Table of contents :

• catheterization : insertion of a catheter (a tubular, flexible, surgical instrument that is inserted into a cavity of the body to withdraw or introduce fluid). Unit of measure of external diameter of catheters, sounds, and other tubular instruments : 1 charrière (Ch) (referred as French gauge (Fg / G) or French (F) in the USA) = 0.333 mm.

Catheterization devices :
• balloon-tip catheter : a catheter whose tip is provided with an inflatable balloon that holds the catheter in place or is used to dilate the lumen of a vessel, such as in balloon angioplasty; common types are :
• Fogarty catheter
• Gruentzig balloon catheter : a flexible balloon catheter with a short guidewire fixed to the tip, used for dilation of arterial stenoses; the balloon is made of low-compliance plastic to reduce the risk of arterial rupture
• Swan-Ganz catheter (SGC) / pulmonary artery catheter (PAC) : a soft (PVC), flow-directed, 110-cm long cardiac catheter with external diameter =  2.3 mm (7 Ch), a 1.5 mL balloon at the tip for measuring pulmonary arterial pressures and preventing the catheter from perforating the vascular wall. the catheter has fine marks every 10 cm and a black gross mark at 50 cm. It is introduced into the venous system by using a large-diameter catheter via the ...
• basilic vein
• right basilic vein (40 cm from venae cavae-right atrium joint; 70 cm from pulmonary artery)
• left basilic vein (50 cm from venae cavae-right atrium joint; 80 cm from pulmonary artery)
• internal jugular vein (15-20 cm from venae cavae-right atrium joint; 40-55 cm from pulmonary artery)
• subclavian vein (10-15 cm from venae cavae-right atrium joint; 35-50 cm from pulmonary artery)


• femural vein (30 cm from venae cavae-right atrium joint; 60 cm from pulmonary artery)
... and is guided by blood flow into the superior vena cava. Once it has reached the joining of the venae cava in the right atrium, the balloon is slowly inflated with air or CO₂ and the valve is closed, so that respiratory oscillations are seen on the monitor. Introduction into pulmonary artery is seen as increase in diastolic pressure. When a wedge pressure is achieved, the balloon should be slowly deflated. It should be pushed rapidly into the right ventricle and pulmonary artery until wedge occurs to prevent coiling. It has 2 openings, a distal one at the tip and a proximal one 30 cm from the tip. A thermistore is located 4 cm from the tip of the catheter on the external surface. to remove coils in right atrium or ventricle push the catheter back by 1-2 cm, then re-inflate the balloon until the minimal wedge pressure is achieved. Additional accessories are :
• additional way opening 14 from the tip used for infusion or for transient passage of pacemaker wires into right ventricle
• optic fiber system for continuous monitoring of hemoglobin saturation in the mixed venous blood
• thermal wire for continue measurement of cardiac output with the thermodilution method
• rapid response thermistore for measurement of right ventricle ejection fraction

Color codes for openings :
• yellow : distal opening for monitoring pulmonary artery pressures
• blue : proximal opening for monitoring right atrium pressure
• red : exit valve of balloon to obtain PCWP values
• red/white : thermistore connector to measure temperature 4 cm from tip
Patency of internal ways should be maintained with heparin wash-outs.
Alterations in CVP patterns :
• atrial fibrillation : loss of "a peak" (no effective atrial systole), rise in "c peak" (greater atrial volume at the beginning of systole due to unemptied atrium)
• tricuspid valve failure : rise in "c peak and "v peak", ventricularization of right atrium pressure


• tricuspid valve stenosis : rise in mean CVP, rise in "a peak" due to compensatory atrial hypercontractility, decrease in "y fall" due to decreased atrioventricular blood flow


• cardiac tamponade : reduced venous return, rise in CVP, equalization of end-diastole pressure in all cardiac chambers, almost monophasic CVP with prominent "x fall" and less accentuated "y fall"


• closed end-hole catheter : one lacking a hole in its tip; used for rapid injection of large volumes of contrast solution
• spiral-tip catheter : a catheter with an off-center filiform tip
• vertebrated catheter : a catheter made in small sections fitted together so as to be flexible
• Dormia basket : to remove multiple stone fragments from ureter or biliary tract


Catheterization routes :
• oesophageal catheter is introduced through the nose
• tracheal catheter : an instrument for removing mucus from the trachea by application of suction
• transtracheal oxygen catheter : a catheter inserted into the trachea through a tracheostomy for patients who cannot tolerate a nasal or oral cannula
• eustachian catheter : an instrument for inflating the eustachian tube for treatment of diseases of the middle ear
• urinary catheter is introduced through the urethra (see also movie)
• urethral catheter : a catheter for insertion through the urethra into the urinary bladder.
• 2-way, double-current or double-lumen catheter : a catheter having 2 channels, one for injection and one for removal of fluid
• 3-way catheter
• prostatic catheter : a urethral catheter having a short angular tip for passing an enlarged prostate.
• catheter coudé / elbowed catheter : a urethral catheter with a sharp bend near the beak; used principally in cases of enlarged prostate
• bicoudate catheter / catheter bicoudé : an elbowed catheter with 2 bends
• female catheter : a short urethral catheter for passage through the female urethra
• Malecot catheter : a 2- or 4-winged female catheter.
• filiform-tipped catheter : a catheter used to dilate tight urethral strictures and to bypass obstructions due to angulations or calculi in the ureter
• indwelling catheter / catheter à demeure : a urethral catheter that is held in position in the urethra
• self-retaining catheter : a urethral catheter constructed to be retained in the bladder and urethra
• flexible catheters (latex or silicone)
• Foley catheter : an indwelling urethral catheter retained in the bladder by a balloon inflated with air or liquid
• Rocco's catheter
• semiflexible catheters (hard rubber)
• Nélaton's catheter : a type of flexible rubber urethral catheter
• Couvelaire's catheter
• Mercier's catheter
• Tiemann's catheter
• Phillips' catheter : a urethral catheter with a woven filiform guide.
• Béniqué catheter
• Freundenberg boring-bar
• bougie [Fr. “wax candle”] : a slender, flexible, hollow or solid, cylindrical instrument for introduction into the urethra or other tubular organ, usually for the purpose of calibrating or dilating constricted areas
• bulbous bougie / bougie à boule : one with a bulb-shaped tip
• acorn-tipped bougie : a bulbous bougie with a tip shaped like an acorn.
• olive-tipped bougie (fig B) : a bulbous bougie with a tip shaped like an olive.
• Otis bougie à boule (fig A)
• conic bougie : one with a cone-shaped tip.
• cylindrical bougie : one with a round or circular section.
• elbowed bougie : one with an elbow or sharp bend near the tip.
• filiform bougie : one of very slender caliber; often used for the gentle exploration of strictures or sinus tracts of small diameter with multiple false passages.
• fusiform bougie (fig C) : one with a belly or expansion in its shaft.
• dilating bougie : a bougie whose diameter can be increased by turning a screw; commonly used for dilating a stricture of the urethra.
• elastic bougie : one made of rubber or other elastic material.
• caustic bougie : one that has a piece of silver nitrate or other caustic agent attached to its end; used as a portcaustic.
• Hurst's bougies : a series of mercury-filled tubes of graded diameter for dilating the cardioesophageal region.
• Maloney bougies : a series similar to Hurst's bougies but having cone-shaped tips.
• rosary bougie : a beaded bougie for use in a strictured urethra.
• wax-tipped bougie : a long, slender, flexible bougie with a wax tip for passage into the ureter through the cystoscope to confirm the diagnosis of ureteral calculus.
• whip bougie : one with a filiform point and a stem of gradually increasing caliber.
bougienage / bouginage : the passage of a bougie through a tubular structure or organ, to increase its caliber, as in the treatment of stricture of the esophagus.

