on this
aspect will reduce the preventable morbidity related to LMA. We recommend that LMA
cuff pressure should be monitored routinely when it is used in clinical practice.”
Sure Seal USP – Cuff Pilot
Why should we promote Cuff PilotTM?
Venous congestion of the neck; its relation to laryngeal mask cuff
pressures - R. J. Lenoir Portsmouth, UK
«This audit has demonstrated that much higher volumes of air are used to inflate
LMAs than are necessary, and that after nitrous oxide diffusion, this can lead to very
high cuff pressures, well above the standard of 60 cm water recommended. The
incidence of venous congestion was also reduced in association with lower cuff
volumes, and not observed at all in patients in whom the LMA cuff was inflated just
above airway leak pressure. This would have particular relevance in patients
undergoing general anaesthesia for eye or head and neck surgery, where raised
venous pressure may lead to raised intra-ocular pressure or increased bleeding. In
any circumstances, obstructed venous drainage of the head and neck cannot be
Sure Seal USP – Cuff Pilot
Why should we promote Cuff PilotTM?
• Nandwani N, Fairfield MC, Krarup K, Thompson J. The effect of LMA insertion on
the position of the internal jugular vein. Anaesthesia 1997; 52: 77–83 (on USB Key)
• Margot R. Pressure exerted by the laryngeal mask airway cuff upon the pharyngeal
mucosa. Br J Anaesth 1993; 70: 25–9 (abstract on USB Key)
• Colbert SA, O’Hanlon DM, Flanagan F, Page R, Moriarty DC. The laryngeal mask
airway reduces blood flow in the common carotid artery bulb. Can J Anaesth 1998;
45: 23–7 (abstract on USB Key)
• Wong JG, Heaney M, Chambers NA, Erb TO, VON Ungern-Sternberg. Impact of
laryngeal mask airway cuff pressures on the incidence of sore throat in children.
Paediatr Anaesth. 2009 Mar 5. Department of Anaesthesia, Princess Margaret
Hospital for Children, Subiaco, WA, Australia (abstract on USB Key)
• Brimacombe J, Holyoake L, Keller C, et al. Emergence characteristics and postoperative laryngopharyngeal morbidity with the laryngeal mask airway: a
comparison of high vs low initial cuff volume. Anaesthesia 2000; 55: 338-43
• Asai T, Brimacombe J. Cuff volume and size selection with the laryngeal mask.
Anaesthesia 2000; 55: 1179–84 (abstract on USB Key)
Sure Seal USP – Cuff Pilot
Why is Cuff PilotTM the best option for cuff pressure monitoring?
• Blanch Paul B. Comparison of 4 cuff pressure indicators - Respiratory
care 2004, vol. 49, no2, 166-173. Department of Anesthesiology, University of
Florida College of Medicine, Gainesville, Florida, USA (study on USB Key)
– 4 cuff inflators tested
– All differ in bias and precision
– None of them accurately measure cuff pressure
– None allowed cuff-pressure checks without decreasing cuff pressure
• Integrated device
– Attaching a monitor to an ET tube cuff can be extremely dangerous
– ICU space is already too crowded with other systems
– Always at the ready to avoid hassle factor with locating a separate
• Disposable device
– The practice of taking an Endotest from room to room is a potential
source for cross-contamination
– Patients in contact isolation rooms may not get cuff pressure
checked  higher incidence of tracheal fistulas and other symptoms
of excessive cuff pressure
– No need for cleaning &/or checking cleanliness of device
• Need to assure & document proper pressure from a liability
Sure Seal Features & Benefits
Why promote a silicone cuff ?
Good seal with less pressure on the hypopharynx
Risk of patient trauma reduced
Consistent seal pressure throughout the mask (better than PVC)
When deflated, the silicone cuff will retract perfectly to allow for easier
insertion & removal
Why is a laryngeal mask with PVC cuff less efficient ?
PVC masks are more rigid  more trauma
PVC must get warmed up first before
– Most OR’s are at 16 – 19C degrees centigrade
– Human body obviously is a lot warmer
– Some anaesthetists put PVC masks in hot water for a few minutes
to make them more pliable prior to using them to make sure
– they “adapt” to the pharyngeal space
– they provide an adequate seal
– PVC cuff can take some minutes before a seal can be achieved
Silicone seal
– Silicone contours are softer than PVC
– Silicone adapts immediately to patient anatomy
Sure Seal Features & Benefits
Why should pressure be always monitored when using a
silicone cuff ?
