Emergency AirwaysEmergency AirwaysModification of Transtracheal Modification of Transtracheal

Jet Ventilation and Jet Ventilation and Retrograde Intubation Retrograde Intubation

TechniquesTechniques

BME 272 Senior DesignBME 272 Senior Design

Group 20Group 20

Project Undertaken by: Fritz HaimbergerProject Undertaken by: Fritz Haimberger

Advisor: Dr. Steven J. White, Asst. Professor of Advisor: Dr. Steven J. White, Asst. Professor of Emergency Medicine and Pediatrics, VUMCEmergency Medicine and Pediatrics, VUMC

BackgroundBackground

• Emergency Airway Emergency Airway MaintenanceMaintenance– Pre-hospital carePre-hospital care

• PtLPtL

• CombitubeCombitube

• Endotracheal (ET) Endotracheal (ET) TubeTube

• Nasotracheal TubeNasotracheal Tube

• Laryngeal Mask AirwayLaryngeal Mask Airway

– Hospital CareHospital Care• ET tubeET tube

Transtracheal Jet Ventilation Transtracheal Jet Ventilation (TTJV)(TTJV)

• Used to rapidly initiate Used to rapidly initiate ventilation in a ventilation in a trauma case with trauma case with difficult airway access difficult airway access in the ERin the ER

• Temporizing measure Temporizing measure until a patent airway until a patent airway can be secured via ET can be secured via ET tube placementtube placement

• Usually followed by Usually followed by retrograde intubationretrograde intubation

Retrograde Intubation (RI)Retrograde Intubation (RI)• Performed via second Performed via second

puncture hole in puncture hole in cricothyroid membranecricothyroid membrane

• Catheter is aimed cephalad Catheter is aimed cephalad instead of caudadinstead of caudad

• Wire inserted through Wire inserted through catheter, advanced up catheter, advanced up trachea and out mouthtrachea and out mouth

• ET tube placed over guide-ET tube placed over guide-wire and advanced down wire and advanced down the windpipe into position the windpipe into position for use as a patent airwayfor use as a patent airway

• VideoVideo• Video2Video2

A picture is worth 1,000 A picture is worth 1,000 words…words…

• Transtracheal Jet Transtracheal Jet Ventilation ProcedureVentilation Procedure

• Retrograde IntubationRetrograde Intubation

• Images Courtesy: www.images.mdImages Courtesy: www.images.md

Tracheal Anatomy and Device Tracheal Anatomy and Device PlacementPlacement

Project DefinitionProject Definition

• Come up with one device that conforms to Come up with one device that conforms to the following requirements:the following requirements:

1.1. Provide rapid temporary airway with manual jet Provide rapid temporary airway with manual jet ventilatorventilator

2.2. Provide means to perform retrograde intubationProvide means to perform retrograde intubation3.3. Accomplishes retrograde intubation through Accomplishes retrograde intubation through

separate lumen in catheter that allows for separate lumen in catheter that allows for insertion of wire to be eventually withdrawn insertion of wire to be eventually withdrawn from mouth and used for ET tube insertionfrom mouth and used for ET tube insertion

4.4. Safely combines these two sequential Safely combines these two sequential procedures (one being rapid and temporizing procedures (one being rapid and temporizing while the other is more time-consuming yet while the other is more time-consuming yet definitive) into one step that significantly definitive) into one step that significantly decreases the composite risk decreases the composite risk

Market AnalysisMarket Analysis

• Ability for use in any emergency Ability for use in any emergency department, most likely a Level 1 Trauma department, most likely a Level 1 Trauma Center (VUMC)Center (VUMC)

• Any case with upper airway compromiseAny case with upper airway compromise

• Total cost, disposable and non-disposable Total cost, disposable and non-disposable equipment approaches $1,000equipment approaches $1,000

• Disposable (tubes, catheters) = $250-300Disposable (tubes, catheters) = $250-300

• Non-disposable (laryngoscope blades, Non-disposable (laryngoscope blades, oxygen regulator, jet ventilator) = $600oxygen regulator, jet ventilator) = $600

Recent ProgressRecent Progress• Original prototyping with heat-shrink tubing did not Original prototyping with heat-shrink tubing did not

work (too rigid)work (too rigid)• Worked with Dr. White last Tuesday evening; great Worked with Dr. White last Tuesday evening; great

real-world experience and time to work on project real-world experience and time to work on project with himwith him

• Decided that original design option #1 was unfeasibleDecided that original design option #1 was unfeasible• Came up with new option, as well as slight Came up with new option, as well as slight

modification to our original design #2modification to our original design #2• Flow testing with central line cath. and angiocath. on Flow testing with central line cath. and angiocath. on

ET tube with glove attachedET tube with glove attached• By Dr. White’s standards, sufficient inflation capability By Dr. White’s standards, sufficient inflation capability

reached even down to a 20G catheterreached even down to a 20G catheter• Two 20G catheters easily put together to create a Two 20G catheters easily put together to create a

double lumen catheterdouble lumen catheter• Determined that Martech Medical has capability to Determined that Martech Medical has capability to

extrude custom catheters to any specification – extrude custom catheters to any specification – ordered sample catheters that should be in ordered sample catheters that should be in today/tomorrowtoday/tomorrow

EquipmentEquipment

Proposed Design #1Proposed Design #1

• Martech MedicalMartech Medical

• www.martechmedical.comwww.martechmedical.com

• Double Lumen Split CatheterDouble Lumen Split Catheter

• Short (<1cm) insertion needleShort (<1cm) insertion needle

• Inserted perpendicular to cricothyroid membr.Inserted perpendicular to cricothyroid membr.

• Marked catheter introducedMarked catheter introduced

• One lumen flexes caudad, one cephaladOne lumen flexes caudad, one cephalad

• Instant ventilation and wire insertion Instant ventilation and wire insertion capabilitycapability

Proposed Design #2Proposed Design #2

• Typical marked double Typical marked double lumen, central line-type lumen, central line-type cathetercatheter

• Inserted toward headInserted toward head• Normal retro. intubation Normal retro. intubation

possiblepossible• Catheter pulled out slightly, Catheter pulled out slightly,

flexed (not kinked) to point flexed (not kinked) to point hole/lumen caudadhole/lumen caudad

• Catheter pushed back in for Catheter pushed back in for immed. ventilationimmed. ventilation

• Wire insertion next to Wire insertion next to provide for retrograde provide for retrograde intubationintubation

• Would ultimately require Would ultimately require manufacture of new double manufacture of new double lumen catheterlumen catheter

Area of larger boreand inner lumen (rigiduntil just distal of exit)

Oxygen exitOxygen entry

Future WorkFuture Work

• Receive shipment of sample catheters, Receive shipment of sample catheters, test for style/design feasibility on throat test for style/design feasibility on throat modelmodel

• Test samples on pig or dog (similar Test samples on pig or dog (similar anatomy and proportions)anatomy and proportions)

• Begin talks with Martech rep. about Begin talks with Martech rep. about building a prototype to our specs.building a prototype to our specs.

• Begin work on paper and putting together Begin work on paper and putting together final poster presentationfinal poster presentation

Questions???Questions???