• Braasch bulb catheter : a bulb-tipped ureteral catheter used for dilation and determination of the inner diameter of the ureter
• conical catheter / Garceau catheter : a ureteral catheter that has a cone-shaped tip designed to dilate the lumen
• de Pezzer catheter : a self-retaining urethral catheter having a bulbous extremity
• Gouley's catheter : a solid, curved steel instrument, grooved on its inferior surface so that it can be passed over a guide through a urethral stricture
• Robinson catheter : a straight urethral catheter with 2-6 openings to allow drainage, especially useful in the presence of blood clots which may occlude one or more openings
• winged catheter : a urethral catheter that has winglike projections on the end to retain it in the bladder.
• retrourethral catheterization : passage through the urethra of a catheter first introduced through an incision into the bladder, and then passed through the internal urethral orifice
• vesical catheter
• ureteral catheter : a catheter inserted into the ureter, either through the urethra and bladder or posteriorly via the kidney.
• corn-tipped catheter : one used in ureteropyelography to occlude the ureteral orifice and prevent backflow from the ureter during and following the injection of an opaque medium
• olive-tip catheter : a ureteral catheter with an olive-shaped end, used to dilate a constricted ureteral orifice; larger sizes are also utilized for dilating urethral strictures or for calibrating the diameter of such strictures
• Jackson-Pratt (JP) drains are commonly used after urologic surgery. One of the complications associated with the use of JP drains occurs when the drain breaks, leaving the distal fenestrated part at the time of attempted removal.
Standard sizes : Ch 8 to Ch 26 (Ch 14 is the most used)

size	colour coding	indications for use
10 Ch / 3.3 mm	black	initial catheterisation (female). Clear urine. No grit (encrustation), debris, or haematuria
12 Ch / 4 mm	white	initial catheterisation (male or female). Clear urine, no grit, debris, or haematuria
14 Ch / 4.7 mm	green	initial catheterisation (male or female). Clear urine, no grit or debris, no haematuria
16 Ch / 5.3 mm	orange	initial catheterisation (male). Clear or slightly cloudy urine, both sexes. No or mild grit. Light haematuria with no clots
18 Ch / 6 mm	red	initial catheterisation (male). Moderate to heavy grit and debris. Haematuria with moderate clots
20 Ch / 6.7 mm	yellow	avoid unless urine is very cloudy, with heavy grit and debris. Heavy haematuria with large clots. Following prostatectomy and bladder surgery
22 Ch / 7.3 mm	violet	severe haematuria with large blood clots. Following prostatectomy and bladder surgery
24 Ch / 8 mm	blue	severe haematuria with large blood clots. Following prostatectomy and bladder surgery

There are 3 lengths of catheter currently in use:
• paediatric (30 cm)
• female (23-26 cm)
• standard (40-44 cm) : it is now termed the ‘male-length’ catheter, which is confusing because there is no such thing as a ‘male’ catheter.
Risks associated with over-inflation are:
• balloon rupture leaving fragments inside the bladder
• distortion of the catheter/balloon inside the bladder
• the catheter tip can rise and irritate the trigone area.
• irritation of the detrusor muscle
• pain, spasm, bypassing and haematuria.
Risks associated with under-inflation are:
• catheter dislodgement into the prostatic urethra (males) and urethra in both sexes.
• drainage eyes can become blocked if they enter the balloon area.
• failure of the catheter to drain urine and catheter dislodgement.
• bladder neck and urethral irritation, bypassing, pain, haematuria and urethral trauma
• obstetric catheters
• Drew-Smythe catheter : an instrument used for the artificial rupture of the amniotic membranes to induce labor
• DeLee catheter : a catheter used to suction meconium and amniotic debris from the nasopharynx and oropharynx of neonates
• Tenckhoff catheter : any of several types of catheter commonly used in peritoneal dialysis, consisting of a flexible silicone rubber tube with end and side holes and 1 or 2 extraperitoneal Dacron felt cuffs that help provide a bacteria-tight seal


• thermodilution catheter : a catheter used in thermodilution for introduction of the cold liquid indicator into the cardiovascular system
• toposcopic catheter : a miniature catheter that can pass through narrow, tortuous vessels to convey chemotherapy directly to brain tumors
• vascular access devices (VAD)

Aims :
• administrationof drugs or fluids
• blood sampling
• insertion of intravascular catheters for :
• cruent measure of intravascular or intracardiac pressure :
• fluid-filled catheter : an intravascular catheter connected by a saline-filled tube to an external pressure transducer
• manometer-tipped catheter : one with a small pressure transducer on its tip
• angiographic catheter : a catheter through which a contrast medium is injected for visualization of the vascular system of an organ (selective angiography); it may have a preformed end to facilitate selective locating (as in a renal or coronary vessel) from a remote entry site. Different types may be named according to the site of entry and destination, such as femoral-renal or brachial-coronary
Routes (cannulation) :
• arterial accesses (see also movie and intraarterial injection): arterial puncture may result in vasospasm, intraluminal clotting, or bleeding and haematoma formation, as well as a transient obstruction of blood flow, and infection. These factors may decrease the arterial flow in distal tissues unless adequate collateral arterial vessels are available
• femoral artery has not adequate collateral supplies
• brachial artery has not adequate collateral supplies
• radial artery has good collateral supply from the ulnar artery in case of vasospasm or clotting. Patency should be assessed before with Allen's test : the radial and ulnar arteries are occluded by firm digital pressure while the fist is clenche. The hand is opened and the arteries released one at a time to check their ability to return blood flow to the hand
• arterialised ear lobe samples provide an alternative to arterial puncture for occasional samples. A capillary tube is used to sample blood from a warmed, vasodilated earlobe. The PaCO₂ values agree well with those obtained from arterial samples, but accuracy of the PaO₂ depends on good technique in arterialisation of the ear lobe.
It is kinder to patients to use local anaesthesia over the radial artery before puncture. Analgesic patches can be used for children. Use a 20 or 21 gauge needle with a preheparinised syringe. Express the sodium heparin from the syringe before taking the sample; adequate heparin will remain in the 0.2 ml dead space of the barrel and needle. At least 3 ml of blood is required to avoid a dilution effect from the heparin.
Any sample with more than fine air bubbles should be discarded. Air bubbles result in gas equilibration between the air and the arterial blood, lowering PaCO₂ and increasing PaO₂. The cellular constituents of blood remain metabolically active so arterial gas tensions in the sample will change over time increasing PaCO₂ and lowering PaO₂. If the sample cannot be analysed quickly it should be cooled to 5°C immediately. The sample can then be stored for up to 1 hour with little clinically significant effect on the result.
• arterial catheterization
• atherectomy catheter : a catheter containing a rotating cutter and a collecting chamber for debris, used for atherectomy and endarterectomy; it is inserted percutaneously under radiographic guidance
• directional atherectomy catheter : a type of atherectomy catheter whose direction can be shifted to shave off additional plaque
• transluminal endarterectomy catheter : a type of atherectomy catheter with a conical cutting window, inserted through the lumen of the vessel; debris is collected in a special vacuum bottle
• Fogarty catheter : a type of balloon-tip catheter used to remove thrombi and emboli from blood vessels
• pigtail catheter : an angiographic catheter ending in a tightly curled tip that resembles the tail of a pig
• Judkins pigtail left ventriculography catheter : a specialized pigtail catheter used for left ventriculography
• venous accesses (see also intravenous injection)
• peripheral venous accesses
• upper limb veins
• cubital vein (percutaneous venipuncture)
• basilic vein
• cephalic vein
• lower limb vein
• popliteal or saphenous vein (after phlebolysis)
• external jugular vein (after phlebolysis)
Devices :
• short-term accesses : teflon needle-cannulas


• mid-term accesses : midline catheters (round and closed tip, single-lumen, 3-projection valve, 20 cm in length, 3-4 Fr = 20-18 G, internal volume = 0.2-0.3 ml. May be kept for up to 3 wekks


• long-term accesses
• central venous catheter (CVC) / central venous access devices (CVADs) : a catheter introduced via a large vein into the superior vena cava or right atrium to administer parenteral fluids (as in total parenteral nutrition (TPN)) or medications or to measure central venous pressure.
• internal jugular vein
• subclavian vein
• femoral vein (echo-assited with echogenic needle)

• temporary (non-tunnelled) catheters : single/multi-lumen
• short-term


• hemodialysis/apheresis catheters : double-lumen
• HemoSplit^® Dialysis catheter


• mid-term
• Arrow^® catheter (triple lumen)
• Hohn^® catheter : percutaneously inserted silicone CVCs


• Centrally-Inserted Cook^®
• peripherally inserted central catheters (PICC)
• Groshong^® NXT PICC catheters


• Poly RadPICC^® catheter
• Poly Per-Q-Cath^® PICCs
• long term (tunneled) catheters
• open tip
• Broviac^® catheter : a type of CVC similar to a Hickman catheter but with a smaller lumen


• Hickman^® catheter : a type of CVC used for the long term administration of substances via the venous system, such as antibiotics, total parenteral nutrition (TPN), or chemotherapeutic agents; it can be used for continuous or intermittent administration and may have either a single or a double lumen


• Groshong^® catheter (source : Bard Access Systems) : double-lumen, valve



Advantages :
• decreased risk of blood reflux and gaseous embolism
• no need to clamp catheter
• decreased frequency of catheter washings when nonfunctional
• no need for heparin to maintain catheter patency
• subcutaneously implanted venous ports (long-term)
• Port-A-Cath^®


• Infus-A-Port^®


• Mediport^®
• X-Port^® Isp Port
• long-term hemodialysis/apheresis catheters : double-lumen tunnelled catheters are emerging as an alternative permanent haemodialysis vascular access.
• PermCath™, Quinton Instrument Co, Seattle is a dual-lumen silicone catheter