Nitrous oxide diffusion into the cuffs of disposable laryngeal mask airways - P.
Maino, A. Dullenkopf, V. Bernet and M. Weiss
Departments of Anaesthesia and Intensive Care, University Children’s Hospital
Zurich, Switzerland
«In conclusion, we found that the susceptibility to cuff pressure increases due to
N2O in disposable laryngeal mask airways is mainly influenced by the type of
material from which the cuffs are constructed, with considerable advantages
seen with cuffs constructed from PVC compared to silicone.»
HENCE Cuff Pilot
Sure Seal Features & Benefits
What is the use of epiglottis bars according to Dr Brain?
The purpose of aperture bars is to prevent a large epiglottis from falling into the
aperture, blocking it and occluding the airway. Aperture bars in the bowl of the
mask tend to elevate the epiglottis and thus protect against its migration into the
mask aperture. The aperture bars need to be flexible enough so an endotracheal
tube can pass through them and push them aside and yet firm enough to withstand
the pressure of an epiglottis
Jonathan L. Benumof MD - San Diego, California
“ I found that in most of these patients the epiglottis entered the breathing shaft of
the aperture bar-less Portex laryngeal mask, which made it difficult to identify
supralaryngeal and laryngeal anatomy. In order to identify anatomy and intubate the
trachea fibreoptically in these patients, I had to pull the Portex back approximately
0.5 to 1.0 cm; the pull back allowed disengagement of the epiglottis from the
breathing shaft of the mask (of varying degrees from partial to total) and
identification of the anatomy.”
Epiglottis bars value
• hold epiglottis back
• prevent airway obstruction
• prevent damage to the epiglottis
Sure Seal Features & Benefits
Why did we choose to have epiglottis bars?
Many physicians believe it is really useful to avoid epiglottis
falling back & obstruct the airway
Others just « don’t care »
No adverse literature exist – only a few studies showing it is not
as useful as LMA has always claimed
We cannot carry both ranges – would double the nb of ref.
Cost of good is the same with & without epiglottis bars
Consequently, we believe that
It’s more an advantage to have them than a drawback
Not having them can stop us from selling, having them will rarely
impede our chances of success
Sure Seal Features & Benefits
Why promote single use devices?
• Better infection control
– Sterile, single use products fully eliminate cross infection risks
– Risk of pathogens survival is still high after sterilisation
• Convenience
– Always at the ready
– No need for follow-up cards
– Long & fastidious cleaning & sterilisation process is avoided
• Cost effectiveness
– Sterile single use devices are less expensive in the long run
– Sterilisation is costly in equipment & human resources
– Cost better known = 1 and for all…
• Revenue stream for Teleflex & partners….
Sure Seal Features & Benefits
Why promote single use devices?
Costs Associated with the Use of Reusable Laryngeal Masks
3 - Use
in OR
2 - Transfer
to OR
5 - Cleaning
1 - Sterilisation
6 - Visual
10 - Storage
7 - Packaging
9 - Follow
Up Card
4 - Transfer to
* For discoloration, cut, ruptures, chemical degradations…
8 -Sterilisation
Sure Seal Features & Benefits
Why promote single use devices?
Costs Comparison between Reusable & Single Use Laryngeal Masks
Soulias – CHU Dijon - AFAR 2006
(abstract on USB Key)
“Disposable LM cost was calculated as
the sum of product cost and elimination
cost. Reusable LM were autoclaved
after hospital purchasing in two
separate sterilizing processing units of
the same hospital. Reusable LM cost
was determined combining material
and labor costs. RESULTS: The
reusable LM cost depended on the
sterilizing processing unit concerned
and varied between € 9.59 and 9.69 vs
CONCLUSION: With the cost savings
made possible by use of disposable
LM in both labor and consumables, this
practice should be considered.
