J P Mulier MD PhD Silent aspiration prevention in bariatric surgery J P Mulier MD PhD Sint Jan...

Silent aspiration prevention in bariatric surgery

J P Mulier MD PhDJ P Mulier MD PhD

Sint Jan Brugge-OostendeSint Jan Brugge-Oostende

www.publicationslist.org/jan.mulierwww.publicationslist.org/jan.mulier

1150 1850 1947 1977 2010

Sint Jan Brugge-OostendeSint Jan Brugge-Oostende

www.publicationslist.org/jan.mulierwww.publicationslist.org/jan.mulier

1150 1850 1947 1977 2010

The Negative Impact ofPost-Intubation Pulmonary

ComplicationsJ P Mulier MD PhDJ P Mulier MD PhD

JPMulier New York 13 dec 2009 3

The Negative Impact ofPost-Intubation Pulmonary

ComplicationsDoes it begin in the Operating Room?Does it begin in the Operating Room?

Silent aspiration prevention in bariatric surgery:A pilot study of new endotracheal tube technology

Jan-Paul Mulier, MD, PhD, Anesthesiologist, Critical Care Physician Chairman Anesthesiology, Sint Jan Brugge-Oostende President, European Society for Periopertive Care of the Obese

Patient Affiliated Researcher, Katholieke Universiteit Leuven

This program is not associated with or part of the 63rd PostGraduate Assembly in Anesthesiology.

Jan P Mulier received support from Covidien for giving this lecture.


What are the What are the complications?complications?

Intubation trauma during insertionIntubation trauma during insertion Laryngeal trauma by tube or cuff Laryngeal trauma by tube or cuff Ventilation trauma by the ventilatorVentilation trauma by the ventilator

VILI: Ventilation induced lung injuryVILI: Ventilation induced lung injury BarotraumaBarotrauma VolutraumaVolutrauma

Ventilation induced lung diseaseVentilation induced lung disease VAP: Ventilation associated pneumoniaVAP: Ventilation associated pneumonia Long term changes in post op lung functionLong term changes in post op lung function

Surgery induced lung injurySurgery induced lung injury Anesthesia induced lung injuryAnesthesia induced lung injury Fluid therapy induced lung oedemaFluid therapy induced lung oedema


> 60 years of intubation > 60 years of intubation expertiseexpertise

Improvements in intubation Improvements in intubation technology brought each time new technology brought each time new complications.complications. Use of an endotracheal tubeUse of an endotracheal tube Use of anesthesia and muscle relaxants Use of anesthesia and muscle relaxants

to intubateto intubate Use of an inflatable cuffUse of an inflatable cuff Use of a low pressure high volume cuffUse of a low pressure high volume cuff

New safety alerts, vigilance training, New safety alerts, vigilance training, but also inventions were needed but also inventions were needed each time.each time.


Use of endotracheal Use of endotracheal tubestubes

What size?What size?

•Who to intubate?Who to intubate?


Use of anesthesia and Use of anesthesia and muscle relaxantsmuscle relaxants

Non traumatic intubation Non traumatic intubation possiblepossiblebutbut

Aspiration risk at inductionAspiration risk at induction Hemodynamic collapsHemodynamic collaps

•Sellick maneuvre ?Sellick maneuvre ?•No food no liquid 24 hNo food no liquid 24 h•Gastric phGastric ph•Fluid therapyFluid therapy•Safer anestheticsSafer anesthetics•……


Invention of a cuffInvention of a cuff

No leak of air with positive pressure No leak of air with positive pressure ventilationventilation

Size of tube might be smaller and is Size of tube might be smaller and is less criticalless critical


But post intubation But post intubation stenosis…stenosis…

Question of Question of What tube size?What tube size?

became became What cuff pressure?What cuff pressure?


Use of a high volume low Use of a high volume low pressure cuffpressure cuff

Low pressure possibleLow pressure possible No N20 or Pressure controlNo N20 or Pressure control Ischemia risk solved, butIschemia risk solved, but

New threatNew threat Silent aspirationSilent aspiration


Silent aspiration due to leaks Silent aspiration due to leaks around cuffs of endotracheal tubes around cuffs of endotracheal tubes

Petring OUPetring OU Anesth Analg. Anesth Analg. 19861986 Jul;65(7):777 Jul;65(7):777 Methylene blue bronchoscopic test in Methylene blue bronchoscopic test in

patientspatients: Rüsch tube vs Mallinckrodt tube : Rüsch tube vs Mallinckrodt tube AspirationAspiration more frequent with the more frequent with the

