Tube feed or not tube feed?

Tube feeding should always be considered relative to patient goals. Physicians should be prepared to discuss tube feeding as an option bearing in mind what evidence (or lack thereof) exists that tube feeding will help reach such goals.     

A novel method for replacement of the dislodged tracheostomy tube: The nasogastric tube “guidewire” technique

Unscheduled replacement of dislodged tracheostomy tubes can be a challenging procedure for the physician and a frightening event for the patient. Forceful attempts at replacement are both painful and dangerous; such attempts may disrupt the soft tissues adjacent to the tracheostomy tract, creating a false passage and potentiating acute respiratory failure. We describe a technique using a standard nasogastric tube that allows safe and precise replacement of tracheostomy tubes in both sedated and combative patients under routine and emergent conditions.     

The Mucus Slurper: a novel tracheal tube that requires no tracheal tube suctioning. A preliminary report

Objective The buildup of mucus within the endotracheal tube (ETT) progressively reduces its internal volume. We devised the Mucus Slurper as an integral part of the tracheal tube to aspirate all mucus automatically at its distal tip. Design and setting In vitro, and in vivo studies in sheep at the National Institutes of Health, NHLBI, PCCMB.Subjects Six sheep, sedated, paralyzed, and mechanically ventilatedInterventions We evaluated the Mucus Slurper in vitro, and we evaluated its efficacy and safety in three healthy sheep during 24 h on volume-controlled mechanical ventilation in comparison to three sheep managed with open tracheal tube suctioning.Measurements and results In vitro: with the Mucus Slurper connected to a source of vacuum of 450–500 mmHg the total volume of a single suction lasting 0.1, 0.2, and 0.3 s was, respectively, 75.4 ± 7.9, 114.5 ± 4.6, and 143.4 ± 8.7 ml; with the measured vacuum within the lumen of the Mucus Slurper ring of 37 cmH₂O. In vivo: during mechanical ventilation we aspirated through the Mucus Slurper 13.4 ± 3.3 cc mucus/24 h. During the course of single aspiration the Mucus Slurper never affected the level of applied PEEP. The tracheal tube was free of tracheal secretions in the Mucus Slurper group while thin secretions were found within the ETT in the control group.Conclusion The Mucus Slurper is a novel device designed to keep the tracheal tube and proximal trachea free of mucus. In studies in sheep lasting 24 h the Mucus Slurper was safe and prevented all mucus accumulation within the ETT.Patent has been applied for the Mucus Slurper by National Institutes of Health     

Endotracheal tube fires still happen – A short overview

Laser generated operating room fires have been reported ever since lasers have been used for therapeutic indications. This occurs because, when an ignition source such as the laser, is used in the vicinity of high oxygen concentrations, and materials, such as the endotracheal tube (ETT), can then be easily ignited. This paper shows examples of ETTs after such a fire, together with the severe injuries incurred. Even though over the years a great deal of experience has been collected in the management and handling of these patients, accidents with ETT fires still occur.Many different materials have been tested for ETTs with regard to their incendiary characteristics, and special constructions of ETTs for use with lasers have been developed accordingly. Whereas wrapping the ETT with metal foil gives a false sense of safety, the so-called ‘laser-tubes’ exhibit an increased resistance to damage by laser radiation. However, even using these, ETT fires have still occurred due to contamination with blood or because the laser has hit the connection of the cuff with the shaft of the tube. These particular aspects have recently been investigated, and international standards are being prepared, which will hopefully promote the development of proven laser-suited ETTs in an effort to reduce the frequency of these severe accidents.     

Vocal rehabilitation by vocal tube after complete laryngectomy of phase I

VocaltubeBlom－Singerimplantationduringphaseofcompletelaryngectomycanavoiddistressassociatedwiththesecondsurgery．VocaltubeimplantationofphaseIunderbrightfieldissimplerandreliablecomparedwiththatofphaseII．１Subjectandmethod１．１SubjectFromOctober１９９８toOctober２００１，vocalrehabili－tationbyvocaltubeBlom－SingeraftercompletelaryngectomyofphaseIwasperformedon１３patients．Allpatientsweremenaged５６～６８yearsandsufferedfromsquamouscarcinomaprovedpathologically．１．２Method（１）Fis…     

Emergency chest tube placement in trauma care-Which approach is preferable?

BACKGROUND: Pneumothorax is present in about 20% of blunt major trauma cases. Insertion of an intercostal tube drainage is one effective treatment, however it is unclear whether the thoracostomy has more advantages if placed in the ventral (2.-3. intercostal space) or lateral (4.-6. intercostal space) approach. The aim of this study was to determine, whether there are any differences between the two approaches in respect of malposition and complications. MATERIAL AND METHODS: The data from 851 consecutive patients, admitted to our trauma centre from January 2000 to June 2004, was collected and analysed prospectively. The inclusion criteria were: ISS > or = 16, insertion of an intercostal tube and subsequent thoracic computed tomography. Epidemiological and physiological data were analysed together with the location of the tube (ventral or lateral). The attending physician was free to choose the location of insertion. Chest tubes placed both on-scene and in-hospital chest tubes were investigated. Malpositions, defined as extrathoracic, abdominal, parenchymal or interlobal positions, were analysed by reviewing the computed tomography of the thorax (CT). Complications, like injuries to vessels or organs, infection or empyaema were analysed using our standardised prospective trauma protocol. Furthermore, the rate of clinically relevant malfunctions due to malposition was investigated as well as the number of chest tubes that had to be replaced. RESULTS: One hundred and one chest tubes were inserted in 68 patients with multiple trauma (mean age 40.7, ISS=38.1, AIS thorax=3.9). In 21 cases a ventral approach was chosen (20.8%) and in 80 a lateral approach (79.2%). CT revealed malposition in two of the ventrally placed tubes (9.5%) and in 20 of the laterally placed tubes (25%) (p=0.15, Fisher's exact test). One tube was identified in a subcutaneous location 17 chest tubes, after ventral approach all of them as a result of lateral approaches, were placed in the interlobe. No interlobal positions were observed in the ventral group. The interlobal position was found to be significantly higher in the lateral approach (p=0.013, Fisher's exact test). Clinically relevant malfunction was diagnosed in 6 of the 22 malpositioned chest tubes (5.9%). These tubes had to be repositioned, one was placed ventrally, the other five were placed laterally. CONCLUSIONS: In our setting physicians preferred the lateral approach on-scene as well as in-hospital. In every fifth patient malpositioning of the tube was observed, mostly interlobal after lateral chest tube, however only few were associated with relevant clinical malfunctions. The probability of interlobal malpositioning is significantly higher when using the lateral approach as opposed to the ventral approach. Correction of malpositioned and ineffective chest tubes was necessary in every 17th case. No statistically significant difference between the two approaches for functional malposition was observed. Hence both approaches for emergency chest tube insertion seem to be equally justified.