Tim M Cook, Consultant Anaesthetist
Royal United Hospital, Bath – 2004
(editorial on USB Key)
“Other reasons cited to change to
single-use devices include cost and
convenience. In the UK, a cLMA costs
approximately £90 and sterilization
£1–3. Single-use laryngeal masks
cost £3.50–7.00 with the price
decreasing as a result of competition.
Some reports suggest the average
cLMA is used less than 20 times.
• Reusable device = £90 + (£2x30)
= £150
• Single use device = £4x30 = £120
• Cross infection costs not included:
ICU stay, hospital stay, antibiotics,
Sure Seal Features & Benefits
Why promote single use devices?
Risks Associated with the Use of Reusable Laryngeal Masks
“Supplementary cleaning does not remove protein deposits from re-usable
laryngeal mask devices”
Canadian Journal of Anesthesia 51:254-257 (2004)
Joseph Brimacombe, MB CHG FRCA MD, Tisha Stone, MB BS & Christian Keller,
To determine if supplementary cleaning facilitates removal of protein deposits from
the laryngeal mask
Staining was similar before and after supplementary cleaning
Supplementary cleaning does not remove protein deposits from reusable laryngeal
masks … the infectious risk associated with the protein deposits remains to be
Sure Seal Features & Benefits
Why do we have a SureSeal with PVC tube & a full PVC
Crystal Clear?
PVC tube is clear & thermosensitive
Good visibility through tube during use
Gas exchange can be easily visualized: condensation on the tube
Blood traces or gastric aspiration may be seen through the tube at all
Best price options
Why do we have such a large range, including reusable?
To be able to provide products for each & every request based on
– Quality
– Patient safety
– Tenders
– Preference
– Price
One-stop shopping strategy
Products Part Numbers & Positioning
St le
a n Us
Pi da e
lo rd
C eU
f P se
St sab
an le
B da
al rd
on Pil
T y pe of produc t R ang e P os itioning
Fanatics of
Brand Name
P art
Sure Seal Laryngeal Mask
100% Silicone
Sure Seal Reinforced
Laryngeal Mask
100% Silicone
Sure Seal Laryngeal Mask
PVC Tube Silicone Cuff
For those who
Sure Seal Laryngeal Mask
pressure issues & 100% Silicone
care for infections
Sure Seal Reinforced
Laryngeal Mask
100% Silicone
Sure Seal Laryngeal Mask
PVC Tube Silicone Cuff
Sure Seal Laryngeal Mask
For everyone else 100% Silicone
Sure Seal Reinforced
Laryngeal Mask
100% Silicone
Teleflex Laryngeal Masks
Competitive Review
Competitive Information - LMA
• Reusable Silicone
• 8 sizes
• Single Use PVC
• 7 sizes
• Sterile
Competitive Information - LMA
Flexible Reusable & Single Use
Competitive Information - LMA
Proseal (Reusable) & Supreme (Single Use) – what they claim
• Strong cuff allowing 2 x seal at the same pressure
• High seal pressure up 30 cmH20
• Provides a tighter seal against the glottic opening with no increase in mucosal
• Enables use of higher PPV w/ and w/o muscle relaxants
• Built-in drain tube designed to channel fluid away and permit gastric access
Competitive Information - LMA
Fastrach Reusable & Single Use
• Designed for difficult airway & CPR
• Facilitates continuous ventilation during
• Rigid curved tube for an 8mm cuffed ETT
• Rigid handle to facilitate one-handed insertion,
removal & adjustment of the position to enhance
oxygenation & alignment with the glottis
• Can be inserted in a confined environment
• No need to move patient’s head
• No need to insert finger in patient’s mouth
• Epiglottic elevating bar in mask aperture to lift
epiglottis as ETT is passed through and a ramp
which directs the tube
• Available in 3 sizes
• Comes with a specially designed reusable LMA
Fastrach™ ETT
Competitive Information - AMBU
Aura40 & AuraOnce – what they claim
• Unique feature: special curved molded tube
– Replicates the natural human anatomy
– Helps avoid abrasion of the upper airway
• Special reinforced tip to resist folding
