Applications and clinical use
Minimize contamination risks while managing the ‘stenotic’ airway with Tritube and Evone
New options for airway management
Airway management remains a critical step in daily practice. Alternatives to manage the difficult airway, such as jet ventilation, tracheostomy or even extra-corporal-membrane oxygenation, often bring along challenges and draw backs. The recent pandemic triggered urge to reduce aerosol generation.
FCV® allows ventilation using the ultrathin endotracheal tube Tritube® (ID 2.4 mm). It provides an easy access to the airway and an unprecedented view for the laryngeal surgeon. Tritube minimizes aerosol generation by sealing the trachea with a cuff.
Specific application areas of Tritube® are indicated below.
Please refer to our regular literature page for an extensive overview on publications regarding our products.
Airway stenosis – challenges and solution
Patients admitted to the ICU often require prolonged mechanical ventilation. The European Laryngological Society has issued an important statement, alerting clinicians for an unprecedented increase of laryngo-tracheal stenosis (LTS)1.
COVID-19 has made safe performance of airway procedures a challenge, for diagnosis as well as treatment. It requires preparedness for prevention and timely management of LTS, with special attention to infection control.
The current strategies to manage the compromized airway include jet ventilation, high flow nasal oxygenation, tracheotomy and ECMO. While the first two options are minimally invasive, aerosols are generated and spread, also ventilation may be less effective in specific patients (e.g. obese). The opposite counts for the latter two options: tracheotomy and ECMO are highly invasive techniques with less aerosol generation and adequate ventilation.
Tritube® is an ultrathin endotracheal tube (OD 4.4mm) with a cuff. It provides a minimally invasive intubation in the compromized airway2,3, provides a great surgical exposure2–6, reduces aerosol generation and spread, and enables highly effective ventilation using Evone®,5-7. As such Tritube and Evone were found key tools in managing the infraglottic difficult airway in the setting of the Coronavirus pandemic.8
Tracheostomy – challenges and solution
Tracheostomy is a highly aerosol generating procedure, exposing health care providers to viral contamination via air droplets9. Though it is performed often in patients requiring prolonged mechanical ventilation. In the light of the COVID-19 pandemic, approaches to reduce the risk of virus spreading are urgently needed. While conventional tracheostomy is a highly aerosol generating procedure, introduction of Tritube and FCV ventilation using Evone uniquely allows the placement of a transtracheal cannula in a sealed airway10. Thereby, virus spread by air droplets is contained, and adequate ventilation of potentially severely hypoxic patients without apneic periods is ensured. The small outer diameter of Tritube additionally provides a good working space for the surgeon.
Laryngeal surgery – challenges and solution
During upper airway surgery, jet ventilation through a small lumen allows intubation of difficult airways and provides surgical space. Airway patency is required to allow passive backflow of gases, which in turn causes movements of tissue (vocal cords) and secretions/debris, hampering the surgeon’s working conditions and increase contamination risk. To avoid these movements, periods of apnea may be applied. However, during apnea the surgeon has a limited amount of time to perform the required handling, which is considered stressful, and sequential periods of apnea will significantly add to the surgical time. Alternatively, the use of a cuffed micro-laryngeal tube (MLT) with a smaller inner diameter (ID) than conventional tubes (5–6 vs. 7–8 mm) allows passive expiration in most cases and prevents the undesirable movement of anatomical and physiological structures. Moreover, the cuff seals the airway and protects the patient from aspiration. However, the 5 mm ID tubes in particular may cause ventilation issues as the pressure in the lungs cannot be reduced fast enough.
Tritube improves intubation and surgical conditions as compared to MLT-6 (figure)5. From a surgeon’s point of view Tritube and Evone have benefits over jet ventilation6. Further, Tritube is well tolerated when left in situ after surgery and can therefore be of value to reduce extubation risks2,3.
Tritube and Evone – supporting evidence
Case report: Post-COVID-19 patient tracheal stenosis
A Post-COVID-19 patient presented with severe tracheal stenosis. While the ECMO team was standby Dr Nabil Shallik managed to successfully intubate and ventilate this patient with Tritube and Evone. Tritube provided the surgeons the workspace they needed, with minimized aerosol generation.
The video demonstrates:
- Field of interest examination on the airway and guidewire placement under spontaneous ventilation
- Advancing Tritube over the guidewire
- First time balloon dilatation
- Removal of fibrous tissue
- Second time balloon dilatation
- Near normal tracheal shape and size
Tritube and Evone - clinical benefits
Ample clinical data clearly demonstrated clear benefits of using Tritube and Evone, managing the difficult airway or during laryngeal surgery. The following benefits were found:
- Minimized contamination risk for healthcare professionals, due to a sealed airway8
- An unprecedented view of the intubated airway, due to the thin lumen 2,5,6
- A large surgical exposure and hygienic and clear sight with non-moving vocal cords 2,4–6
- Easy intubation even in difficult airways due to the small outer diameter and malleable stylet 2,3,9
- Awake intubation in patients with a difficult airway 2,9
- Well tolerated when left in situ postoperatively, allowing patients to breathe and talk 2,3,9
- More efficient ventilation, better oxygenation and CO2 removal7,10,11
- Piazza, C. et al. Long-term intubation and high rate of tracheostomy in COVID-19 patients might determine an unprecedented increase of airway stenoses: a call to action from the European Laryngological Society. European archives of oto-rhino-laryngology: official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS): affiliated with the German Society for Oto-Rhino-Laryngology – Head and Neck Surgery (2020) doi:10.1007/s00405-020-06112-6.
