18. Roles in other surgery; E.N.T., Oro-Dental, Facio-Maxillary surgery
18. Roles in other surgery; E.N.T., Oro-Dental, Facio-Maxillary surgery
The Tulip allows the approach to these previously perplexing specialties to be greatly simplified, in terms of anaesthetic management, manoeuvers and cost. It should be appreciated that the design of Tulip is based upon the principle of the air-tight oropharyngeal seal. This air, blood and secretion-tight seal allows the device to generate manual ventilating pressure and confidently protect the laryngeal inlet from descending blood and secretions with a blood and secretion-tight seal above the level of the cords, but below the impending surgery. This then enables the Tulip to be used instead of endotracheal intubation and throat packs, as the glottic protection is afforded by the large balloon-cuff that generates an air, blood and secretion-tight seal above the level of the laryngeal inlet, keeping it safe from descending blood and secretions from the surgery that is occurring above the Tulip’s air-tight cuff.
Reinforced versions of the Tulip are recommended for such procedures to maintain safety of the airway when it cannot be seen, or when there is an excessive risk of tubal kinking or obstruction, such as the lateral and prone positions. Ventilating pressures must be minimized (<20cmH2O) to prevent gastric insufflation and dilation. Reflux and regurgitation must be monitored in such Patient positions.
Be careful not to allow the weight of the breathing circuit to twist or displace the light-weight Tulip when connected (see 7.14). Catheter and tube-mount connectors with a rotating “free-swivel” connection are recommended as a minimal amount of rotational traction is then applied by the breathing circuit and its connection to the light-weight Tulip.
The effectiveness of the anatomical seal can be demonstrated breath by breath, as the oropharyngeal seal can be considered to be competent if it is possible to ventilate against it reliably to pressures of +/-20cmH2O. If the seal is not competent, then the initiation of manual ventilation will induce an audible gaseous leak around the edge of the seal. This may be heard, felt whilst bagging or seen as inadequate CO2 gas return upon capnography. Such a situation of an audibly leaking seal has been described previously and can be managed by checking placement of the Tulip and checking the inflation of the pilot balloon, initially between forefinger and thumb. If inflation of the pilot balloon and the Tulip is felt to be inadequate and the Patient’s ventilatory pressures have not exceeded normal recommended limits, then it may be necessary to further inflate the Tulip to allow higher cuff and therefore higher seal pressures. Any audible leak must be obliterated if the Tulip is used in facio-maxillary, oro-dental or E.N.T. surgery to ensure full protection of the laryngeal inlet from descending blood and secretions from such surgery. The pressure within the pilot balloon and cuff must be measured using a dedicated pressure guage, to confirm that excessive pressures are not generated. Please refer to the sections of this instruction manual that deal specifically with problem shooting, and recommended corrective drills.