• Cuff and airway tube are a single unit
• Depth marks on the tube
• Available in 8 sizes
• Soft cuff to ensure good seal (0.4mm)
• Color coded pilot balloon & pouch to identify mask size
Competitive Information - AMBU
Non-curved version also available
Not as good a seal with the curved version in adults
• Does not suit 10 to 20% of patients’ anatomy
• Inner rings (at curve) may prevent insertion of bronchoscopes
Cuff and airway tube single moulded
• Flexible tip with risk of folding over (requires finger to prevent folding)
Airway tube has a smaller diameter
• Increased work of breathing
• Smaller area to view condensation
Competitive Information - PORTEX
Portex (Smiths Medical)
• Provider of medical devices for the hospital, emergency & home markets
• Evolution through acquisitions to become a strong provider of respiratory and
anesthesia/critical care devices
• Comprehensive range in airway management
SoftSeal Single Use
Launched in 2003
PVC no epiglottis bars
Silicone Single Use
Launched in 2007
Silicone with epiglottis bars
“we listened to you”
Competitive Information - INTERSURGICAL
Intersurgical Co
• Solus in May 2005 (developed by a
former LMA engineer)
• Solus MRI in 2006
• Non-ferrous valves guaranteed not to interfere
with the magnet in an MRI unit
• Packaging clearly marked 'MRI compatible‘
• Yellow pilot balloon & valve plunger for
Competitive Information - INTERSURGICAL
Solus Sales Claims
• Classic cuff shape – mostly like CAM
• Firm smooth back plate – same as CAM, can hit soft palate causing trauma to
• Clear airway tube – same as most products
• Non removable ink – irrelevant for single use product
• Accurately aligned cuff indicators – Is the patients anatomy accurately aligned?
• Optimal airway tube flexion – irrelevant as placement is all down to technique
• Two Piece Design
– Risk of separation
• Limited details on cuff inflation
Competitive Information - INTERSURGICAL
• Launched early 2007 –1.5M units
sold in 2009
• Non-inflatable gel cuff, fits onto
perilaryngeal wall
• 6 sizes, adult from 30 over 90 kgs,
pediatric from 2 to 35 kgs
• Intubation through I-gel possible (6
to 8 mm ETT)
• Epiglottis blocker: prevents
epiglottis from down-folding
• Suction channel available (suction
cath 12 & 14)
• Integral bite block + “buccal cavity
stabilizer” = widened part to
eliminate potential for rotation after
Competitive Information
Reusable Devices
• Endotest-like devices
• The Rusch EndoTest is an accurate endotracheal tube cuff
inflator and manometer that can monitor the pressure of
high volume, low pressure cuffs. The function adapted
design enables the device to be used with one hand
• Cross contamination risk
• Not available at all times, at all beds
• Management and inventory hassle
• Calibration requirements
• Replacement when needed
• Pressure Monitors
1 per bed needed
Not enough space in the ICU
Inflation line attached to the ETT???
Sure Seal Sales Strategy
• Focus on our Unique Selling Proposition = Cuff PilotTM
• Sure Seal is a « mind-changer »
– First pressure monitoring laryngeal mask
– Could change the way laryngeal masks are considered
• Promote pressure monitoring & Cuff PilotTM to all departments & users
– Anesthesiologists
– Nursing Staff
– Pharmacy
– Infection Preventionists
– Purchasing Dpt
• Remember other key benefits
• Comprehensive range & sizes
• Single Use
– Sterile - maintain focus on infection control argument
– Ready to use – involve nursing staff
– Money & time gain – involve budget holders and senior management to
reallocate budgets if needed
• 100% silicone
– Potential for reduction of sore throat & trauma – talk to anesthesiologists
– Better seal with less pressure – talk to anesthesiologists
• ‘Basket deals’ where possible
• ETT + LM + Circuits + Filters….etc – get to know purchasing people
• Mak ‘em try!!!
