Sint Jan Brugge-Oostende Study on methylene blue cuff leak in morbid obese patients Standard tube versus Taperguard Jan P Mulier MD PhD Filip Van den Brande MD

J P Mulier ESICM2 Is silent aspiration possible? Fluid in oral cavity can leak along tracheal cuff. Fluid in oral cavity can leak along tracheal cuff. Gastric content Gastric content Blood Blood Leak test Leak test In vitro and in vivo test with methylene blue have frequently been positive: leak through the cuff plica In vitro and in vivo test with methylene blue have frequently been positive: leak through the cuff plica

J P Mulier ESICM3 Silent aspiration due to leaks around cuffs of endotracheal tubes Petring OU Anesth Analg Jul;65(7):777 Petring OU Anesth Analg Jul;65(7):777 Petring OU Petring OU Methylene blue bronchoscopic test in patients: Rüsch tube vs Mallinckrodt tube Methylene blue bronchoscopic test in patients: Rüsch tube vs Mallinckrodt tube Aspiration more frequent with the Mallinckrodt tube than the Rüsch tube Aspiration more frequent with the Mallinckrodt tube than the Rüsch tube

J P Mulier ESICM4 Leakage of fluid around high-volume, low-pressure cuffs Asai T, Anaesthesia Jan;56(1):38-42 Asai T, Anaesthesia Jan;56(1):38-42 Asai T Asai T A comparison of four (high-volume, low- pressure cuffs) tracheal tubes in a model trachea and lung. A comparison of four (high-volume, low- pressure cuffs) tracheal tubes in a model trachea and lung. Large leak: Large leak: Portex Profile, Mallinckrodt Lo-Contour Portex Profile, Mallinckrodt Lo-Contour Smaller leak: Smaller leak: Portex Soft Seal, and Mallinckrodt Hi-Lo tubes Portex Soft Seal, and Mallinckrodt Hi-Lo tubes

J P Mulier ESICM5 Fluid leakage past 4 pediatric tube cuffs: in vitro evaluation of the new Microcuff tube Dullenkopf A, Dullenkopf A, Intensive Care Med (2003) 29:1849 A: Mallinckrodt B: ICU, Portex Profile Soft Seal, Rusch C: Super Safety Clear, and Sheridan CF. D: HiLo, Microcuff HVLP A, B, C did leak fluid at pressures above 10 A, B, C did leak fluid at pressures above 10 D: ultra-thin polyurethane membrane markedly improved tracheal sealing D: ultra-thin polyurethane membrane markedly improved tracheal sealing

J P Mulier ESICM6 Effect of positive expiratory pressure and type of tracheal cuff on the incidence of aspiration in mechanically ventilated patients in an intensive care unit. Lucangelo U Crit Care Med Feb;36(2):409 Lucangelo U Crit Care Med Feb;36(2):409 Lucangelo U Lucangelo U Hi-Lo (20 pt), vs SealGuard (20 pt) Hi-Lo (20 pt), vs SealGuard (20 pt) One hour after peep stop: One hour after peep stop: Hi-Lo 100% leak Hi-Lo 100% leak SG 70% leak SG 70% leak At the fifth hour, two patients of the HL group failed the test. One hour after positive expiratory pressure removal, all subjects in group HL exhibited a dyed lower trachea. On the other hand, one patient in group SG presented a leak at the eighth hour, and at the 12th hour three of them were still sealed At the fifth hour, two patients of the HL group failed the test. One hour after positive expiratory pressure removal, all subjects in group HL exhibited a dyed lower trachea. On the other hand, one patient in group SG presented a leak at the eighth hour, and at the 12th hour three of them were still sealed

J P Mulier ESICM7 This study compares cuff leak Taperguard versus PolyVinylChloride : Laparoscopic gastric bypass operations Laparoscopic gastric bypass operations Orotracheal tube needed Orotracheal tube needed Methylene blue 300 ml in gastric pouch with overflow in mouth at moment of leak test Methylene blue 300 ml in gastric pouch with overflow in mouth at moment of leak test Cuff leak tested with 10 ml methylene blue Cuff leak tested with 10 ml methylene blue Ventilation VCV with 5 cm peep Ventilation VCV with 5 cm peep Man 8,0 OTT Woman 7,0 OTT Man 8,0 OTT Woman 7,0 OTT Group A: Hi contour Mallinckrodt Group A: Hi contour Mallinckrodt Group B: TaperGuard Mallinckrodt Group B: TaperGuard Mallinckrodt

J P Mulier ESICM8 Oro-tracheal tubes compared Group A: Group B: Hi contour Mallinckrodt TaperGuard Mallinckrodt

J P Mulier ESICM9 In vitro Methylene blue test Group A: Group B: Hi contour Mallinckrodt TaperGuard Mallinckrodt

J P Mulier ESICM10 Methods in vivo test Automatic cuff pressure control. Automatic cuff pressure control. Set at 25 cmH20 Set at 25 cmH20 2 ml methylene blue + 8 ml H20 injected above cuff. 2 ml methylene blue + 8 ml H20 injected above cuff. Blue fluid must be bronchoscopic visible above cuff. Blue fluid must be bronchoscopic visible above cuff. Bronchsocopic control after 5 and 15 minutes. Bronchsocopic control after 5 and 15 minutes. Is blue fluid visible below cuff, between trachea and tube? Is blue fluid visible below cuff, between trachea and tube?

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J P Mulier ESICM12 In vivo Methylene blue test Group A: Group B: Hi contour Mallinckrodt TaperGuard Mallinckrodt vitro Under up view Bronchoscopic view

Human Methylene blue leak test 29 Obese patients, CMV, 5 peep: bronchoscopic view after 5 minutes when blue is visible above cuff (9 patients excluded as no blue above cuff) 9 pts 11 pts

J P Mulier ESICM14 Impact of tracheal tube size Larger tube more plica, deeper run in Larger tube more plica, deeper run in taperguard 7,0taperguard 8,0

J P Mulier ESICM15 More Questions Is cuff leak for fluids dangerous? Is cuff leak for fluids dangerous? Is post operative pneumonia caused by silent leakage? Is post operative pneumonia caused by silent leakage? Impact of peep? Impact of peep? Lower incidence but still existing Lower incidence but still existing Impact of cuff pressure? Impact of cuff pressure? Higher cuff pressure does not improve protection? Higher cuff pressure does not improve protection? Impact of tube movement? Impact of tube movement? Impact of pharyngeal packing? Impact of pharyngeal packing? Amount of fluid leak? Amount of fluid leak? Impact of fluid type? Impact of fluid type? Gel is not protecting 100% Gel is not protecting 100%

J P Mulier ESICM16 Conclusion Taperguard prevents 100% silent cuff leak Taperguard prevents 100% silent cuff leak Patients at risk Patients at risk Long intubated patients at ICU Long intubated patients at ICU Full stomach Full stomach Oro-nasal interventions, nasal bleeding: oral blood Oro-nasal interventions, nasal bleeding: oral blood Gastric bypass operations, gastric regurgitation Gastric bypass operations, gastric regurgitation

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J P Mulier ESICM18 President Jan P Mulier Vice-President Yigal Leykin Secretary Luc De baerdemaeker Treasurer Nick Kennedy ESPCOP founded feb 2009

J P Mulier ESICM19 Attend first ESPCOP meeting 14 nov 2009 Ostend Belgium “The sea” from Georges Grard “The sea” from Georges Grard Better known as Better known as “fat Mathilde of Ostend”

J P Mulier ESICM20 Our Results in lap RNY gastric bypass