ARE SINGLE USE BOUGIES FIT FOR PURPOSE?
Although the Eschmann Tracheal Tube Introducer [Smiths Medical, Ashford, UK] was once considered the gold standard, concerns about cross-infection with multiple-use devices1, 2 have led to an increasing reliance upon single-use alternatives3. The Frova Intubating Introducer [Cook® Medical, Bloomington, USA] is a commonly used example and has a high success rate for tracheal intubation in manikins4-6. There may however be increased potential for tissue trauma, suggested by both manikin studies4, 5 and reports in the literature7-12. We recently reported such a case13 in which a Frova traumatised the intermediate bronchus, causing major haemorrhage into the tracheobronchial tree. The injury created a flap of tissue which obstructed the right middle and inferior bronchi with a ball-valve effect.
The distal ‘hold up’ sign14 at the carina is not recommended by the manufacturer of the Frova15. This renders it unsuitable for useas an adjunct when following the current guidelines from the Difficult Airway Society16, in which this is a recognised technique for gauging correct intra-tracheal placement. The evidence for cross infection with the Eschmann is not robust and likely to be due, in part, to a failure to follow proper decontamination proceedures1, 2. Understandable concerns about infection control have driven the widespread introduction of single-use equipment.However, if the performance of single-use alternatives is inferior, there is clearly a balance to be struck between the risk to patients from cross-infection and the risk to patients from the use of potentially damaging equipment17. Additionally, a recent bench and manikin study has shown that the manufacturer’s recommendationto limit the number of decontamination cycles to five is unnecessarily cautious18, giving the Eschmann an additional economical advantage.
The Eschmann has recently been re-introduced at the Royal Devon and Exeter Hospital.Following a cost analysis and risk assessment its re-introduction is currently being consideredat Derriford Hospital, Plymouth.This process willbe presented, together with a discussion surrounding our reported case and the relevant literature.
1st Author:
Dr James Simpson
ST6 Peninsula Trainee
2nd Author of Case Report (Reference 13):
Dr Mike Duffy
Formerly Consultant in Anaesthesia and Intensive Care Medicine
Derriford Hospital, Plymouth, UK
Currently Consultant in Anaesthesia and Intensive Care Medicine
Raigmore Hospital, Inverness, Scotland
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