• Tesio™, Med Comp, Inc, Harleysville PA


• VasCath Soft Cell™, Bard Instrument Company, Toronto


Device occlusion is defined as the inability of infuse fluid or withdraw blood
Aetiology :
• drug precipitation:
• "3 in 1" solution (this is a TPN/lipid solution frequently used with home care patients on TPN):
• lipid precipitate
• calcium/phosphorus precipitate
• known incompatible drugs:
• phenytoin and IV dextrose
• amphotericin and any IV solution with electrolytes (e.g., Na, KCl)
• heparin and aminoglycosides
• heparin and vancomycin
• heparin and doxorubicin
• heparin and idarubicin
• heparin and pristinamycin
• poorly soluble drugs
• calcium/phosphate in TPN (amino acids act as a buffer)
• diazepam
• etoposide can crystallize in aggregates undetectable to the naked eye.
• cotrimoxazole poorly soluble in NA
• when flushing device, ask patient if :
• noise near the ear when flushing may indicate the catheter tip is malpositioned up the jugular vein
• pain, burning or discomfort near the port body may indicate catheter separation from the portal body and infiltration of IV fluid or medication into the subcutaneous tissue
• pain, burning or discomfort near the entry point of the catheter into the blood vessel may indicate infiltration of IV fluid or medication into the subcutaneous tissue.
Treatment :
• prior to using dissolving agents (MD order required), try all of the other conventional methods to restore patency, in the following order:
• remove end cap/positive pressure valve or IV tubing. Attach a 12 ml luer lock syringe filled with 8 ml of normal saline to the hub of the device. Attempt to flush in a push-pull fashion. DO NOT forcefully attempt to flush the device if occlusion is met because excessive pressure may cause catheter breakage.
• change position of patient (try multiple positions). Have patient lift arms overhead or forward to "lift" clavicle off of the subclavian vein, otherwise known as "pinch-off sign".
• have patient take a deep breath and cough forcefully while attempting to irrigate and withdraw blood.
• if the device is an implanted port, flush with 5 ml heparin 100U/ml prior to deaccessing. Reaccess with a new non-coring needle to ensure correct needle placement.
• attempt use of alteplase per policy to dissolve possible intraluminal clots.
• dissolving agents
• do not use ethanol in patients with a history of allergy to alcohol.
• do not use ethanol in Arrow triple lumen catheters or any other polyurethane catheters. Alcohol can break down the polyurethane device material.
• there are no published or anecdotally reported adverse effects or damage to device material from the use of NaHCO₃ or HCl at these concentrations and volumes.
• equipment/supplies
• for acidic precipitates: 1 ml 0.1 N HCl
• for alkaline precipitates: 1 ml NaHCO₃
• for lipid precipitates: 1 ml 95% ethanol
• 12 ml luer lock syringe
• alcohol wipes
• sterile end cap/positive pressure valve, if heparin locking
• prefilled NS syringes
Clamp catheter (do not clamp Groshong catheters and PICC catheters), then disconnect SafSite valve and/or tubing. Attach syringe to device hub and unclamp device. Slowly pull back on syringe plunger to the 8-9 ml mark to remove saline. Slowly allow plunger to move back to neutral position (A gentle push-pull technique will distend the silicone enough to "mix" to the tip. Do not force dissolving agent as it could cause catheter to rupture or dislodge a precipitate). Call the physician if unable to instill dissolving agent. Reclamp catheter (do not clamp Groshongs and PICC catheters), taping syringe in place. Unclamp device and attempt to aspirate dissolving agent. If no blood is aspirated, reclamp device and wait an additional 15 minutes. It may take longer than 30 minutes for dissolution to occur. If a mixed precipitate is suspected, or the precipitate is unknown, HCl, NaHCO₃, and then ethanol can be used successively in an attempt to achieve patency. "Rinse" device lumen between dissolving agents by using 3-4 ml NS in a syringe and alternately pulling on the syringe and letting go to allow saline to go into device. There are no reports of damage to device with using different dissolving agents successively. However, it is prudent to attempt to "rinse" device lumen to allow the dissolving agent to work most effectively. If blood can be aspirated, withdraw 5-6 ml and discard. Irrigate device with 20 ml NS in a push-stop-push fashion. A push-stop-push technique causes turbulence in the device and flushes out blood and drug more effectively.
Catheterized organs :
• cardiac catheter : a long, fine catheter especially designed for passage, usually through a peripheral blood vessel, into the chambers of the heart under radiologic control; used to obtain blood samples and intracardiac pressures, in diagnosing cardiac abnormalities, and in therapeutic intervention.
• Brockenbrough transseptal catheter : a curved steel inner needle that can puncture the interatrial septum; used to catheterize the left ventricle when the aortic valve cannot be crossed in a retrograde approach
• cardiac catheter-microphone / phonocatheter : a device similar in appearance to a conventional catheter, with a microphone at the tip; used in recording the sounds of the heart and great vessels.
• Judkins coronary catheter : a preformed J-shaped angiographic catheter used in coronary arteriography to cannulate and deliver contrast material to one of the coronary arteries via a percutaneous femoral route. It is composed of polyurethane or polyethylene with a fine wire braid within its walls; right and left catheters are shaped specifically for use in the respective coronary arteries
• Amplatz coronary catheter : a preformed J-shaped angiographic catheter used as an alternative to a Judkins coronary catheter in coronary arteriography
• Castillo catheter : similar to an Amplatz catheter in shape and use, but shorter and introduced via the brachial artery.
• Cournand catheter : a single end hole; used for pressure measurement, usually in the right heart
• electrode catheter : containing one or more electrodes; it may be used to temporarily pace the heart (pacing catheter) or to deliver high-energy shocks
• end-hole catheter : a hole in the tip, through which a guidewire may be passed or pressure monitored
• Gensini coronary catheter : a nonpreformed catheter used for coronary arteriography; it has an end-hole to accommodate a guidewire or monitor pressure as well as side holes for rapid injection of large volumes of contrast material
• NIH catheter : a nonpreformed catheter used for coronary arteriography; it has a closed end and several side holes for rapid injection of large volumes of contrast material
• retrograde catheterization : passage of a cardiac catheter along an artery, usually the femoral artery, against the direction of blood flow and into the heart
• left coronary catheter : one designed for coronary arteriography of the left coronary artery
• right coronary catheter : one designed for coronary arteriography of the right coronary artery
• snare catheter : one designed to remove intracardiac catheter fragments introduced iatrogenically
• Sones coronary catheter : a woven Dacron or polyurethane catheter used in coronary arteriography to cannulate and deliver contrast material to the coronary arteries via the brachial artery. It is not preformed and may be used for several tasks or approaches
• transseptal catheterization : passage of a cardiac catheter through the right atrium and across the interatrial septum into the left atrium; used in cases of valve obstruction and in techniques such as balloon mitral valvuloplasty
• hepatic vein catheterization : passage of a cardiac catheter through an arm vein, right atrium, inferior vena cava, and hepatic vein, into a small hepatic venule, for recording of intrahepatic venous pressures.
Techniques :
• Seldinger technique (1950) : a method for introducing a radio-opaque catheter into a hollow lumen structure or body cavity; a narrow Seldinger needle is used to enter the structure, a guidewire is passed through the needle, the needle is removed, and the catheter is advanced over the wire. Used in angiography, cardiac catheterization, and cannulation of the central venous system
• intubation : the insertion of a tube (an elongated hollow cylindrical instrument) into a body canal or cavity
• Casselberry's position : a prone position employed after intubation so that the patient may swallow without danger of fluid entering the tube
• Fowler’s position : elevation of the head of the bed with patient in supine position: low-Fowler’s (6-10 inches), semi-Fowler’s (12-18 inches), Fowler’s (18-20 inches) and high Fowler’s (24-30 inches)
• Bouchut's tubes : a set of tubes for use in the intubation of the larynx.
• Celestin's tube : a plastic tube used to keep the esophagus open in inoperable esophageal carcinoma
• drainage tube : a tube used in surgery to facilitate the escape of fluids.
• empyema tube : a tube for draining a pleural empyema
• T tube : a self-retaining drainage tube in the shape of a T .
• oral intubation : insertion of a tube through the mouth.
• nasal intubation : insertion of a tube through the nose, such as a nasogastric or endotracheal tube.
• endobronchial tube : a double-lumen tube inserted into the bronchus of one lung and permitting the complete deflation of the other lung; used in anesthesia and thoracic surgery
• Carlens' tube : an early type of endobronchial tube equipped with a small hook to hold the tube in position at the tracheal bifurcation; used for ventilation of the left lung.
• Robertshaw tube : an endobronchial tube that has various improvements over the Carlens tube such as lack of the positioning hook and availability for ventilation of either lung
• control of airway patency : 34% of anaesthesiological accidents are due to lack of control on airways^ref. Alternative airway devices :
• basal techniques
• jaw thrust
• chin lift
• airway : a device for securing unobstructed passage of air into and out of the lungs during general anesthesia or when the patient is not ventilating properly.
• esophageal obturator airway : a hollow tube inserted into the esophagus to maintain upper airway patency in unconscious persons and to permit positive-pressure ventilation through the face mask connected to the tube.
• nasopharyngeal airway or cannula : a hollow tube inserted into a nostril and directed along the floor of the nose to the nasopharynx to prevent the tongue from blocking off passage of air in unconscious persons.
• oropharyngeal airway or cannula : a hollow tube inserted into the mouth and back of the throat to prevent the tongue from blocking off passage of air in unconscious persons.
• Mayo oropharyngeal airway is a metal (anatomically not correctly) open-cage oropharyngeal airway. Various modifications of this airway were developed and manufactured :
• modification with side feed tube
• Lumbard modification
• Lumbard modification with bite block section

