Standard tube versus Taperguard Jan P Mulier MD PhD Filip Van den Brande MD

1. 1150 1850 1947 1977 2010 Standard tube versus Taperguard Jan P Mulier MD PhDFilip Van den Brande MD Sint Jan Brugge-Oostende www.publicationslist.org/jan.mulier Study on methylene blue cuff leak in morbid obese patients

2. Is silent aspiration possible? • Fluid in oral cavity can leak along tracheal cuff. • Gastric content • Blood • Leak test • In vitro and in vivo test with methylene blue have frequently been positive: leak through the cuff plica J P Mulier 12 10 2009 ESICM

3. Silent aspiration due to leaks around cuffs of endotracheal tubes • Petring OUAnesth Analg. 1986 Jul;65(7):777 • Methylene blue bronchoscopic test in patients: Rüsch tube vs Mallinckrodt tube • Aspiration more frequent with the Mallinckrodt tube than the Rüsch tube J P Mulier 12 10 2009 ESICM

4. Leakage of fluid around high-volume, low-pressure cuffs • Asai T, Anaesthesia. 2001 Jan;56(1):38-42 • A comparison of four (high-volume, low-pressure cuffs) tracheal tubes in a model trachea and lung. • Large leak: • Portex Profile, Mallinckrodt Lo-Contour • Smaller leak: • Portex Soft Seal, and Mallinckrodt Hi-Lo tubes J P Mulier 12 10 2009 ESICM

5. Fluid leakage past 4 pediatric tube cuffs: in vitro evaluation of the new Microcuff tube • Dullenkopf 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, C did leak fluid at pressures above 10 • D:ultra-thin polyurethane membrane markedly improved tracheal sealing J P Mulier 12 10 2009 ESICM

6. Effect of positive expiratory pressure and type of tracheal cuff on the incidence of aspiration in mechanically ventilated patients in an intensive care unit. • Lucangelo UCrit Care Med. 2008 Feb;36(2):409 • Hi-Lo (20 pt), vs SealGuard (20 pt) • One hour after peep stop: • Hi-Lo 100% leak • SG 70% leak J P Mulier 12 10 2009 ESICM • At the fifth hour, two patients of the HL group failed the test. One hour after positive expiratory pressure removal, all subjects in group HL exhibited a dyed lower trachea. On the other hand, one patient in group SG presented a leak at the eighth hour, and at the 12th hour three of them were still sealed

7. This study compares cuff leak Taperguard versus PolyVinylChloride: • Laparoscopic gastric bypass operations • Orotracheal tube needed • Methylene blue 300 ml in gastric pouch with overflow in mouth at moment of leak test • Cuff leak tested with 10 ml methylene blue • Ventilation VCV with 5 cm peep • Man 8,0 OTT Woman 7,0 OTT • Group A: Hi contour Mallinckrodt • Group B: TaperGuard Mallinckrodt J P Mulier 12 10 2009 ESICM

8. Oro-tracheal tubes compared Group A: Group B: Hi contour Mallinckrodt TaperGuard Mallinckrodt J P Mulier 12 10 2009 ESICM

9. In vitro Methylene blue test Group A: Group B: Hi contour MallinckrodtTaperGuard Mallinckrodt J P Mulier 12 10 2009 ESICM

10. Methods in vivo test • Automatic cuff pressure control. • Set at 25 cmH20 • 2 ml methylene blue + 8 ml H20 injected above cuff. • Blue fluid must be bronchoscopic visible above cuff. • Bronchsocopic control after 5 and 15 minutes. • Is blue fluid visible below cuff, between trachea and tube? J P Mulier 12 10 2009 ESICM

11. J P Mulier 12 10 2009 ESICM

12. In vivo Methylene blue test Group A: Group B: Hi contour MallinckrodtTaperGuard Mallinckrodt Under up view Bronchoscopic view vitro J P Mulier 12 10 2009 ESICM

13. Human Methylene blue leak test 29 Obese patients, CMV, 5 peep: bronchoscopic view after 5 minutes when blue is visible above cuff(9 patients excluded as no blue above cuff) 9 pts 11 pts

14. Impact of tracheal tube size • Larger tube more plica, deeper run in taperguard 7,0 taperguard 8,0 J P Mulier 12 10 2009 ESICM

15. More Questions • Is cuff leak for fluids dangerous? • Is post operative pneumonia caused by silent leakage? • Impact of peep? • Lower incidence but still existing • Impact of cuff pressure? • Higher cuff pressure does not improve protection? • Impact of tube movement? • Impact of pharyngeal packing? • Amount of fluid leak? • Impact of fluid type? • Gel is not protecting 100% J P Mulier 12 10 2009 ESICM

16. Conclusion • Taperguard prevents 100% silent cuff leak • Patients at risk • Long intubated patients at ICU • Full stomach • Oro-nasal interventions, nasal bleeding: oral blood • Gastric bypass operations, gastric regurgitation • Jan.mulier@azbrugge.be • www.publicationslist.org/jan.mulier J P Mulier 12 10 2009 ESICM

17. J P Mulier 12 10 2009 ESICM

18. ESPCOP founded feb 2009 President Jan P Mulier Secretary Luc De baerdemaeker Treasurer Nick Kennedy Vice-President Yigal Leykin www.publicationslsit.org/ESPCOP www.espcop.org J P Mulier 12 10 2009 ESICM

19. Attend first ESPCOP meeting14 nov 2009 Ostend Belgium • “The sea” from Georges Grard • Better known as “fat Mathilde of Ostend” J P Mulier 12 10 2009 ESICM

20. Our Results in lap RNY gastric bypass J P Mulier 12 10 2009 ESICM