Double Lumen Tubes
Anatomy of the bronchi
Left and right
mainstem bronchus
• Lobe bronchi
Anatomy of the bronchi
Adult trachea
• Fibrocartilaginous tube about
15cm long
• Thoracic portion is 5-6 cms long
and terminates a the carina
• Extends from lower end of
cricoid cartilage
• Tracheal diameter is roughly the
same as patient’s index finger
• C- shaped anteriorly due to the
presence of 16-20 cartilages
rings joined posteriorly by
fibroelastic tissue and muscle
Anatomy of the bronchi
Mainstem Bronchi
• Are circular
• Right bronchus
– About 2,5cms long
– Upper lobe starts at 2 cms
– Vertical angle at 25°
– Has 3 lobes and 10
bronchopulmonary segments
• Left bronchus
– About 5 cms long
– Upper lobe starts at 5 cms
– Vertical angle is 45°
– Has 2 lobes and 8 segments
Lung isolation techniques
A reliable method for lung isolation is essential for a variety of
thoracic surgical procedures.
Currently two types of devices are used as the basis of modern
lung isolation techniques.
• The double-lumen endo-bronchial tube (DLT)
• Several bronchial blockers (BB) positioned through the single
lumen endo-tracheal tubes (ETT)
Indications for lung isolation and one-lung ventilation (OLV) are
primarily related to the type of surgery, and include different
• Lung-,
• Cardiac-,
• Oesophagus-, and
• Vascular surgical procedures.
Main Indications for Bronchial Intubation
Surgical exposure with strong indication
Thoracic aortic aneurysm repair
Upper lobectomy
Mediastinal exposure
Vascular surgery
Lung transplant (uni & bilateral)
Surgical exposure with moderate indication
Middle and lower lobectomy
 Subsegmental resection
 Esophageal resection
 Procedures on the thoracic spine
Minimal invasive procedures using VAT & VATS (Video Assisted
Thoracoscopy Video Assisted Thoracic Surgery)
Post-cardiopulmonary bypass status
Severe hypoxemia from unilateral pulmonary process
Requirement for differential ventilation for critical care
Indications for lung isolation
1. To avoid contamination of a non-diseased lung
• Infection (e.g. unilateral pulmonary abscess)
• Massive pulmonary hemorrhage
• Unilateral pulmonary lavage
2. Control of distribution of ventilation
Bronchopleural fistula
Bronchopleural cutaneous fistula
Surgical opening of major conducting airway
Tracheobronchial tree disruption
Life-threatening hypoxemia due to unilateral lung disease
Contra-Indications for bronchial intubation
Absolute Contraindications
• Airway (especially laryngeal or tracheal) mass that may be occluding,
dislodged, traumatized, or hemorrhaging
Relative Contraindications
• Patients requiring rapid intubation to prevent aspiration of gastric
• Patients who are likely to be difficult to intubate
Various types of endobronchial tubes
•Single lumen tube
•Double lumen tube left or right - known also as Robertshaw
•Double lumen tube left with hook – known also as Carlens
• Carina hook used for securing the tube in the correct position
• Positioned in the left lung usually for left lung sealing
•Double lumen tube right with hook – known also as White
• Positioned in the right lung usually for right lung sealing
•DLTs offer the flexibility of switching ventilation from one lung to
the other lung (for bilateral procedures) or to two-lung ventilation
simply by clamping or unclamping lumens
•Ability to suction blood or secretions easily from either lung.
•Main features
Low-pressure, high volume cuff
Transparent tube
Coloured endobronchial cuff for ease of bronchoscopic recognition
Angled tip
Positioning of a DLT
• Insertion of right sided tube
into right bronchus for right
side sealing
• Insertion of left sided tube
into left bronchus for left side
Positioning of a DLT
Right tube for right lung occlusion
Left tube for left lung occlusion
20° angle
30° angle
Bronchial cuff
3 lobes in right lung
Bronchial cuff
Eye for ventilation
of right upper lobe
Left bronchus
Tracheal cuff
2 lobes in left lung
Tracheal cuff
DLT issues
Failed intubation
Incorrect tube position & inability to achieve adequate lung isolation
particularly in case of airway abnormalities
Traumatic injury to the airway during placement or removal
Sore throat
Ecchymosis of the mucous membranes
Vocal cord rupture or paralysis
Tracheal or bronchial laceration or rupture
Right bronchial cuff blocking right upper lobe bronchus can lead to
• failure of ventilation of the right upper lobe
• collapse of right upper lobe
Amputation of the hook from a Carlens & resulting airway foreign
DLT issues
• Inadvertent relocation of the double-lumen tube after insertion
• during patient positioning
• by surgical traction
• during lung volume reduction surgery
Malpositioned DLTs have been reported to be found at
bronchoscopy in 37-78 % of cases in which auscultatory
findings suggested correct placement.
