U.S. patent number 3,776,222 [Application Number 05/211,388] was granted by the patent office on 1973-12-04 for fiber optic entubator and method of entubation of the trachea through the nasopharynx.
This patent grant is currently assigned to Anthony M. Lurosso. Invention is credited to Joseph F. Smiddy.
United States Patent |
3,776,222 |
Smiddy |
December 4, 1973 |
**Please see images for:
( Certificate of Correction ) ** |
FIBER OPTIC ENTUBATOR AND METHOD OF ENTUBATION OF THE TRACHEA
THROUGH THE NASOPHARYNX
Abstract
An entubator for an endotracheal tube which includes a coherent
flexible fiber optic bundle which can be positioned within the
central cavity or lumen of the endotracheal tube for viewing the
anatomy of a patient as the endotracheal tube advances through the
patient during the insertion procedure. The entubator also includes
a means for directing the course of travel of the endotracheal tube
which enables the operator to navigate the endotracheal tube
through anatomical passageways made visible by the fiber optics
bundle. The fiber optic bundle and the means for directing the
course of travel enable the entubation of an endotracheal tube
through the nasopharynx of the patient. Method of entubing an
endotracheal tube through the nasopharynx.
Inventors: |
Smiddy; Joseph F. (Bethesda,
MD) |
Assignee: |
Lurosso; Anthony M. (Bethesda,
MD)
|
Family
ID: |
22786734 |
Appl.
No.: |
05/211,388 |
Filed: |
December 23, 1971 |
Current U.S.
Class: |
600/146; 604/21;
600/120; 385/117 |
Current CPC
Class: |
A61B
1/0056 (20130101); A61M 16/0488 (20130101); A61B
1/07 (20130101); A61B 1/00165 (20130101); A61B
1/2676 (20130101); A61M 16/0461 (20130101) |
Current International
Class: |
A61B
1/267 (20060101); A61M 16/04 (20060101); A61B
1/005 (20060101); A61b 001/06 () |
Field of
Search: |
;128/6,8,351,303.1,348 |
References Cited
[Referenced By]
U.S. Patent Documents
Other References
P Murphy-Anaesthesia Vol. 22, No. 3 July 1967 pp. 489-491.
|
Primary Examiner: Trapp; Lawrence W.
Claims
I claim:
1. An entubator for entubing an endotracheal tube in a patient's
trachea through the patient's nasopharynx comprising a viewing
means for enabling the operator to view the passageway of the
nasopharynx as the endotracheal tube advances therethrough, said
viewing means being capable of being positioned within the lumen of
the endotracheal tube and transmitting to the operator a view of
the passageway formed by the nasopharynx when the endotracheal tube
with said viewing means so positioned is in the nasopharynx and a
directing means for directing a force applied at a point remote
from the distal end of the endotracheal tube to remove the distal
end of the endotracheal tube sufficiently to enable the operator to
point the distal end of the endotracheal tube into the nasopharynx
as the endotracheal tube advances therethrough, both said viewing
means and said directing means being capable of being combined with
an endotracheal tube and bending sufficiently to conform to the
passageway formed by the nasopharynx so that the operator can
navigate the endotracheal tube through the nasopharynx by moving
the distal end of the endotracheal tube so that it points into the
nasopharynx as the passageway of the nasopharynx is viewed by the
operator during entubment.
2. The entubator as set forth in claim 1 wherein said viewing means
is a flexible coherent fiber optic bundle.
3. The entubator as set forth in claim 2 also comprising a channel
which is capable of being positioned within the lumen of the
endotracheal tube along with said bundle for delivering a local
anaesthetic to the patient during the entubment procedure.
4. The entubator as set forth in claim 3 wherein said bundle and
said channel is enclosed in a flexible covering and wherein said
directing means is a tension wire anchored to said covering, said
tension wire being capable of moving the entubator with sufficient
force to cause the distal end of the endotracheal tube to point
into the nasopharynx as the endotracheal tube advances therethrough
when said entubator is positioned in said endotracheal tube and
when a force is applied and directed along said tension wire.
5. The entubator as set forth in claim 2 wherein said directing
means is attached to the endotracheal tube.
6. The entubator as set forth in claim 2 wherein said directing
means is contained in the entubator.
