Dysfunctional ETT with pt in prone position

[YounghPAStudent]

What do you do if the pt is the prone position during a sterile procedure and the ett dysfunctions?... is there anyway to fix the airway without moving the pt to the supine position and breaking the sterile field?

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[UTSouthwestern]

Look through the tube with a fiberoptic scope to see if it has changed positions. Most likely it has migrated deeper, especially if you are on a face pillow on an OSI bed or Jackson frame. If you are on a horseshoe or in Mayfield pins, you should be able to get under the table and trouble shoot. In that scenario, usually the weight of the circuit is pulling the tube out so always secure it to the frame in some way.

If it hasn't, you have to look at the possibility that it isn't the tube. Always make sure that your patient has some sort of bite block before turning prone so that positioning, repositioning, edema, etc. do not cause the tube to kink.

 

[2ndyear]

I really like the nasal route for prone Mayfield pin cases. Ain't goin' nowhere. For prone pillow cases use whatever elbows, straight, curved gooseneck connectors you can so as not to kink the tube.

 

[YounghPAStudent]

The reason I asked was because someone once told me that they used the grease hopper air system from ophthamology in a case once, when I believe the cuff on the ett broke in this very situation... Has anybody ever heard of this technique? I think the reasoning is that the air system provides continuous positive pressure so maybe the cuff remains open and secures the airway during the remaining of the surgery----- Does that sound reasonable?

 

[toughlife]

What do you do if the pt is the prone position during a sterile procedure and the ett dysfunctions?... is there anyway to fix the airway without moving the pt to the supine position and breaking the sterile field?

call your attending.

 

[VentdependenT]

The reason I asked was because someone once told me that they used the grease hopper air system from ophthamology in a case once, when I believe the cuff on the ett broke in this very situation... Has anybody ever heard of this technique? I think the reasoning is that the air system provides continuous positive pressure so maybe the cuff remains open and secures the airway during the remaining of the surgery----- Does that sound reasonable?

If you cuff blows, and you are still getting ETCO2:

you can call for help (extra hands are useful) ,crank up your o2 flow rates to overcome the massive leak, get a fiberoptic to confirm that your now "cuffless" tube is in the trachea/r/o accidental extubation, then slap a bougie/tube exchanger down there, then..well...exchange the tube.

 

[Intubate]

What do you do if the pt is the prone position during a sterile procedure and the ett dysfunctions?... is there anyway to fix the airway without moving the pt to the supine position and breaking the sterile field?

LMA.

 

[CerebralEdema]

I just read this thread...

Tube kinked or endobronchial then I agree, look with a FOB...

BUT if tube is OUT, then time is of the essence so don't #$%& around with tube changers or FOBs or anything. Tell the surgeon to pack the field, place a sealed sterile dressing like an IOBand, and then get the patient turned supine or lateral so that you can reintubate ASAP before your patient is dead... or worse, with a hypoxic brain injury.

If you are really slick, maybe an LMA will save you, but I bet only 1 out of 10 people are experienced enough to place an LMA in the prone position.
Just my 2 cents.

 

[Idiopathic]

yeah everybody says LMA in this case, but I think so much of that placement would be luck that it isnt even worth the time it takes to attempt it.

 

[loveumms]

Actually, LMA could be a life saver. It would be easier to place an LMA in the prone position then supine because you have gravity working for you ... tongue/mandible is already hanging which will allow you to just slip the LMA into the post oropharynx. Then you have bought yourself some time to figure out what the next step is (whether you can finish the case with the LMA or if you have to get the surgeon to stop and flip the pt).

Perosnally I would probably try an intubating LMA before I flipped the pt. Might be a little more difficult but, if it works you have saved yourself (and the pt) the risk of flipping.

 

[Idiopathic]

Actually, LMA could be a life saver. It would be easier to place an LMA in the prone position then supine because you have gravity working for you ... tongue/mandible is already hanging which will allow you to just slip the LMA into the post oropharynx. Then you have bought yourself some time to figure out what the next step is (whether you can finish the case with the LMA or if you have to get the surgeon to stop and flip the pt).

Perosnally I would probably try an intubating LMA before I flipped the pt. Might be a little more difficult but, if it works you have saved yourself (and the pt) the risk of flipping.

yeah...i guess in pins, but with most of our big prone cases (i.e. spines) there are face pillows that pretty much make prone LMA impossible.

you also have to sacrifice your ETT which is hard to do, especially when you arent sure if that is the problem. pulling out the ETT in that situation must be pretty hard

 

[dfk]

in the prone position, anatomy falls in your favor.
ETT really isn't that hard.
actually easier than supine...
just be flexible and you're golden

 

[KungPOWChicken]

We had a patient extubated prone at institution midcase . LMA was placed and the patient was ventilated through the remainder of the case with the LMA. No complications.