«We suggest that fiberoptic bronchoscopy should be performed
through both the tracheal and bronchial lumen of a DLT to check the
position, and repeated after lateral positioning.»
Positioning the double-lumen endobronchial tube
Jae-Hyon Bahk, MD, Ho-Geol Ryu, MD and Byun-Moon Ham, MD
Placement of blockers and DLT’s
There is a wealth of scientific publications elaborating on the difficulties
in placement, the trauma caused by those devices, the dislocation of the
devices while moving the patient, the dislocation of the devices while
manipulating the lung, hereunder an example;
“With the increasing demand for one-lung ventilation in both thoracic
surgery and other procedures (e.g., spine surgery), identifying the most
effective device (double-lumen endotracheal tube or bronchial blocker) for
the anesthesiologist with limited experience in lung isolation techniques
would benefit our patients. However, we were unable to demonstrate any
advantage associated with the use of any of the three devices* tested. In
fact, we observed a high incidence of placement failure or device
malpositioning with all three techniques. Failure to properly place the three
devices was similar among faculty (39%) and senior residents (36%)
despite each participant having received a tutorial before each study.”
Devices for Lung Isolation Used by Anesthesiologists with Limited Thoracic Experience: Comparison of Double-lumen Endotracheal
Tube, Univent(R) Torque Control Blocker, and Arndt Wire-guided Endobronchial Blocker®Campos, Javier H. M.D.; Hallam, Ezra A.
B.A.; Van Natta, Timothy M.D.; Kernstine, KempH. M.D., Ph.D. Anasthesiology. February 2006 - Volume 104 - Issue 2 - pp 261-266
Insertion of a double lumen tube - video
DLT Insertion Video
Teleflex bronchial tubes
• Disposable and reusable
• BRONCHOSAFE single lumen
bronchial tubes
• Right and left sided
• BRONCHOPART double lumen
bronchial tubes
• Robertshaw
• Carlens
• White
• Tracheostomy
Single lumen tubes
• Optimally suited for post-operative
ventilation after pneumonectomy
Disposable PVC
• Left-side intubation 115900
• Right-side intubation 115901
• For emergency intubation
• Sizes 6.5 mm & 8 mm
• Colour-coded cuffs & pilot balloons
Double lumen tubes
(without hook)
Carlens / White
(with hook)
Carlens  Left
White  Right
Double lumen tubes
• Robertshaw type
• Disposable, made of PVC
• For left side intubation
• For right side intubation
• Set composed of
• Tube
• 2 suction catheters
• 2 angled connectors
• Y connector
Double lumen tubes
• Carlens = left with Carina Hook
• For left-side intubation
• Disposable PVC 116101
• Reusable Soft rubber
• White = right with Carina Hook
• For right-side intubation
• Disposable PVC 116201
• Reusable Soft rubber
Double lumen tubes
Double lumen tracheostomy tube
Disposable PVC
For left side intubation 116400
For right side intubation 116401
Set composed of
• Tube
• Neck band
• 2 suction catheters
• 2 angled connectors
• Y connector
SHERIDAN - Sher-i-Bronch
• No carina hook
• Right Bronch double-cuff
supposed to facilitate
positioning in right
mainstem bronchus
• No right-sided tube with hook
• Hook is rigid  increased risk
of breakage
• More traumatic for the vocal
cords & the carina
Bronchus Blockers
• Used in lieu of DLTs
• Advantages
• Less trauma
• Less stock –
• 1 size for all (adults)
• can be used right or left
• No hook needed
• Easily inserted in the working channel of the
• No need for DLT replacement if patient needs
• Guidelines: use of a fibroscope to confirm placement
Size comparison DLT’s vs ETT
Double lumen tubes are considered to be extremely large and
therefore uneasy to position and often traumatic.
Size 8.0 ETT seldom
used & largest size
for women
DLT 35 Fr seldom
used & smallest size
for women
EZ-Blocker® requires
a standard ETT from
size 7.0 onwards (7.5
is best)
Diameter of the
bronchus (usually
the left) to be found
chest X-ray. Once
this is known, the
correct size DLT
can be selected.