Mallinckrodt tube than the Rüsch tubeMallinckrodt tube than the Rüsch tube

0

5

10

15

20

25

30

35

Leak percentage

RushMallinckrodt

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Petring%20OU%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus


Leakage of fluid around high-Leakage of fluid around high-volume, low-pressure cuffsvolume, low-pressure cuffs

Asai TAsai T, Anaesthesia. , Anaesthesia. 20012001 Jan;56(1):38-42 Jan;56(1):38-42

A comparison of four A comparison of four (high-volume, (high-volume, low-pressure cuffs)low-pressure cuffs) tracheal tubes tracheal tubes in a in a modelmodel trachea and lung. trachea and lung. Large leakLarge leak::

Portex Profile, Mallinckrodt Lo-Contour Portex Profile, Mallinckrodt Lo-Contour Smaller leakSmaller leak::

Portex Soft Seal, and Mallinckrodt Hi-Lo Portex Soft Seal, and Mallinckrodt Hi-Lo tubes tubes

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Asai%20T%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus


Fluid leakage past 4 pediatric tube Fluid leakage past 4 pediatric tube cuffs: cuffs:

in in vitrovitro evaluation of the new Microcuff tube evaluation of the new Microcuff tube

Dullenkopf ADullenkopf A, , Intensive Care Med (2003) 29:1849 A: Mallinckrodt B: ICU, Portex Profile Soft Seal, Rusch C: Super Safety Clear, and Sheridan CF. D: HiLo, Microcuff HVLP

A, B, CA, B, C did did leakleak fluid at pressures above fluid at pressures above 1010

D:D: ultra-thin polyurethaneultra-thin polyurethane membrane membrane markedly improved tracheal sealingmarkedly improved tracheal sealing


Effect of positive expiratory Effect of positive expiratory pressure and type of tracheal pressure and type of tracheal

cuff cuff on the incidence of aspiration in on the incidence of aspiration in

mechanically ventilated patients in mechanically ventilated patients in an intensive care unit. an intensive care unit.

Lucangelo ULucangelo U Crit Care Med. Crit Care Med. 20082008 Feb;36(2):409Feb;36(2):409

Hi-Lo (20 pt), vs SealGuard (20 pt) Hi-Lo (20 pt), vs SealGuard (20 pt) One hour after peep stop: One hour after peep stop:

Hi-Lo 100% leakHi-Lo 100% leak SG 70% leakSG 70% leak

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Lucangelo%20U%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus


Silent aspiration Silent aspiration

Fluid in oral cavity can leak along Fluid in oral cavity can leak along tracheal cuff.tracheal cuff. Gastric contentGastric content BloodBlood Leak testLeak test

In vitro and in vivo test with In vitro and in vivo test with methylene blue have frequently methylene blue have frequently been positive: been positive: leakleak through the through the cuff plicacuff plica


Does it all begin in the OR? Does it all begin in the OR?

InductionInduction Full stomach / gastric fluid pHFull stomach / gastric fluid pH Mask ventilation air in stomachMask ventilation air in stomach Difficult ventilation/intubation/nasal Difficult ventilation/intubation/nasal

intubationintubation Per operativePer operative

Oral blood from operation, nasal bleeding, Oral blood from operation, nasal bleeding, Leak test in RNYLeak test in RNY

Post operativePost operative Residual relaxation, post op sedation, not Residual relaxation, post op sedation, not

coughingcoughing Abdominal surgery risk groupAbdominal surgery risk group


TaperguardTaperguard

A conical cuff with a large A conical cuff with a large diameter proximal and a small diameter proximal and a small diameter distaldiameter distal


The obese patient is a challenge The obese patient is a challenge for anaesthesia for anaesthesia

if android shape with intra visceral if android shape with intra visceral fat.fat.


Android versus Gynoid fat Android versus Gynoid fat distribution has a different distribution has a different

ElastanceElastance

Abdominal pressure volume relation: Android vs Gynoid

0

5

10

15

20

25

0 1 2 3 4

IAV Liter

IAP

mm

Hg

android

gynoid


Two types of android Two types of android obesityobesity

Intra visceral adiposity Intra visceral adiposity Extra visceral adiposity Extra visceral adiposity Subcutaneus fat is scant and Subcutaneus fat is thick and Subcutaneus fat is scant and Subcutaneus fat is thick and

intra abdominal fat is thick and intra abdominal fat is scant.intra abdominal fat is thick and intra abdominal fat is scant.

