16. Recovery from Anaesthesia and Removal of the Tulip;
16. Recovery from Anaesthesia and Removal of the Tulip;
The Tulip has been designed so that it does not require removal by the Anaesthetist after the cessation of surgery and anaesthesia. It is recommended that there be a delay in the reduction of anaesthetic/volatile percentage, as no manipulation of the airway is necessary.
Breath holding or reflex laryngospasm may occur if there is inadequate depth of anaesthesia, or painful stimulii such as movement post operatively. So it is recommended that the Tulip be removed by the recovering Patient themselves in the recovery room, or by the recovery room attendant when ready.
The Tulip is designed to be removed whilst still fully-inflated by the recovering Patient themselves, after it has been unsecured to prevent any reflex gagging on a rigidly tied airway.
The basic Tulip design of a soft, large balloon containing a large central internal diameter breathing tube allows the Tulip to be removed with minimal obstruction to ventilation, as the balloon functions to occlude the lumen of the mouth on removal, allowing on-going ventilation through the central tube even at a late stage of extubation, e.g. when it is in the mouth.
This self-extubation by the Patient allows the maintenance of a secure airway until the safe return of laryngeal reflexes. The location of the Tulip stimulates the swallowing reflex rather than the cough or gag reflex and allows the Tulip device to be removed with minimal stimulation, and hence the chance of vomiting and aspiration is greatly reduced. It is also recommended that the Tulip is removed in the inflated state, though this is not mandatory.
Upon removal, there will be a slight initial resistance against the removal of the device as the inflated cuff slides past the posterior part of the soft palate and through the palatopharyngeal folds. The Tulip’s cuff is designed as an inverted cone shaped to retain itself, so offers some resistance to its own removal when inflated.
Removing the Tulip in its fully-inflated state allows the effective removal of the oropharyngeal secretions, which is particularly beneficial in facio-maxillary, oro-dental and E.N.T. surgery, where the combination of an inflated balloon and Patient self-extubation allows the airway to be managed with maximal control, reducing the risk of aspiration and laryngeal spasm to a minimum.
This Tulip methodology allows the tonsils to be removed without the need for muscular paralysis, laryngoscopy, intubation and without the use of a throat pack. The Tulip enables the airway to be secured with minimal stimulation of the laryngeal reflexes on either induction or recovery. With the Tulip in place and inflated, a confirmed seal is guaranteed if manual ventilation can be performed without a leak. This means that the airway is sealed against pressurized gas from below the cuff and hence unpressurized descending secretions from above it.
The inflated cuff allows efficient oral suction prior to removal of the Tulip, as all the secretions and blood remain above the Tulip’s cuff for effective evacuation. This reduction in instrumentation and manipulation reduces the fluctuation of the conscious level that may occur secondary to the pain of suctioning, movement or re-positioning of either the airway or the Patient.
The reduction of the number of times the Patient needs to be suctioned or repositioned reduces the possibility of injury, reduces manpower requirements and reduces the possibility of airway displacement.Review Android Smartphone
Upon recovery;
i. The Tulip airway should be left in place until the return of consciousness. Before attempting to remove or deflate the Tulip, it is essential to leave the Patient completely undisturbed until protective reflexes have fully returned. Do not remove the Tulip until the Patient can open their mouth on command.
ii. Look for the onset of swallowing which indicates that the oropharyngeal and laryngeal reflexes have almost been fully restored. It is usually necessary to perform some suctioning for safety, but the correctly used Tulip should protect the larynx from oral secretions above the level of the Tulip’s cuff. Suction equipment should be available at all times.
iii. The Tulip is designed to allow the Patient to self-extubate with a fully-inflated cuff, once unsecured. It is possible to remove the Tulip inflated or un-inflated, as required. The inflated cuff provides the benefit of removing collected secretions from above. If required, deflate the cuff completely just prior to removal, although partial deflation can be recommended in order to assist in the removal of secretions.
iv. Following removal, the single use Tulip must be safely discarded as contaminated medical waste.