Intubation über den Tubuswechsler an einem Intubationstrainer

Zusammenfassung

Hintergrund

Die Atemwegssicherung über einen Tubuswechsler ist eine wichtige Technik in der Anästhesie, deren Erfolg durch ein Einhängen der Tubusspitze v. a. an den rechtsseitigen Kehlkopfstrukturen gefährdet ist. Die Autoren haben positive, klinische Erfahrungen bei der Intubation über einen Tubuswechsler/eine Fiberoptik mit einer 90°-Drehung des Tubus gegen den Uhrzeigersinn gemacht.

Ziel der Arbeit

Der Einfluss der Tubusspitzenposition bei der Intubation über einen Tubuswechsler sollte an einem Intubationstrainer geprüft werden.

Material und Methode

Freiwillige Anästhesisten mit unterschiedlicher Berufserfahrung wurden gebeten, einen Intubationstrainer über einen Tubuswechsler orotracheal zu intubieren. Zwei verschiedene Endotrachealtuben wurden randomisiert, jeweils mit der Tubusspitze ventral, links, dorsal und rechts liegend, verwendet. Bewertet wurde der Erfolg, den Tubus ohne Widerstand in die Trachea vorzuschieben.

Ergebnisse

Zwanzig Anästhesisten mit im Median 9,5-jähriger Berufserfahrung (Range 3 bis 37 Jahre) führten 160 Intubationsversuche durch; davon waren 38 (23,8 %) erfolgreich. Das Vorschieben des Tubus mit ventral liegender Tubusspitze war in 60 % der Fälle erfolgreich, gefolgt von der Intubation mit links, rechts und hinten liegender Tubusspitze und 27,5-, 7,5- resp. 0 %iger Erfolgsrate. Intubationen mit ventral liegender Tubusspitze waren erfolgreicher mit dem Rüsch- als mit dem Covidien-Tubus [16 (80 %) vs. 8 (40 %); p = 0,011]. Es gab keinen Zusammenhang zwischen Berufserfahrung und Intubationserfolg (p = 0,362).

Schlussfolgerung

Der Intubationserfolg über einen Tubuswechsler an einem Intubationstrainer wird maßgeblich von der Position der Tubusspitze beeinflusst. Die 90°-Drehung des Tubus gegen den Uhrzeigersinn, mit ventral liegender Tubusspitze, erhöht den Intubationserfolg.

Abstract

Background

Securing the airway using a tube exchanger catheter is an important and useful technique in anesthesia. Its success is mainly hampered by tube tip impingement of laryngeal structures. Advancing the tracheal tube along its normal curvature via a tube exchanger catheter has a high risk of tube tip impingement mainly of right laryngeal structures. The authors achieved successful clinical experience by rotating the tracheal tube 90° anticlockwise (ventral tube tip position) before railroading the tube via a tube exchanger catheter or a fiber optic bronchoscope through the larynx.

Aim

The aim of the study was to investigate the influence of the tracheal tube tip position while intubating an airway trainer over a tube exchange catheter.

Material and methods

Volunteer anesthetists with varying years of professional experience were asked to intubate an intubation mannequin (Laerdal Airway Management Trainer) using the orotracheal route with an established tube exchange catheter (Cook Airway Exchange Catheter, 11F). Two different brands of tracheal tubes (Rüsch and Covidien, ID 7.0 mm) were used in a randomized order, each with the tracheal tube tip at first positioned right (90°), then ventrally (0°), left (270°) and finally dorsally (180°), resulting in eight intubation attempts for each participant. To ensure the correct tube tip position the tube was withdrawn before every intubation attempt until the tube tip position was visualized. The oropharnyx, larynx, trachea and tube were sufficiently lubricated with silicon spray (Rüsch Silikospray). The tube and airway exchange catheter size selection were made according to the clinical trial of Loudermilk et al. Successful endotracheal intubation without resistance was recorded for each tube tip position and tracheal tube brand.

Results

In total 20 anesthetists (13 consultants and 7 residents) with a median of 9.5 years (range 3–37 years) of professional experience participated in the study. Overall 160 intubation attempts were performed, 2 participants showed no successful intubation attempts at all and 38 out of 160 intubation attempts (23.8 %) were successful. Intubation success with the tracheal tube tip placed ventrally (0°) was 60 % followed by the left (270°) and right (90°) tracheal tube tip positions with 27.5 % and 7.5 % intubation success, respectively. With the tube tip placed dorsally (180°) none of the 40 intubation attempts were successful. Intubation attempts with the Rüsch tube were more successful (28.8 %) than those with the Covidien tube (18.8 %). Placing the tracheal tube tip ventrally, the Rüsch tube was twice as successful as the Covidien tube with 16 (80 %) versus 8 attempts (40 %, p = 0.011). There was no correlation between professional experience and intubation success (p = 0.362).

Conclusion

Tube insertion via an airway exchange catheter or a fiberoptic bronchoscope is a basic technique in anesthesia. Knowledge about the difficulties and their prevention are essential for every anesthetist. The gap between the airway exchange catheter, the fiber bronchoscope and the tube diameters is one of the major reasons for tube tip impingement. This investigation showed that intubation success via a tube exchange catheter, as investigated in an intubation mannequin, is considerably influenced by the tracheal tube tip position. A 90° anticlockwise rotation, placing the tracheal tube tip ventrally, considerably increased intubation success. This is of particular importance if an anesthesia department has no appropriately sized tube exchange catheters or fiber bronchoscope for every age group of patients.