Subcutaneus FatSubcutaneus Fat Visceral fatVisceral fat


Pulmonary complications 4x Pulmonary complications 4x higher in morbid obese patientshigher in morbid obese patients


Clinical study compares cuff Clinical study compares cuff leak leak

Taperguard versus Taperguard versus PolyVinylChloridePolyVinylChloride::

Laparoscopic gastric bypass operationsLaparoscopic gastric bypass operations Orotracheal tube neededOrotracheal tube needed Methylene blue 300 ml in gastric pouch Methylene blue 300 ml in gastric pouch

with overflow in mouth at moment of leak with overflow in mouth at moment of leak testtest

Cuff leak tested with 10 ml methylene blueCuff leak tested with 10 ml methylene blue Ventilation VCV with 5 cm peepVentilation VCV with 5 cm peep

Man 8,0 OTT Woman 7,0 OTTMan 8,0 OTT Woman 7,0 OTT Group A: Hi contour MallinckrodtGroup A: Hi contour Mallinckrodt Group B: TaperGuard MallinckrodtGroup B: TaperGuard Mallinckrodt


Study on per op preventionStudy on per op preventiontaperguard vs PVC OTT:taperguard vs PVC OTT:

Laparoscopic gastric bypass operationsLaparoscopic gastric bypass operations OTT neededOTT needed Methylene blue 300 ml in gastric pouch with Methylene blue 300 ml in gastric pouch with

overflow in mouth at moment of leak testoverflow in mouth at moment of leak test Risk for silent aspiration pneumonia?Risk for silent aspiration pneumonia? Ventilation VCV with 5 peepVentilation VCV with 5 peep

Man 8,0 OTT Woman 7,0 OTTMan 8,0 OTT Woman 7,0 OTT Group A: Hi contour Mallinckrodt dryGroup A: Hi contour Mallinckrodt dry Group B: Hi contour Mallinckrodt with gelGroup B: Hi contour Mallinckrodt with gel Group C: TaperGuard Mallinckrodt dryGroup C: TaperGuard Mallinckrodt dry

Black line above and below cuffBlack line above and below cuff


Group A B CGroup A B C

A B CA B C


Methods Methods

Automatic cuff pressure control.Automatic cuff pressure control. Set at 25 cmH20Set at 25 cmH20

2 ml methylene blue + 8 ml H20 2 ml methylene blue + 8 ml H20 injected above cuff.injected above cuff.

Bronchsocopic control after 5 Bronchsocopic control after 5 minutes.minutes. Blue fluid must be visible above cuff.Blue fluid must be visible above cuff. Blue visible below cuff, between Blue visible below cuff, between

trachea and tube?trachea and tube?


In vitro testsIn vitro tests

A A B CB C

Runs throughRuns through stop on top stop on top runs & runs & stopstop


Methylene blue testMethylene blue test

PVC 7,0 vs taperguard 7,0 at PVC 7,0 vs taperguard 7,0 at lower end cuff. Look upsidelower end cuff. Look upside

PVCPVCTaperguardTaperguard


Impact of OTT size Impact of OTT size

Larger OTT more plica, deeper Larger OTT more plica, deeper run in run in

taperguard 7,0taperguard 7,0 taperguar 8,0taperguar 8,0


PGA PGA posterposter

Total Number Total Number of patients: of patients: 4040

Human Methylene blue leakHuman Methylene blue leakObese patients, CMV 5 peep after 5 minutes when blue is Obese patients, CMV 5 peep after 5 minutes when blue is

visible above cuff 81 patientsvisible above cuff 81 patients

Bronchoscopic visualized methylene blue leak

0

5

10

15

20

25

30

35

Hi contour Mallinckrodt Hi contour Mallinckrodtwith KY gel

TaperGuard Mallinckrodt

nu

mb

er

of

pa

tie

nts

leakno leak


Still a lot of QuestionsStill a lot of Questions

Is post operative pneumonia caused by Is post operative pneumonia caused by silent leakage?silent leakage?

Is fluid leakage dangerous?Is fluid leakage dangerous? Amount of fluid leak over what time?Amount of fluid leak over what time? Fluid type impact?Fluid type impact?

Gastric contentGastric content Oral bloodOral blood Leak test fluidsLeak test fluids

How long is gel protecting? Not possible How long is gel protecting? Not possible with NTT?with NTT? Impact of peep not sufficient?Impact of peep not sufficient?

Impact of tube movement?Impact of tube movement?


Where can we reduce Where can we reduce silent aspiration?silent aspiration?

