26. The use of the Tulip in the Failed Intubation Drill

26. The use of the Tulip in the Failed Intubation Drill

If the situation occurs whereby the trachea cannot be intubated, it is recommended that the Patient be kept optimally oxygenated and maintained at an adequate level of anaesthesia to suppress laryngeal reflexes that may exacerbate the situation by inducing laryngeal spasm.

The Tulip is a “one-size-fits-all-adults” device that ensures an individual, anatomical, oropharyngeal seal, which once in place allows ventilating pressure to be generated under normal circumstances. The ventilating seal is formed above the larynx and indeed is independent of any abnormalities that may occur caudally of the cuff.

The Tulip forms a ventilating seal at a point where the cuffs seal may be formed in a simple, if anatomical, tube that is the oropharynx. The Tulip is easy to introduce and is inherently designed to be self-retaining. The Tulip may establish a fully hands-free ventilating airway within 10-15 seconds, which can be life-saving in such scenarios.

The establishment of a cuff barrier pressure at +/- 60mls volume enables us to generate manual ventilation pressure for Patient airway management. Normally this translates into +/-20cmH2O ventilation pressure which is normally adequate. However, in “failed intubation” other factors may be at play and higher ventilation pressures may be required in an emergency. In such a situation, the Tulip’s intra-cuff volume and pressure may be increased, increasing in turn the ventilation seal integrity allowing higher ventilation pressures to be generated for emergency use. At pressures >20cmH2O there is an increased likely hood of gastric insufflation and dilation so such use should be limited to emergency management whilst alternative airway provisions are being instigated. The Tulip is designed to perform optimally in such conditions allowing the security of individual anatomical fitment in every Patient without any ventilation leaks at times of emergency if ventilation pressures are high, which is often the case in the emergency airway scenario.

It must be remembered that a lack of ventilation may be secondary to obstruction by secretions, anatomy or kinking, or by bronchospasm and laryngospasm. If ventilatory pressures are raised a cause must be identified whist maintaining saturations and the level of anaesthesia.
Use of the Tulip in the failed intubation drill is recommended but it must be remembered that the Tulip offers no protection against aspiration. The Tulip may be used in conjunction with cricoid pressure to minimize any likely hood of aspiration of gastric contents. The release of airway obstruction in itself will reduce the likely hood of aspiration but it must be considered that the Patient is more at risk of significant morbidity and mortality from hypoxic damage than from aspiration.

It cannot be stressed adequately enough that the Patient must be adequately oxygenated at all times, as failure to ventilate is of greater significance than either the inability to intubate or the problem of aspiration.

It is possible to use the central breathing tube lumen of a Tulip as a guide to the introduction of either an intubating bougie, a small diameter endotracheal tube or a fibreoptic endoscope.

The Tulip’s simplicity of design and “one-size-fits-all-adults” philosophy equates to the rapid establishment of a fully secure, blindly introduced, hands-free ventilating airway which connects directly to wall oxygen or anaesthetic breathing circuits. This may be secured in 10-15 seconds after some initial experience. The Tulip requires little training, and may be easily used by the uninitiated with the aid of simple printed instructions.