Sint Jan Brugge-OostendeSint Jan Brugge-Oostende

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

Study on methylene blue Study on methylene blue cuff leak in morbid obese cuff leak in morbid obese patientspatients

1150 1850 1947 1977 2010

Standard tube versus Taperguard Standard tube versus Taperguard

Jan P Mulier MD PhDJan P Mulier MD PhDFilip Van den Brande MDFilip Van den Brande MD

J P Mulier 12 10 2009 ESICM 2

Is silent aspiration Is silent aspiration possible?possible?

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

J P Mulier 12 10 2009 ESICM 3

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

J P Mulier 12 10 2009 ESICM 4

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

J P Mulier 12 10 2009 ESICM 5

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

J P Mulier 12 10 2009 ESICM 6

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

J P Mulier 12 10 2009 ESICM 7

This study compares cuff leak This study compares cuff 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

J P Mulier 12 10 2009 ESICM 8

Oro-tracheal tubes Oro-tracheal tubes comparedcompared

Group A: Group A: Group B: Group B: Hi contour Mallinckrodt Hi contour Mallinckrodt TaperGuard TaperGuard

MallinckrodtMallinckrodt

J P Mulier 12 10 2009 ESICM 9

In vitro In vitro Methylene blue Methylene blue testtest

Group A: Group A: Group B: Group B: Hi contour MallinckrodtHi contour Mallinckrodt TaperGuard TaperGuard

MallinckrodtMallinckrodt

J P Mulier 12 10 2009 ESICM 10

Methods in vivo test Methods in vivo test

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. Blue fluid must be bronchoscopic Blue fluid must be bronchoscopic

visible above cuff.visible above cuff. Bronchsocopic control after 5 and Bronchsocopic control after 5 and

15 minutes.15 minutes. Is blue fluid visible below cuff, Is blue fluid visible below cuff,

between trachea and tube?between trachea and tube?

J P Mulier 12 10 2009 ESICM 11

J P Mulier 12 10 2009 ESICM 12

In vivo Methylene blue In vivo Methylene blue testtest

Group A: Group A: Group B: Group B: Hi contour MallinckrodtHi contour Mallinckrodt TaperGuard TaperGuard

MallinckrodtMallinckrodt

vitrovitro

Under up viewUnder up view

Bronchoscopic viewBronchoscopic view

Human Methylene blue leak test Human Methylene blue leak test 29 29 Obese patients, CMV, 5 peep: bronchoscopic view after Obese patients, CMV, 5 peep: bronchoscopic view after

5 minutes when blue is visible above cuff5 minutes when blue is visible above cuff(9 patients excluded as no blue above cuff)(9 patients excluded as no blue above cuff)

methylene blue leak

0%

20%

40%

60%

80%

100%

Hi contour Mallinckrodt TaperGuard Mallinckrodt

Lea

k p

erce

nta

ge

leak

no leak9 pts 11 pts9 pts 11 pts

J P Mulier 12 10 2009 ESICM 14

Impact of tracheal tube Impact of tracheal tube size size

Larger tube more plica, deeper Larger tube more plica, deeper run in run in

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

J P Mulier 12 10 2009 ESICM 15

More QuestionsMore Questions

Is cuff leak for fluids dangerous?Is cuff leak for fluids dangerous? Is post operative pneumonia caused by Is post operative pneumonia caused by

silent leakage?silent leakage? Impact of peep?Impact of peep?

Lower incidence but still existingLower incidence but still existing Impact of cuff pressure?Impact of cuff pressure?

Higher cuff pressure does not improve Higher cuff pressure does not improve protection?protection?

Impact of tube movement?Impact of tube movement? Impact of pharyngeal packing?Impact of pharyngeal packing? Amount of fluid leak?Amount of fluid leak? Impact of fluid type?Impact of fluid type?

Gel is not protecting 100%Gel is not protecting 100%

J P Mulier 12 10 2009 ESICM 16

ConclusionConclusion

Taperguard prevents 100% silent cuff leak Taperguard prevents 100% silent cuff leak Patients at riskPatients at risk

Long intubated patients at ICULong intubated patients at ICU Full stomachFull stomach Oro-nasal interventions, nasal bleeding: oral Oro-nasal interventions, nasal bleeding: oral

bloodblood Gastric bypass operations, gastric Gastric bypass operations, gastric

regurgitationregurgitation Jan.mulier@azbrugge.beJan.mulier@azbrugge.be www.publicationslist.org/jan.mulierwww.publicationslist.org/jan.mulier

J P Mulier 12 10 2009 ESICM 17

J P Mulier 12 10 2009 ESICM 18

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

J P Mulier 12 10 2009 ESICM 19

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”

J P Mulier 12 10 2009 ESICM 20

Our Results in lap Our Results in lap RNY gastric bypassRNY gastric bypass