12. Malposition of the ~Tulip

12. Malposition of the Tulip

Insertion of a Tulip is simple, and it is designed to be effective even in the hands of non-medical personnel.

• Obstruction can occur if the Tulip becomes dislodged or is incorrectly inserted.
• Obstruction can occur if the Tulip becomes twisted.
• Obstruction can occur if the epiglottis is pushed down with an excessive depth of insertion, or poor insertion technique. Check by auscultation of the neck and correct by withdrawing the device slightly. If this is unsuccessful removal, deflation and re-insertion will be required, or elevation of the epiglottis using a laryngoscope.
• Malposition of the Tulip tip into the glottis may mimic bronchospasm.
• Malposition/folding of the epiglottis over the front of the Tulip breathing tube may present a “flap-valve”, intermittent obstruction.
• Intermittent obstruction that allows inspiration but not expiration may occur if the Tulip is over-inserted. Pull the Tulip back out gently until both inspiration and expiration occur.
• Avoid moving the Tulip about in the oropharynx when the Patient is in a light plane of anaesthesia, or if the Tulip is fully-inflated. Re-inserting a fully-inflated Tulip may cause epiglottic inversion/folding and consequent airway obstruction.
• The Tulip may be re-introduced when partially-inflated (+/-30mls), but not when fully-inflated (60mls).
• Air may be withdrawn from the cuff during anaesthesia to maintain a constant intra-cuff pressure, ideally 40mmHg (54cmH2O), or added to obliterate any audible leak on ventilation.