• Guedel oropharyngeal airway (1933) is a hard rubber oropharyngeal airway with a straight bite-block section, an anatomically shaped pharyngeal curve section, a hole at the distal end of the tube, and a flange at the proximal end to prevent overinsertion. Later, they were made of plastic material


• Safar oropharyngeal airway (1957) for mouth-to-mouth ventilation in resuscitation


• supraglottic ventilatory devices
• facial mask / facemask
• Greenberg's cuffed oropharyngeal airway (COPA™, Mallinkrodt Medical, Inc., Athlone, Ireland)^{ref1, ref2} consists of a Guedel oropharyngeal airway shaped airway with a specially designed cuff and a 15-mm connector. is an inexpensive, disposable device, which combines a Guedel airway with an inflatable distal high volume, low-pressure cuff and a 15 mm proximal adapter. It is designed to create an effective airway without stimulating the larynx and can be used when facemask ventilation has proved to be difficult, as an adjunct to fiberoptic intubation, and with positive pressure ventilation. It can support the airway in spontaneously breathing anaesthetised patients and compares favourably with the laryngeal mask airway for spontaneously breathing adults. Tracheal intubation using fiberoptic guidance requires maintenance of a patent airway during viewing of the vocal cords and passage of the endotracheal tube. In anaesthetised patients, devices such as the LMA are generally limited to the oral route, require a smaller tracheal tube to pass within the device and a technique to exchange or remove the laryngeal mask when tracheal intubation has been accomplished. This can cause airway trauma or even loss of the airway during the maneuver. Intubation using an appropriately sized tracheal tube and without the need for potentially dangerous tube exchange when intubation has taken place would be an advantage. The COPA may allow fibreoptically guided tracheal intubation via either the oral or nasal route, using a tracheal tube of any (appropriate) size, and without the need for subsequent exchange to an alternate tube


• laryngeal tube (LT™, VBM Medizintechnik GmbH, Sulz, Germany) is a newly developed, multi-use, latex-free, single-lumen silicon tube with oropharyngeal and esophageal low-pressure cuffs, a ventilation outlet in between and a blind distal tip (almost like a single-lumen, shortened Combitube). Ventilation and oxygenation capabilities are similar to the LMA and Combitube. Simple handling, possible aspiration protection and availability in newborn-adult sizes are considered to be advantages of this airway device.
• O'Dwyer laryngeal tube (1895) : life-saving alternative to tracheotomy for the treatment of diphtheritic laryngeal obstruction, inserted using a special curved forceps and digital palpation as guide; the upper flange prevented it falling through the larynx.
• Pharyngeal Airway Xpress (PAX™, Vital Signs Inc., Totowa, NJ) is a sterile, latex-free, single-use airway device intende for use during routine anesthesia procedures. It is curved tube designed with ana antomically shaped gilled tip at the distal end, a large oropharyngeal cuff and an open "hooded window" that allows ventilation placed in between. It is placed blindly, without the aid of any instrument, and when positioned correcty should provide an effective seal.
• glottic aperture seal airway (GO₂™, Augustine Medical Inc, Eden Prairie, MN) is a newly developed, disposable, single-lumen airway that is capable of achieving a highly effective seal against and within the laryngeal inlet. It is inserted with the aide of a stainless steel insertion instrument (blade). Thus far, 2 adult sizes have been developed and pediatric sizes are under consideration.
• Esophageal Tracheal Combitube™ (ETC, Tyco-Kendall Co., Manchester, NH) is a disposable double-lumen tube that combines the features of a conventional ET and that of an esophageal low-pressure cuff with 8 ventilatory holes in between. Ventilation is possible with either tracheal or esophageal intubation. It can be used in patients greater than 4 feet in height in elective or emergent situations, both in and out of the hospital environment. Like the Proseal, the Combitube should protect against aspiration. It is especially useful for patients in whom direct visualization of the vocal cords is not possible, as in patients with massive airway bleeding or regurgitation, limited access to the airway and in patients in whom neck movements is contraindicated. 2 adult sizes are currently available and a pediatric version is under development. The blue tube should be placed in trachea and filled with 100 ml of air, while the white tube should finish into esophagus and filled with 15 ml of air. When the oral cavity if closed by the filled balloon of the blue tube and the esophagus is closed by the filled balloon of the white tube, all air exiting the 2 holes at the end of the blue tube enters the larynx and the white tube can be used to empty stomach. Lung expansion is asssed with capnograph, disk or phonendoscope.


If the blue tube is mistakenly placed into esophagus, the white tube is used for ventilation. Prolonged use of the Combitube may incur greater risk of airway complications such as tongue engorgement^ref.
• laryngeal mask airway (LMA™; LMA North America, Inc., San Diego, CA) is the single most importnt development in airway devices in the past 20 years (Archie Brain, 1983). It is a device for maintaining a patent airway without tracheal intubation, consisting of a tube connected to an oval inflatable cuff that seals the larynx. The LMA has revolutionised airway management in anaesthesia and seems set to do so for resuscitation. Since its introduction into clinical practice, has been used in > 100 million patients worldwide without fatality. Although originally developed for airway management of routine cases with spontaneous ventilation, it is now listed in the ASA Difficult Airway Algorithm in 5 different places as either an airway (ventilatory device) or a conduit for endotracheal intubation. It can be used in both pediatric and adult patients in whom ventilation with a face mask or intubation is difficult or impossible. Also, it can be used as a "bridge to extubation" and with pressure support or positive pressure ventilation. There have been several new variants of the LMA including the LMA Classic™ (standard LMA), such as the LMA Flexible™ (wire reinforced flexible LMA), LMA Unique™ (disposable LMA), LMA Fastrach™ (intubating LMA) and most recently, the LMA Proseal™ (gastric LMA). The Proseal was designed with a modified posterior cuff to improve the laryngeal seal and incorporates a second tube to provide a channel for gastric tube placement or passage of regurgitated fluid. It is postulated that the Proseal will replace the Classic LMA, as it is designed to provide a better seal, as well as protect the airway against aspiration.
• ProSeal™ LMA (PLMA) : at 60 cmH₂O intracuff pressure, PLMA gives twice the seal  pressure of the standard device (LMA-Classic™) and permits blind insertion of a gastric tube in all cases. It allows fluid in the oesophagus to bypass the pharynx and mouth when the drainage tube is open. Both the LMA, and the PLMA with a closed drainage tube, attenuate liquid flow between the oesophagus and pharynx. It is more difficult to insert unless an introducer tool is used. When correctly positioned, the PLMA isolates the glottis from the upper oesophagus with possible implications for airway protection
• laryngeal tube suction™ (LTS)

