Project Undertaken by: Fritz Haimberger Emergency Airways Modification of Transtracheal Jet Ventilation and Retrograde Intubation Techniques BME 272 Senior Design Group 20 Project Undertaken by: Fritz Haimberger Advisor: Dr. Steven J. White, Asst. Professor of Emergency Medicine and Pediatrics, VUMC

Background Emergency Airway Maintenance Pre-hospital care PtL Combitube Endotracheal (ET) Tube Nasotracheal Tube Laryngeal Mask Airway Hospital Care ET tube

Transtracheal Jet Ventilation (TTJV) Used to rapidly initiate ventilation in a trauma case with difficult airway access in the ER Temporizing measure until a patent airway can be secured via ET tube placement Usually followed by retrograde intubation

Retrograde Intubation (RI) Performed via second puncture hole in cricothyroid membrane Catheter is aimed cephalad instead of caudad Wire inserted through catheter, advanced up trachea and out mouth ET tube placed over guide-wire and advanced down the windpipe into position for use as a patent airway Video Video2

A picture is worth 1,000 words… Transtracheal Jet Ventilation Procedure Retrograde Intubation Images Courtesy: www.images.md

Tracheal Anatomy and Device Placement

Project Definition Come up with one device that conforms to the following requirements: Provide rapid temporary airway with manual jet ventilator Provide means to perform retrograde intubation Accomplishes retrograde intubation through separate lumen in catheter that allows for insertion of wire to be eventually withdrawn from mouth and used for ET tube insertion Safely combines these two sequential procedures (one being rapid and temporizing while the other is more time-consuming yet definitive) into one step that significantly decreases the composite risk

Market Analysis Ability for use in any emergency department, most likely a Level 1 Trauma Center (VUMC) Any case with upper airway compromise Total cost, disposable and non-disposable equipment approaches $1,000 Disposable (tubes, catheters) = $250-300 Non-disposable (laryngoscope blades, oxygen regulator, jet ventilator) = $600

Recent Progress Original prototyping with heat-shrink tubing did not work (too rigid) Worked with Dr. White last Tuesday evening; great real-world experience and time to work on project with him Decided that original design option #1 was unfeasible Came up with new option, as well as slight modification to our original design #2 Flow testing with central line cath. and angiocath. on ET tube with glove attached By Dr. White’s standards, sufficient inflation capability reached even down to a 20G catheter Two 20G catheters easily put together to create a double lumen catheter Determined that Martech Medical has capability to extrude custom catheters to any specification – ordered sample catheters that should be in today/tomorrow

Equipment

Proposed Design #1 Martech Medical www.martechmedical.com Double Lumen Split Catheter Short (<1cm) insertion needle Inserted perpendicular to cricothyroid membr. Marked catheter introduced One lumen flexes caudad, one cephalad Instant ventilation and wire insertion capability

Proposed Design #2 Typical marked double lumen, central line-type catheter Inserted toward head Normal retro. intubation possible Catheter pulled out slightly, flexed (not kinked) to point hole/lumen caudad Catheter pushed back in for immed. ventilation Wire insertion next to provide for retrograde intubation Would ultimately require manufacture of new double lumen catheter Area of larger bore and inner lumen (rigid until just distal of exit) Oxygen exit Oxygen entry

Future Work Receive shipment of sample catheters, test for style/design feasibility on throat model Test samples on pig or dog (similar anatomy and proportions) Begin talks with Martech rep. about building a prototype to our specs. Begin work on paper and putting together final poster presentation

Questions???