See table.
X-Ray size mm
Bronchus Blockers
Teleflex has 3 different p/n
• Inserted in the working channel
of the bronchoscope after biopsy
to stop bleeding
• Insert the bronchus blocker
• Inflate the cuff
• Opening end of the bronchus
blocker is used for instillation
• Possibility to remove the
bronchoscope without removing
the tube (long enough – need
only remove the connector)
• 330600 can be positionned at
any of those sites
Bronchus Blockers
• Inserted in a standard ETT to replace a single lumen tube or a
• Insert the ETT
• Pass the bronchus blocker inside
• Inflate the cuff to block the main bronchus
• Main advantage is cost
• Same as 330601 except
• Latex free cuff
• Curvature of the tip makes it easier to insert
Bronchus blockers
Coopdech Blocker
Univent &
Uniblocker (Fuij)
Cohen (Cook Medical)
Arndt blocker with
2 types of cuff
(Cook medical)
Product Training
Carol Seroussi
November 2009
Other Intubation Devices
• Guedel airways
• For quick and safe airway opening with or without intubation
• Dimensions according to ISO 5364
• Colour coded
• Various materials available :
• Disposable : PE 124900, PVC 124700
• Reusable : soft red rubber 124501, 124400 for FO intubation,
124500 soft black rubber
• Nasopharyngeal airways
• For quick and safe airway opening with or without intubation
• Mainly used in UK, Germany & USA
• Used in OR or post-op. in lieu of O2 canulas
• 185420, single use, Wirupren, with adjustable flange
• 125410, single use, soft transparent PVC
• 125200, reusable, soft rubber with adjustable flange
• 125600, reusable, soft rubber with adjustable flange & oxygen
Intubation Stylets
Universal Adapters
Pressure Gauge
Silicone Spray
Intubation Stylets – PVC, Red Rubber, Flexislip
Universal Adapters
Silicone spray
Accessories - Intubation Stylets
• EndoGuide T 503100 & 503110
• Device to be used as a tube exchanger for tracheal and
tracheotomy tubes & intubation aid in standard and difficult
• Stainless steel guide wire imbedded in the wall of the tube
allows pre-forming of the tube if necessary
• Large lumen allows oxygen supply or jet ventilation during the
whole procedure of intubation or tube exchange
• Oxygen supply: guide wire needs not be removed
• Connection system: safe and easy either 15 mm standard or
Luer Lock connector
For use with
503100 - 000025 EndoGuide T tracheal / tracheostomy tubes 3 - 6 mm ID
503100 - 000060 EndoGuide T tracheal tubes 6´.5 - 11 mm ID
tracheostomy tubes & intubation aid for
503110 - 000060 EndoGuide T tracheal tubes 6´.5 - 11 mm ID
ID (mm)
OD (mm) Length (mm)
Accessories - Intubation Stylets
• EndoGuide T 503100
• size 2.5 length 700 mm
• to use with tracheal tubes from 3 - 6 mm ID
• size 6.0 length 830 mm
• to use with tracheal tubes from 6.5 - 11 mm ID
• EndoGuide T 503110
• Size 6 length 525 mm
• to use with tracheal & tracheostomy tubes from
6.5 - 11 mm ID
Accessories - Intubation Stylets
Eschmann stylet (Portex) bent tip 60cm 17ch, nonhollow
Vygon stylet – same as Eschman – hollow single use
Accessories - Intubation Stylets
• Cook
Accessories – Universal Adapters
• Universal Mainz adapter 514800 / 514805
• For fiberoptic intubation during ventilation
• Connector for fibroscopy on face masks, tracheal
tubes and laryngeal masks
• Feeding tube insertion
• Lateral connector for anaesthetic circuit
• Double sealing cap made of silicone
• Angled connector 514900
• Plastic angled connector
• Double sealing cap made of silicone
• Rotating connectors
Accessories - Others
Hand pressure gauge 112700
To inflate the cuff and measure
the cuff pressure
Silicone spray 556000
• To prevent incrustations on rubber,
latex & PVC devices
• To prevent devices to stick to the
Thank you for your attention