Advantages :
• simple to use : inserted blindly into the pharynx and forms a low pressure seal around the laryngeal inlet. Its appeal is based largely on less need for skill and training than with either facemask or an endotracheal tube^ref. All paramedic crews and emergency departments have the laryngeal mask as standard equipment, and its popularity in hospital resuscitation is growing
• atraumatic to insert : minimally stimulating to the airway, thus avoiding the unwanted sympathetic stimulation associated with laryngoscopy
• helpful in overcoming an obstructed airway, filling the gap between tracheal intubation and the use of a face mask.
• reusable : the LMA is constructed of medical-grade silicone rubber with no latex in any part. This allows the LMA to withstand repeated autoclaving.
• cost-effective
The face mask falls short, stopping at the mouth and nares, and the endotracheal tube (ETT) goes too far, penetrating the lumen of the trachea. Furthermore, the ETT cuff applies a high lateral pressure to the delicate epithelial surface of the respiratory tree, provoking undesirable autonomic responses. The LMA was first used at the Royal London Hospital in 1981^ref. It was subsequently used successfully in a pilot series of 23 patients^ref. In 1983, Brain reported the first use of the LMA in a failed intubation. The LMA became commercially available in the UK in 1988, and it has been reported^ref that the device is used in 50% of general anesthetics in some centers there. In August 1991, the LMA was approved by the US FDA. In the USA, interest in the device has increased as more experience is gained with the LMA in elective operations, patients with a difficult airway, and trauma patients. The device has a shaft ranging from 5.25 to 12 mm in internal diameter, depending on the size of the LMA. The shaft is fused at a 30° angle to a distal elliptical spoon-shaped mask with an inflatable rim resembling a miniature face mask. The shaft is marked with a longitudinal black line along the posterior aspect. The shaft opens into the concavity of the ellipse via a fenestrated aperture with 3 orifices to prevent the epiglottis from falling back and blocking the lumen. 5 sizes are now available, and a size 5 LMA that will accommodate a 7.0 ETT will soon be available. Presently, the LMA retails for approximately $200. Studies are under way to determine how many times the device can be reused. It is estimated that each device may be used at least 50 times before cuff deterioration necessitates replacement. Although the cuff survives repeated autoclaving, it is easily torn on jagged teeth. Because these devices tend to be lost or thrown away, some form of accountability is indicated. For routine use, the insertion of the LMA requires an anesthetic depth similar to that which allows insertion of oropharyngeal airway. A recent study looked at end-tidal concentration (ETC) for laryngeal mask airway insertion and for tracheal intubation in children. It was determined that the ETC for laryngeal mask insertion was the same as minimum alveolar concentration for halothane, enflurane, and sevoflurane and was less than ETC required for tracheal intubation^ref. Most induction agents have been used successfully. A study comparing sodium thiopental and propofol as induction agents indicated that propofol resulted in less coughing and gagging as compared with thiopental at appropriate dosing^ref. Insertion of the LMA requires no laryngoscopy. The patient is placed in the sniffing position. The head is held in slight extension by having the nonintubating hand stabilize the occiput. The jaw is allowed to fall open or is held open by an assistant. Brain's original insertion technique describes the distal tip of the deflated LMA cuff as being pressed against the hard palate using the index finger to guide the tube over the back of the tongue. The tube is advanced until a characteristic resistance is felt as the upper esophageal sphincter is engaged. Without holding the tube, the cuff is inflated with the appropriate amount of air. This will result in a characteristic outward movement of the tube of up to 1.5 cm. This occurs as the cuff centers itself around the laryngeal inlet and results in a slight movement of the thyroid and cricoid cartilages. The longitudinal black line on the shaft of the tube should lie in the midline against the upper lip. A deviation may result in misplacement of the cuff and partial airway obstruction. A variation on insertion technique has been described in the pediatric population. McNicol^ref inserts the device upside down, with the laryngeal aperture pointing cephalad. As the LMA enters the pharynx, it is rotated through 180¡. Other maneuvers to aid in insertion include slight inflation of the cuff, a jaw thrust maneuver, and, in the rare instance, laryngoscopy. Spontaneous or controlled ventilation may be chosen once the LMA is correctly placed. The LMA has been used without complications in operations of up to 7 hours in duration. It is important to remember that the silicone rubber cuff of the LMA is highly permeable to nitrous oxide and both cuff volume and pressure increase during N₂O anesthesia^ref. With intermittent positive pressure ventilation, an audible leak at 15 to 20 cmH₂O is common. Correct positioning is achieved on the first attempt in 88-90% of patients, rising to 95% to 98% on the second attempt^ref. When correctly positioned, the tip of the LMA cuff lies at the base of the hypopharynx against the upper esophageal sphincter, the sides lie in the pyriform fossae, and the upper border of the mask lies at the base of the tongue, pushing it forward. The epiglottis often lies within the bowl of the LMA, but the device functions satisfactorily with the epiglottis in the upright horizontal or downfolded position. A radiologic study showed that in 24 elderly men, there was epiglottic downfolding in 66% of these cases^ref. Removal of the LMA as described by Brain4 should be done once the patient is awake and can open the mouth on command. The LMA cuff protects the larynx from pharyngeal secretions and the risk of inducing laryngospasm by early removal. Others believe it is reasonable to remove the LMA at a deeper plane of anesthesia. This allows the anesthesiologist to lighten the plane of anesthesia and have the patient ready for transfer to the post anesthesia care unit. One must be careful to first suction gently around the cuff before deflation, in order to decrease the risk of secretions inducing laryngospasm. An airway with the LMA does not guarantee an airway with a mask. The LMA is reusable, and the manufacturers guarantee each mask for 10 autoclavings^ref. Some institutions have recorded more than 250 cycles with normal function of the LMA. The longevity of the LMA under routine use is being studied. The most vulnerable part of the device is the valve. The LMA is washed with soap and water, then autoclaved at 134¡C for at least 3 minutes. The critical point in the cleaning process is to make sure that the cuff is entirely deflated before autoclaving. The LMA is contraindicated if a risk of aspiration exists. The inflatable cuff does not guarantee an airtight seal to protect the larynx from aspiration of vomitus. Studies have shown that with the LMA in the proper position to provide satisfactory ventilation, the esophagus is visible via fiberoptic evaluation in 6% to 9% of patients. A study compared the incidence of gastroesophageal reflux in anesthetized patients who were being managed with either the LMA or a face mask. Reflux was assessed with small pH probes placed in the esophagus. A significantly higher percentage of LMA patients had pH <4.0^ref. It has also been shown that controlled ventilation via the LMA with high inflation pressure increases intragastric pressure and contributes to gastric regurgitation. Therefore, the LMA should not be used if a high inflation pressure of more than 20 cmH₂O is required. The risk of aspiration is greater in patients who receive positive pressure ventilation via the face mask than in patients spontaneously breathing through the LMA^ref. Brain recommends that a wide-bore tube be passed before the LMA is inserted, or, alternatively, an orogastric tube may be passed later if the LMA is deflated slightly. Others believe that the orogastric tube may compromise the integrity of the lower esophageal sphincter and increase the risk of regurgitation. Measures to decrease the likelihood of aspiration are as follows:
• outinely test the cuff for defects before use
• avoid lubricating the anterior surface of the mask, since the lubricant may be aspirated
• insert the LMA only when an adequate depth of anesthesia has been reached
• avoid disturbing the patient during emergence from anesthesia
• keep the cuff inflated until the patient is awake.
These are the recommendations of the manufacturer. If aspiration occurs, Brain recommends leaving the LMA in place, tilting the patient's head down, and suctioning through the LMA. Cricoid pressure may make the placement of the LMA more difficult. One study showed that only 3 of 22 patients could have the LMA correctly placed when cricoid pressure was being applied. It appears that transient release of cricoid pressure would facilitate the passage of the LMA^ref. One must weigh the risks of aspiration against the ability to maintain a patent airway. In 1991, Benumof^ref reviewed the difficult airway algorithm and included the LMA in the "cannot ventilate, cannot intubate" scenario. In this section, the LMA is grouped with the Combitube and transtracheal ventilation. All techniques have a low risk-benefit ratio and can be instituted quickly and blindly. Several other limitations apply to the LMA. If the mouth cannot be opened more than 1.5 cm, the LMA cannot be used. The LMA does not provide protection against aspiration. It also may be difficult to provide adequate ventilation if large airway pressures are required. Finally, there may be as high as a 10% to 50% failure rate, especially with cricoid pressure. However, it is a reasonable airway to try before attempting a more invasive technique such as transtracheal jet ventilation. When the LMA is correctly positioned, the distal aperture sits directly over the laryngeal inlet. This allows a variety of blind or fiberoptically guided techniques to intubate the trachea. Since the LMA can be inserted rapidly and blind intubation through the LMA does not require additional equipment, it may play a role in both emergency and elective procedures in both anesthetized and awake patients. A number of objects have been described that can be passed through the LMA into the trachea and followed by an endotracheal tube. In one report^ref, a gum elastic bougie was passed through the LMA and the LMA was then removed. Next, an endotracheal tube was "railroaded" over the bougie through the vocal cords into the trachea. The downside of this technique is the period during which the airway is neither controlled nor protected. In addition, this technique is reported to have an 84% to 88% success rate. We elect to pass an uncut, lubricated, 6.0 mm cuffed endotracheal tube through the shaft of a size 3 or 4 LMA. The length of the LMA is such that when the ETT is fully inserted, about 8 cm project beyond the distal aperture and the upper margin of the tube cuff lies approximately 3 cm below the vocal cords. Correct placement of the ETT is confirmed by bilateral breath sound auscultation and positive identification of end-tidal CO₂. If a larger endotracheal tube is needed, we use a endotracheal tube exchanger (preferably one that allows oxygenation), which is placed through the LMA/ETT system. The two devices are then removed as a unit, and an appropriately sized ETT is passed over the tube exchanger. This technique was used in a study of 50 patients, 72% of whom were intubated within 13 seconds and a further 12% after minor adjustments^ref. A similar degree of success was reported using size 1 and 2 LMAs. A study of 100 patients revealed a success rate of 90%. The figure fell to 56% with the application of cricoid pressure. Problems were more frequent in men having a large floppy epiglottis that folded down over the laryngeal inlet. The use of a fiberoptic bronchoscope (FOB) may both enhance placement and confirm correct positioning. There have been attempts at altering the LMA to aid intubation via the LMA. Brimacombe^ref devised an LMA with its distal aperture bars removed and a longitudinal slit up its shaft. A fiberoptic bronchoscope with a mounted tracheal tube is passed through the LMA into the trachea; the LMA is then peeled off and the tube passed over the FOB. These modifications are not simple and are not recommended by the manufacturer. The smaller sizes of the LMA are scaled-down versions of the sizes 3 and 4 used in adults. Brain studied the pediatric airway using infant cadavers and concluded that their airway was similar to that of adults. There are, however, many anatomic differences of which most physicians are aware. These include the infant's relatively large tongue; a higher, smaller, and more anterior larynx; and a more acute angle between the floor of the mouth and the pharyngeal lumen. Experience in using the LMA should be gained in adults before using it in children. Pediatric patients tend to have more complications, particularly with the size 1 LMA. There appears to be a smaller margin of error in positioning the device in children. Even with proper position of the LMA, there may be inflation of the stomach if airway inflation pressure exceeds the LMA cuff seal pressure of 20 cmH₂O. Breath-holding and laryngospasm may be mistaken for incorrect placement. Thus, an adequate depth of anesthesia is necessary and tends to be deeper than that for adults. Other problems that may occur more frequently in the pediatric patient are centered around insertion^ref. Various maneuvers that may be used to minimize these problems include
• inserting the LMA laterally rather than in the midline
• applying the mask firmly against the hard palate
• pulling the tongue forward
• repositioning the head
• adding or removing air from the cuff
• adding constant positive airway pressure
• using a laryngoscope
• using a rotational technique as described by McNicol^ref.
Mitzushima^ref inserted the size 1 LMA in 50 infants. A clinically acceptable airway was obtained in 94% of the cases on the first attempt, though fiberoptic examination showed that perfect positioning had been obtained in only 44%. Mitzushima concluded that a clinically patent airway does not guarantee ideal LMA positioning or continued airway patency in infants. St. Clair Logan studied the use of the LMA in 507 children in Manchester, England. Attempted insertion was unsuccessful in 2%, and there were difficulties with insertion in 7.1%. A total of 31 children (16%) had complications in the recovery period. Most of the complications were related to inadequate depth of anesthesia and were not clinically significant. Excessive secretions led to the potential for clinically significant complications (ie, laryngeal spasm). The author recommended measures to reduce secretions, such as minimizing crying and premedicating with an antisialagogue. One other area of controversy is the proper time to remove the LMA. Some authors recommend removal after allowing the patient to awaken. If this route is chosen, use of a bite block is recommended to avoid the common complication of attempted biting on the LMA. Others prefer to remove the LMA at a deeper level of anesthesia. The reasoning behind this approach is that it is easier to lighten the level of anesthesia as the surgeons are finishing, leading to a more expeditious room turnover, and if one treats the LMA as a glorified face mask, one is less apt to create a problem. With this technique, there does not appear to be an increased incidence of aspiration or laryngospasm. There is also less likelihood of damaging the LMA, and there is no need for a bite block.
Side effects : gas leak => gastric inflation^{ref1, ref2} => gastric dilation => gastric rupture => tension pneumoperitoneum^ref
• gold standard endotracheal intubation in direct laryngoscopy :
• laryngoscope with charged batteries
• lighted stylets :
• Trachlight™ : (Laerdal Medical Corp., Long Beach, CA) consists of 3 parts: a reusable handle, a flexible wand and a stiff, retractable stylet. It is especially useful in situations in which the FOB is unavailable (e.g. ambulances, emergency departments) or in which bronchoscopy is difficult to perform (e.g. airway obscured by blood or secretions, head cannot be flexed or head extended). This device is now provided with 3 stylets which are reusable and will accommodate tracheal tubes from 2.5-10 mm (ID)
• Ventus Seeing Eye Stylet System™ (American West Medical Co., Leneza, Kansas) was recently developed to improve the limitations of the standard flexible FOB. It has the simple form of a standard stylet, but has the advantage of a fiberoptic view and maneuverability of its tip. It can be used alone without difficulty, and is especially useful for thouse unable to maintain skills with a bronchoscope
• AeroView Endotracheal Scope System™ (Imagyn Medical Technologies, Newport Beach, CA) is a new portable fiberoptic management system in which the scope is used to with disposable sheaths. A lever controls its distal tip unidirectionally and the view is projected to and endoview camera system
• Bonfils Retromolar™ (MVM) Intubation Fiberscope (Karl Stortz, Gmb & Co, KG, Tuttlingen, Germany) is a 5.0 mm optical stylet that allows a retromolar approach to the difficult airway. It is designed to position a 6.5 mm or larger endotrcheal tube directly in front of vocal cords with minimal manipulation of the epiglottis
• laryngoscope straight or curved blades with functioning light source
• endotracheal or tracheal tube (ETT) of various diameters : a tube inserted into the trachea through the mouth, the nose, or a tracheostomy for
• administration of anesthesia
• maintenance of an airway
• aspiration of eventual secretions in the tracheobronchial tree
• positive presure mechanical ventilation of the lungs
• prevention of entrance of foreign material into the tracheobronchial tree.
• aspiration system with flexible tubes
• syringe to inflate the cuff of the ETT
• endotracheal tube guides :
• single-use
• Frova Intubating Introducer™ (Cook Critical Care, Bloomington, IN) was recently designed for facilitation of endotracheal intubation to allow simple endotracheal tube exchange. Its distal tip is angulated like the GEB, but it has 2 side ports. It has a hollow lumen and is packaged with  a stiffening cannula, which is not necessary for use, as well as a removable Rapi-fit adapter that permits ventilation.
• Arndt Airway Exchange Catheter Set™ (Cook Critical Care, Bloomington, IN) can be used for the excange of LMAs and ETs using a fiberoptic bronchoscope (FOB). It has a tapered end, multiple side ports, and is packaged with a stiff wire guide, bronchoscopic port, and Rapi-fit adapter.
• Aintree Airway Exchange Catheter™ (Cook Critical Care, Bloomington, IN) can also be used for the exchange of LMAs and ETs using a  FOB. Like the Supkis airway exchange catheter, its hollow lumen allows insertion of a FOB directly through the catheter
• VETT System™ (PulmonX, Inc., Palo Alto, CA) involves integration of ultra thin FOB bundles into ETs, intubation stylets, laryngoscope blades and allows television monitor projection of the image seen from the end of the device. It may be useful adjunct in the management of the difficult airway, as it enables fiberoptic visualization of all airway structures during intubation
• multiple-use
• Eschmann Tracheal Introducer (Eschmann Health Care, Kent; UK or SIMS Portex; US) also known as the gum elastic bougie (GEB) is conidered the first choice of intubation aides in the UK and is also very popular in the US. It is useful in patients with an "anterior larynx" and those with limited mouth opening. Straight Eschmann tracheal tube guides are designed for endotracheal tube exchange :
• Ambu ballooon ventilation apparatus with relative connectors for the ETT
• oropharyngeal airway
• oxygen
• Magill's intubating forceps are used for nasotracheal intubation, endotracheal suctioning, passing gastric tubes, placement of tampons in the nasopharynx and extraction of foreign material from the pharynx. There are several disadvantages of the standard Magill forceps; however: the danger of cuff perforation, the necessity of readjusting the forceps when placing a tube or catheter, and the risk of injury to the mucous membrane. For these reasons the standard Magill forceps have been modified: the jaws of the forceps have been changed to give curved atraumatic parts without any serrations or sharp edges. The resulting benefits are as follows: reduced risk of injuring the mucous membrane and perforating the cuff. Tubes and catheter are safely guided between the semiround jaws, making it unnecessary to open the forceps repeatedly to advance the tube. Tampons being placed in the throat no longer get caught between the serrations, and even small foreign objects can easily be extracted from the pharynx.