Oral bloodOral blood Oral pharyngeal surgery ( maxillo facial)Oral pharyngeal surgery ( maxillo facial) Nasal surgery ( septum surgery)Nasal surgery ( septum surgery) Naso gastric tube, oro trcheal tube, naso Naso gastric tube, oro trcheal tube, naso

tracheal tube inserted with bleedingtracheal tube inserted with bleeding Patient under heparines ( cardiac, vascular)Patient under heparines ( cardiac, vascular)

Gastric fluid in oral cavityGastric fluid in oral cavity Post induction regurgitation (urgent, obstruction)Post induction regurgitation (urgent, obstruction) Bad gastric drainage, gastroscopy, laparoscopy, Bad gastric drainage, gastroscopy, laparoscopy,

trendelenburgtrendelenburg Water/air injection for leakage testWater/air injection for leakage test

Esophagus, stomach, ( gastric bypass)Esophagus, stomach, ( gastric bypass)


Attractiveness in WHR from 4000 BC until 2000 Attractiveness in WHR from 4000 BC until 2000 ACAC

1,5 1,1 1,5 0,5 0,7 1,5 1,1 1,5 0,5 0,7





Intubation trauma during Intubation trauma during insertioninsertion

Teeth damage is one of the most freq Teeth damage is one of the most freq complications for anesthesiacomplications for anesthesia Broken teeth due to gaatjesBroken teeth due to gaatjes Loose teeth due to peridontitisLoose teeth due to peridontitis Glazuur damage of the front teethGlazuur damage of the front teeth

Teeth protection takes placeTeeth protection takes place Improving patient positioningImproving patient positioning bronchoscopic intubationbronchoscopic intubation

Nasal bleedingNasal bleeding Dyslocation of arytenoidsDyslocation of arytenoids Lip, tongue, eye contusion, cornea Lip, tongue, eye contusion, cornea

abrasionabrasion


Foto of teeth in lungsFoto of teeth in lungs


Laryngeal trauma by cuffLaryngeal trauma by cuff


Laryngeal trauma by cuffLaryngeal trauma by cuff


Ventilation trauma by the Ventilation trauma by the ventilatorventilator

Large tidal volume Large tidal volume overstretching of the lungsoverstretching of the lungs

Foto of rats lung traumaFoto of rats lung trauma


Ventilation induced lung Ventilation induced lung diseasedisease

VAP: Ventilation associated VAP: Ventilation associated pneumoniapneumonia


Long term changes in post Long term changes in post op lung functionop lung function

Decreased lung capacity and Decreased lung capacity and ESW after CABG has been provenESW after CABG has been proven


Surgery induced lung Surgery induced lung injuryinjury

Stress reactionStress reaction


Anesthesia induced lung Anesthesia induced lung injuryinjury

Fluid therapy induced lung Fluid therapy induced lung edemaedema


What preventive What preventive measures?measures?

Correct tube, size and cuff designCorrect tube, size and cuff design Cuff pressure monitorCuff pressure monitor Video assisted laryngoscopyVideo assisted laryngoscopy Protective lung ventilationProtective lung ventilation Anti volutrauma valveAnti volutrauma valve Anti barotrauma O2 therapyAnti barotrauma O2 therapy Prevent silent aspiration pre per Prevent silent aspiration pre per

postpost Correct extubation technique and Correct extubation technique and

momentmoment


Why do we not apply this Why do we not apply this knowledge every time?knowledge every time?

Do we think this does not happen Do we think this does not happen with my patient?with my patient?

This is too expensive to be worth?This is too expensive to be worth?

Other problems are still bigger?Other problems are still bigger?

Not evidence based?Not evidence based?

Always studies that tell opposite?Always studies that tell opposite?


Does it begin in the OR?Does it begin in the OR?

YES becauseYES because you choose the product, you choose the product,

techniquetechnique Yes even Yes even if damage comes laterif damage comes later We do not notice it becauseWe do not notice it because different physician at the ICU, different physician at the ICU,

ward, is part of surgery, is normal…ward, is part of surgery, is normal… listen to them with an open mindlisten to them with an open mind


President President

Jan P MulierJan P Mulier

Vice-President Vice-President

Yigal LeykinYigal Leykin

Secretary Secretary

Luc De baerdemaekerLuc De baerdemaekerTreasurer Treasurer

Nick KennedyNick Kennedy

www.publicationslsit.org/www.publicationslsit.org/ESPCOPESPCOP

www.espcop.org

ESPCOP ESPCOP founded feb founded feb

2009 2009

http://www.espcop.org/


Attend first ESPCOP meetingAttend first ESPCOP meeting14 nov 2009 Ostend Belgium14 nov 2009 Ostend Belgium

““The sea” from Georges GrardThe sea” from Georges Grard

Better known as Better known as

““fat Mathilde of Ostend”fat Mathilde of Ostend”

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