- Kristensen, M. S., de Wolf, M. W. P. & Rasmussen, L. S. Ventilation via the 2.4 mm internal diameter Tritube® with cuff – new possibilities in airway management. Acta Anaesthesiol Scand 61, 580–589 (2017).
- Kristensen, M. S. & Abildstrøm, H. H. Endotracheal video-laryngoscope guided intubation with a 2.4 mm cuff’ed tube and active expiration by a dedicated ventilator versus a standard tube/ventilator. A randomized single blinded study in patients with a predicted difficult airway. – A paradigm shift in airway management? Abstract published at Euroanaesthesia 2019 3755, (2019).
- Schmidt, J. et al. Flow-controlled ventilation during ear, nose and throat surgery: A prospective observational study. Eur J Anaesthesiol 36, 327–334 (2019).
- Schmidt, J. et al. Glottic visibility for laryngeal surgery: Tritube vs. microlaryngeal tube: A randomised controlled trial. Eur J Anaesthesiol 36, 963–971 (2019).
- Meulemans, J. et al. Evone® Flow-Controlled Ventilation During Upper Airway Surgery: A Clinical Feasibility Study and Safety Assessment. Front. Surg. 7, (2020).
- Schmidt, J. et al. Improved lung recruitment and oxygenation during mandatory ventilation with a new expiratory ventilation assistance device: A controlled interventional trial in healthy pigs. Eur J Anaesthesiol 35, 736–744 (2018).
- Nouraei, S. A. R., Girgis, M., Shorthouse, J., El-Boghdadly, K. & Ahmad, I. A multidisciplinary approach for managing the infraglottic difficult airway in the setting of the Coronavirus pandemic. Operative Techniques in Otolaryngology-Head and Neck Surgery 31, 128–137 (2020).
- Pichi, B et al. CORONAsteps for Tracheotomy in COVID-19 Patients: A Staff-Safe Method for Airway Management. Oral oncology. 2020;105:104682
- Magasich-Airola, NP et al. Novel technique for safe tracheostomy during COVID-19 pandemic using Evone® flow-controlled ventilation system. Int J Clin Pract. 2020 Nov 27;(epub).
Ventinova will regularly share clinical experiences doctors are having while ventilating COVID-19 patients with our ventilator Evone.
Is there aerosol spreading during ventilation using Tritube and Evone?
No, Tritube is an ultrathin endotracheal tube with cuff. The cuff prevents the aerosols from spreading
How do I ventilate through Tritube?
Tritube can be used for ventilating together with Evone for up to 72 hours of safe and efficient FCV ventilation. During ventilation intratracheal pressures should be measured via the pressure measurement lumen. Cuff pressures should be intermittently monitored and corrected when needed.
Further tritube can be used with Ventrain, our manual small lumen ventilator. Ventrain is intended to be used for 30 minutes maximally. Of note, while using Ventrain exhausted gas (and potentially blood and secretions) exits via the thumb whole. Therefore Ventrain carries the risk of contamination as it spreads aerosols.
Is it possible to intubate awake patients with Tritube?
Yes this is possible. This has already been done as normal endotracheal intubation as well as nasal intubation.
For movies about this subject click here http://airwaymanagement.dk/171/index.php?option=com_content&view=article&id=27&Itemid=324)
Is Tritube laser resistant?
No Tritube is not laser resistant
What makes Tritube special?
Tritube knows a revolutionary combination of characteristics:
- an ID of ~2.3 mm and an OD of only 4.4 mm, providing easy access to the airway and a spacious surgical site.
- an HVLP inflatable cuff to secure the airway with lower lateral wall pressures.
- made of polyurethane, resulting in an ultrathin cuff, which requires less cuff pressure to seal the trachea and a strong and flexible tubing.
- a separate pressure measurement lumen, which allows continuous or intermittent monitoring of the intratracheal pressure.
- a malleable stylet, which allows Tritube to be bent in any shape for easy endotracheal access.
- allows adequate ventilation of an adult patient using Evone®
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Symposium organized by Erasmus Medical Center
Erasmus Medical Center (Rotterdam, the Netherlands) is organizing a hybrid symposium on Flow Controlled Ventilation blowing away VILI.The event will be held on the 28th of October in Rotterdam but can also be watched online.For more information click...
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