• fixatives for the ETT
• phonendoscope to assess positioning of the ETT
• silica gel or lubrifying
Indications :
• vigile patient in respiratory failure
• coma
• patient undergoing general anesthesia

• endotracheal airway : an ETT that serves as an airway.
• Endotrol tube (Mallinckrodt Critical Care, Inc., St. Louis, MO) has a tracheal ending which can be manipulated on a sagitall plane. It is available in 4 sizes :  6.0, 7.0, 8.0, 9.0 mm of inner diameter. Endotrol has been successfully used together with capnography for orotracheal intubation in 80% of awaken patients and in 90% of patientes undergoing general anesthesia and in spontaneous respiration. It can also be used with the Beck Airway Airflow Monitor^® (Great Plains Balli-stics, Lubbock, TX), consisting of a both inspiratory and expiratory whistle which once connected to EET allows detection of breath sounds
• endotracheal intubation : insertion of an ETT
• Sellick maneuver : the application of pressure to the cricoid cartilage in order to compress the esophagus and prevent passive regurgitation during endotracheal intubation.
• orotracheal intubation : insertion of an orotracheal tube
• orotracheal tube : an ETT that passes through the mouth.
• nasotracheal intubation : insertion of a nasotracheal tube. The median distance between narices and carina is ...
• 32 cm in males
• 27 cm in females
• variable according to to size of head and length of trachea
• nasotracheal tube : an ETT that passes through the nose. Prevented by :
• nasal septal deviation
• nasal polyps
• hypertrophied adenoids or palatine tonsils
• edematous uvula
Kuhn endotracheal intubation set (1900)

