25. Lateral and Prone positioning

25. Lateral and Prone positioning

The recommended reinforced Tulip may safely be used in both the lateral and prone position by an Anaesthetist experienced in the use of a Tulip. It is important that the user is aware of the mechanisms involved in the regulation of cuff pressure.

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 minimum of rotational traction is then applied by the breathing circuit and its connection to the light-weight Tulip.

The Patients head may be turned to either side without compromise of the airway. It is recommended that the Tulip is introduced in the supine position, as normal, and inflated in the usual manner to +/- 60mls volume. It is recommended that the Tulip’s intra-cuff pressure is re-measured after repositioning the Patient and before draping. This is recommended to prevent increases of cuff pressure caused by the re-positioning and manipulation of the head and neck. If in the lateral/prone position there is a ventilatory leak, then it may be necessary to “top up” the gas volume in the cuff.

Misplacement of the Tulip may easily be corrected, ensuring that the Patient is adequately anaesthetized first. The Tulip may be repositioned with ease after deflation. The Tulip must then be re-inflated. It must be remembered that other than mechanical obstruction by anatomy, secretions or kinking, there may be other causes of excessive ventilating pressures. Breath-holding secondary to light anaesthesia and surgical stimulation; bronchospasm secondary to asthma, anaphylaxis and C.O.A.D.; and laryngeal spasm must all be rapidly excluded, whilst maintaining anaesthetic depth and oxygenation.

If Tulip protrudes excessively from the mouth it may be deflated, repositioned and re-inflated. If however the airway is not easily reconfirmed, then the Tulip must be removed, and another reintroduced as recommended. In all positions the Tulip must be adequately secured, and its patency constantly reconfirmed.

Obstruction will be uncommon using a Tulip as its design is simple and its fitment anatomical and atraumatic. Causes of obstruction will commonly be secondary to Patient causes such as light anaesthesia, breath holding and laryngeal spasm.  If mechanical obstruction occurs whilst a Tulip is in place, its position must be checked using the centre-line markings and printing on the Tulip breathing tube. Any deviation from the mid-line must be corrected. Check for under-insertion, over-insertion and rotational twisting.

Introduction of the Tulip’s tip into the vallecula will be a common fault for those who introduce it anteriorly along the tongue, rather than posteriorly along the hard palate.

The Tulip in no way prevents aspiration of regurgitated gastric contents. It is important to be vigilant.