Unfortunately, most of his surgical colleques did not recognize the importance of tracheal intubation since they were influenced by the outstanding surgeon Ferdinand Sauerbruch (1875 to 1951) who refused this technique.
Cormack-Lehane laryngoscopic vision scale^ref :
• grade 1 : whole larynx visible


• grade 2 : only part of the glottis visible


• grade 3 :


• grade 4 :


Cook’s modified laryngeal classification^ref : the best laryngeal view obtained with or without anterior laryngeal pressure is recorded.
• grade 1 : most of the cords visible
• grade 2a : posterior cord visible
• grade 2b : only the arytenoids or the very posterior origin of the cords visible. Grade 2b denotes a laryngoscopic view that is relatively common and is often associated with difficulty passing a tracheal tube.
• grade 3a : epiglottis visible and liftable
• grade 3b : epiglottis adherent to pharynx
• grade 4 : no laryngeal structures seen
These grades are categorized as :
• easy (E) when the laryngeal inlet is visible (grade 1 and 2a)
• restricted (R) when the posterior glottic structures (posterior commissure or arytenoids) are visible or the epiglottis is visible and can be lifted (grade 2b and 3a)
• difficult (D) view is present when the epiglottis cannot be lifted or when no laryngeal structures are visible (grade 3b and 4)

Conditions that predispose to a difficult intubation include :
• incorrect position of the patient.
• inadequate or improper equipment
• difficult airway
• anatomy : small mouth opening, protruding upper teeth, macroglossia, micrognathia, retrognathia, immobility of the head, neck and jaw
• Mallampati's scale :


• distances :
• mentohyoid (MH) distance between more protuding point of mental symphiss and upper part of hyoid bone with hyperextended head (< 45 mm)
• interincisive (II) distance between upper and lower incisor teeth with open mouth (< 35 mm)
• thyromental (TM) distance between the most protruding point of mental symphisis and Adamus' pomus with hyperextended head (< 60 mm)
• mentosternal (MS) distance between mental symphisi and upper border of sternum with hyperextended head (< 12 cm)
• infection: epiglottitis, abscesses, croup, bronchitis, pneumonia
• trauma : maxillofacial fractures, cervical spine injury, laryngeal injury
• endocrine : morbid obesity, diabetes mellitus, acromegaly
• foreign body
• inflammatory conditions : ankylosing spondylitis, rheumatoid arthritis
• upper and lower airways tumours
• congenital problems : choanal atresia, tracheomalacia, cleft palate, Pierre Robin syndrome, Treacher Collins syndrome, Hallermann-Streiff-François syndrome
• pregnancy
• difficult direct laryngoscopy = Cormack-Lehane grade 3 or 4 (2-8%)
• difficult endotracheal intubation = difficult direct laryngoscopy, or > 4 attempts, or > 5 minutes for execution (1.2-3.8%)
• impossible endotracheal intubation (0.1-0.3%)
• difficult mask ventilation (0.01-0.07%) : inability to maintain SpO₂ > 90% with O₂ = 100% or to correct signs of inadequate ventilation for a single health-care worker
Preoperatory anesthesiological examination detects 90% of difficult airways, so that unexpectedly difficult airway (Cormack-Lehane grade 3 or 4) should occur in < 2%. In 56% of difficult airway sequelae are death or permanent cerebral injury. Anesthesiological conduct is inadequate in 60% of these cases^{ref1, ref2}.
• extreme difficulty : awake intubation in local anesthesia with fibroscope allows patient collaboration and oxygenation and allows better view of anatomical structures
• mild difficulty : induction of anesthesia and following laryngoscopic evaluation +/- myorelaxation; preoxygenation (facial mask with 100% O2 for > 3 min)
Give-up after 3 unsuccessful attempts  by experienced personnel.
Additional maneuvers :
• modified Jackson's maneuver
• backwards-upwards-rightwards-pressure (BURP) of the larynx. It has been shown that applying cricoid pressure causes anatomical distortion of the upper airway and makes airway management more difficult^{ref1, ref2}. The application of cricoid pressure may interfere with laryngoscope blade placement^ref. Furthermore, external laryngeal pressure to improve the view of the larynx may not be performed concurrently with cricoid pressure^ref. Applying cricoid pressure worsens the view of the larynx. A gum elastic bougie is superior to a stylet for tracheal intubation during application of cricoid pressure^ref.
Side effects :
• preparation and intubation :
• fractures and luxation of cervical spine
• ocular lesions
• epistaxis
• dental trauma and damage to prostheses
• nasal injuries
• retropharyngeal dissection
• subcutaneous and mediastinic emphysema
• esophageal perforation
• bronchial inhalation of blood, gastric content, teeth, prostheses, lamps of laryngoscope
• ingestion of tooth, prostheses, or lamps of laryngoscope
• esophageal intubation and gastric distension
• intubation of a bronchus
• laryngeal-vagal and laryngeal-sympathetic or laryngo-spinal reflexes
• complications due to drugs used for intubation
• fixed tube
• obstruction of tube by secretions, blood, fragmens of tube, flexures, dislocation of cuff
• intubation of a bronchus
• esophageal intubation
• accidental extubation
• mucosal ischemia
• inhalation due to poorly inflated c
• bronchospasm due to disinfectants or detergents used for laryngoscopes and tubes (formaldehyde, quaternary ammonium bases, phenol)
• extubation :
• self-extubation
• injury to vocal cords and glottis due to undeflated cuff
• edema of glottis
• edema of uvula due to aspiration with excessive pressure
• laryngeal croup
• sequelae immediately or lately after extubation
• laryngospasm
• vomiting and inhalation
• (persistent) laryngeal and subglottic edema
• dysphagia and hoarseness
• ulcerations
• tracheitis
• paralysis of vocal cords
• dislocation of arytenoid cartilage
• necrosis of nasal pinnae
• the abundant sensory innervation of upper airways (expecially mucous free terminations in larynx and pharynx) may cause reflexed vegetative responses mediated by vagus, glossopharyngeal and upper laryngeal nerves, prevented by deep anesthesia :
• swallowing
• sialorrhea
• relaxation of lower esophageal sphincter (LES)
• conatus of vomiting
• cough
• sense of suffocation
• hypoxia and hypercapnia
• increased airway resistance
• bronchoconstriction
• laryngospasm
• systemic arterial hypotension or systemic arterial hypertension
• bradycardia or tachycardia
• intracranial hypertension and intraocular hypertension
• alternative approaches
• nasal
• oral blind
• semiblind or indirect
• special airway techniques :
• flexible fiberoptic intubation is a very reliable approach to difficult airway management and airway assessment. It has more universal application than any other technique. It can be used orally or nasally for both upper and lower airway problems and when access to the airway is limited. It can be used in patients of any age and in any position.
• technological advances including improved optics, battery-powered light sources, better aspiration capabilities, increased angulation capabilities, and improved reprocessing  procedures have been developed
• rescue techniques such as placing a retrograde guide wire through the suction channel may be employed if the glottic opening cannot be located with the scope, or if blood or secretions are present. Insufflation of oxygen or jet ventilation through the suction channel may provide additional time when difficulty arises in passing the ET into the trachea
• retrograde intubation is an excellent technique for securing a difficult airway either alone or in conjunction with other alternative airway techniques. The technique is simple, straightforward, and should be a skill of every anesthesia care provider. It is especially useful in patients with limited neck mobility (cervical spine pathology) or who have suffered airway trauma. Recent advamcements in the technique include the introduction of the Arndt Airway Exchange Catheter™ (Cook Critical Care, Bllomingoton, IN) and needle holder to the preexisting retrograde intubation set. The Arndt catheter will allow patient oxygenation if necessary during the procedure, and is recommended for use with ETs 5.0 mm or larger
• transtracheal jet ventilation is a well accepted method for securing ventilation in rigid and interventional bronchoscopy. It is applied in rigiid bronchoscopy with a specially designed jet valve and in fiberscopes in which the jet injector is attached to the suction channel without intervening tubing. It may also be used to prophylactically secure a difficult airway by placing a cricothyrotomy catheter, or an airway exchange catheter into the trachea in order to establish effective ventilation prior to induction of anesthesia. There are a number or commercial manual jet ventilation devices currently available. The Enk Oxygen Flow Modulator™ (Cook Critical Care, Bloomington, IN) is a new device, which is recommended for use when jet ventilation is appropriate, yet a jet ventilator is not available.
• surgery : in cannot-ventilate, cannot-intubate (CVCI) option
• cricothyrotomy
• tracheostomy
Web resources : The Airway Site
• gastrointestinal tubes
• esophageal or stomach tube : a tube for feeding or for irrigation of the stomach
• Abbott-Rawson tube : a double barreled tube through which fluid may be both injected and aspirated; it may be used for lavage or decompression of the stomach.
• Ewald tube : a tube of large bore used to evacuate the stomach.
• feeding tube : a tube for introducing fluids of high caloric value into the stomach.
• nasogastric tube (NGT) (the most common kind : see also movie) : a tube of soft rubber or plastic inserted through a nostril and into the stomach, for instilling liquid foods or other substances, or for withdrawing gastric contents.
• nasoduodenal feeding tubes
• Entriflex^® (Sherwood Medical, St. Louis, MO)
• single lumen :
• Levine^® tubes : may be clear plastic, red rubber or white radiopaque. These are usually passed through the nares into the stomach and connected to a Gomco machine for the purpose of emptying the stomach of it's contents.
• double lumen :
• Salem Sump^® tube (Argyle Co, St. Louis, Mo) : this is a double lumen sump designed to empty stomach content : the second lumen creates an airway to prevent the tube from adhering to the stomach  when continuous suction is applied and prevent suction from drawing mucosa into drain lumen. It is hooked up to straight wall (low or medium) suction
• Wangensteen's apparatus or tube : a small NGT connected with a special suction apparatus to maintain gastric and duodenal decompression
• decompressing tubes:
• Anderson tubes : a double lumen tube, one side of which is designed for gentle irrigation to keep the tube open.
• Cantor tube
• Miller-Abbott tube
• percutaneous endoscopic gastrostomy (PEG) tube
• percutaneous endoscopic jejunostomy (PEJ) tube
• Dobhoff tube :


Size :
• small bore long term 8 to 12 Fr
• larger bore short term feeding or continuous suction 12 to 16 Fr.
• intestinal tubes
• Harris tube : a single-lumen tube with a mercury weight, used as a diagnostic aid in the study of the small intestine
• horizontal tube : a metal tube attachment placed in a horizontal position on the buccal surface of each anchor molar.
• Cantor tube : adult or pediatric size, this is a single radiopaque tube with a balloon weighted with 1-2 ml mercury on the end for intestinal intubation (a hard rubber probe about 120 cm in length), introduced via the narix : when in pharynx a mercury bag is screwn down the probe to facilitate descent. Used to resolve intestinal subocclusions : progression is facilitated by aspiration of gastrointestinal content
• Miller-Abbott tube : a double-channel intestinal tube with an inflatable balloon at its distal end, for use in the treatment of obstruction of the small intestine; the balloon is weighted with mercury after placement into the stomach, to aid its passage into the intestine; occasionally useful also as a diagnostic aid.


• Shiner's tube : a flexible plastic radiopaque tube for obtaining biopsy material from the jejunum under fluoroscopic control; the jejunal mucosa is drawn by suction into a small aperture in the knife cylinder head at the end of the tube, and a portion is excised.
• tampon tube : a piece of stout rubber tubing wound with iodoform gauze, used in plugging the rectum to control oozing and at the same time to allow the escape of gas.
• Paul-Mixter tube : a large-calibered, flanged drainage tube of glass used for temporary intestinal decompression.
• Ryle's tube : a thin rubber tube with an olive-shaped end used in giving a test meal.
• Sengstaken-Blakemore tube : a multilumen tube used for the tamponade of bleeding esophageal varices: one lumen leads to a balloon which is inflated in the stomach, to retain the instrument in place, and to compress the vessels around the cardia; another leads to a long narrow balloon by which pressure is exerted against the varices in the wall of the esophagus; and a third provides for aspirating contents of the stomach.


• nephrostomy tube : a tube inserted through the abdominal wall into the pelvis of the kidney, for direct drainage of the urine.
• Malecot nephrostomy catheter


• perecutaneous pigtail nephrostomy catheter with needle (PCN)


• double pigtail ureteral stent


• thoracostomy tube : a tube inserted through an opening in the chest wall, for application of suction to the pleural cavity; used to drain fluid or blood or to reexpand the lung in pneumothorax.
• tracheostomy tube : a curved endotracheal tube inserted into the trachea through the opening made in tracheostomy.
• Durham's tube : a jointed tracheostomy tube
• tympanostomy or ventilation tube : a tube inserted after myringotomy in chronic cases of middle ear effusion, such as in secretory or mucoid otitis media; it provides ventilation and drainage for the middle ear during healing.
• extubation / detubation : the removal of a previously inserted tube
• decannulation : extubation, especially of a tracheostomy cannula
• breast pump : a manual or electric pump for abstracting milk from the breast.
• infusion pump : a device for injecting a measured amount of fluid during a specific interval of time.
• infusion-withdrawal pump : a pump for the simultaneous injection and withdrawal of fluid at the same rate.
• insulin pump / continuous subcutaneous insulin infusion : an externally worn pump that can supply insulin to subcutaneous tissues through a plastic tube; a large bolus is infused before every meal and a continuous basal rate of insulin is maintained at other times
• peristaltic pump : a pump that moves liquid through tubing by alternate contractions and relaxations on the tubing.
• stomach pump : a pump for removing the contents from the stomach.
• cannulation / cannulization : the insertion of a cannula
• cannula : a tube for insertion into a vessel, duct, or cavity; during insertion its lumen is usually occupied by a trocar
• nasal cannula or prongs : a cannula that fits into the nostrils for delivery of oxygen therapy
• perfusion cannula : a double tube for running a continuous flow of liquid into and out of an organ.
• washout cannula : a cannula attached to a manometer and inserted into a blood vessel so that the connection between the artery and the manometer can be irrigated in long observations.
• hollow needle (butterfly)
• plastic catheter over hollow needle


• plastic catheter
• inserted in hollow needle (drum, cavafix)
• catheter over guidewire (Seldinger technique)
• catheter through introduce
• needle : a sharp instrument for suturing or puncturing
• biopsy needles for needle biopsies
• Abrams' needle : a biopsy needle designed to reduce the danger of introducing air into tissues, as in pleural biopsy.
• Cope's needle : a blunt-ended hooklike needle with a concealed cutting edge and snare, used in biopsy of the pleura, pericardium, peritoneum, and synovium.
• Menghini needle : a needle that does not require rotation to cut loose the tissue specimen in a biopsy of the liver.
• Vim-Silverman needle : an instrument for taking tissue specimens in needle biopsy, consisting of an outer cannula, an obturator, and an inner split needle with longitudinal grooves in which the tissue is retained when the needle and cannula are withdrawn.
• needles for bone marrow trephine biopsy (BMTB)
• Gardner needle


• Islam needle


• Jamshidi needle


• Janus needle


• Osgood needle


• Turkel needle


• Williams' and Nicholson's modified Sacker's trephine


• aspirating needle : a long, hollow needle for removing fluid from a cavity.
• needles for bone marrow aspiration biopsy (BMAB)
• Mallarmé needle


• Klima-Rosenthal needle



• Salah needle


• transseptal needle : a needle used to puncture the interatrial septum in transseptal catheterization.
• Brockenbrough needle : a curved steel transseptal needle within a Brockenbrough transseptal catheter; used to puncture the interatrial septum.
• cataract needle : one used in removing a cataract
• discission needle : a special form of cataract needle.
• knife needle : a slender knife with a needlelike point, used in discission of a cataract and other ophthalmic operations, as in goniotomy and goniopuncture.
• ligature needle : a slender steel needle with a long handle and an eye in its curved end, used for passing a ligature underneath an artery.
• aneurysm needle : one with a handle, used in ligating blood vessels.
• Deschamps' needle : one with the eye near the point, and a long handle attached; used in ligating deep-seated arteries.
• Chiba fine or skinny needle : a very thin, highly flexible steel needle (2.1 G = 0.7 mm) with a narrow inner core used to cannulate very small bile ducts to perform percutaneous (or fine needle) transhepatic cholangiography
• Hagedorn's needles : surgical needles which are flat from side to side, and have a straight cutting edge near the point and a large eye.
• hypodermic needle : a short, slender, hollow needle used in injecting drugs beneath the skin.
• Reverdin's needle : a surgical needle having an eye which can be opened and closed by means of a slide.
• Seldinger needle : a needle with a blunt, tapered external cannula with a sharp obturator; used for the initial percutaneous insertion characteristic of the Seldinger technique for arterial or venous access.
• stop needle : a needle with a shoulder that prevents it from being inserted beyond a certain distance.
• swaged needle : one permanently attached to the suture material.
• Tuohy needle : one in which the opening at the end is angled 45° so that a catheter or endoscope through its lumen exits at an angle; used for examination or treatment of the epidermal space or subarachnoid space.
• Veress needle : a hollow needle consisting of a sharp trocar with a slanted end surrounding an inner cylinder with a blunt end; after the trocar is introduced into a body cavity the blunt cylinder is advanced outward so that internal organs are not injured by the sharp edge; used for insufflation of a body cavity, such as for pneumoperitoneum in minimally invasive surgery.
• puncture : the act of piercing or penetrating with a pointed object or instrument
• ventricular puncture
• cisternal puncture
• lumbar puncture
• sternal puncture
• tracheoesophageal puncture / Blom-Singer puncture : a one-way plastic valve placed in a surgically-created tracheoesophageal fistula to restore speech after laryngectomy
• transethmoidal puncture : a technique for obtaining postmortem biopsy specimens of the brain, using a trocar inserted through the nostril.
• splenic puncture : puncture of the spleen to obtain a specimen