7. An endotracheal tube which can be entubed in a patient's trachea
through the patient's nasopharynx, said tube containing a flexible
coherent fiber optic bundle positioned within the lumen of the
endotracheal tube for transmitting to the operator a view of the
passageway formed by the nasopharynx as the endotracheal tube
advances therethrough, a directing means for directing a force
applied at a point remote from the distal end of the endotracheal
tube to move the distal end of the endotracheal tube sufficiently
to enable the operator to point the distal end of the endotracheal
tube into the nasopharynx as the endotracheal tube advances
therethrough, both said fiber optic bundle and said directing means
being capable of bending sufficiently to conform to the passageway
formed by the nasopharynx and a channel positioned within the lumen
of the endotracheal tube for delivering a local anaesthetic to the
patient during the entubment procedure.
8. In a method of entubing an end tracheal tube into a patient's
trachea through the patient's nasopharynx in which a flexible
coherent fiber optic bundle is used to view the passageway formed
by the nasopharynx during the entubment procedure wherein the
improvement comprises
utilizing a mechanical means to direct a force applied at a point
remote from the distal end of the endotracheal tube to move the
distal end of the endotracheal tube, and
navigating the endotracheal tube through the nasopharynx by moving
the distal end of the endotracheal tube by applying a force with
said mechanical means so that the distal end of the endotracheal
tube points in the general direction of the passageway formed by
the nasopharynx as the endotracheal tube advances through said
passageway toward the patient's trachea.
9. The method as set forth in claim 8 including the steps of
lubricating the distal end of the endotracheal tube with an
anaesthetic jelly, anaesthetizing the patient's nose and throat and
anaesthetizing the patient's vocal cords with a local anaesthetic
after the endotracheal tube has been navigated through the
nasopharynx.
10. The method as set forth in claim 9 including the step of
passing the endotracheal tube through the patient's vocal cords
while the vocal cords are viewed through the fiber optic bundle and
after the local anaesthetic has taken effect.
Description
BACKGROUND OF THE INVENTION
The field of this invention is a therapeutic instrument for
treating patients who require mechanical ventilation.
It is a standard medical procedure to insert an endotracheal tube
into patients who are unable to breathe for themselves because of
diseased states to provide mechanical ventilation. For example,
when a patient has suffered a heart attack, a stroke, severe
pneumonia, or an epileptic seizure, mechanical ventilation may be
required and thus an endotracheal tube is often inserted into the
patient having these diseased states. The insertion of such a tube
is also a standard medical procedure which is performed whenever
general anaesthetics are administered or whenever routine surgery
is required.
The standard method for performing an entubation of an endotracheal
tube is to place the patient in a prone position, tilt his head
backwards as far as possible, and insert a metal laryngoscope
through the patient's mouth. The endotracheal tube is then passed
alongside the metal laryngoscope and while the patient's vocal
cords are viewed through the laryngoscope, the tube is passed
through the vocal cords.
The foregoing procedure is painful and requires either general
and/or local anaesthetics. Furthermore, well recognized
complications arising from the use of the metal laryngoscope
include neck fractures, aspiration of vomit into the lungs, jaw
fracture, and the breakage of teeth during insertion of the
laryngoscope. In addition to the foregoing disadvantages, the
procedure described above is difficult to perform in patients who
are obese, who have malformations of the jaw, or who have a disease
or fractures of the cervical spine. In fact, it is so difficult to
entube an endotracheal tube with a laryngoscope that death has
occurred in some patients during the attempt to place the
endotracheal tube into the trachea. Such deaths have occurred
because of the insufficient flexibility and capability of the
laryngoscope to rapidly and quickly place the tube into the
trachea.
When the endotracheal tube cannot be placed into the trachea with
the use of the metal laryngoscope, it is common medical procedure
to perform a tracheostomy. A tracheostomy consists of cutting a
hole in the base of the neck and inserting a breathing tube into
the trachea through the hole.
The foregoing disadvantages are greatly reduced by utilizing the
entubator of the present invention which is capable of inserting
the tube into the trachea through the patient's nasopharynx while
the patient's head rests in a natural position without using a
laryngoscope and without causing significant trauma to the patient.
Entubment is faster, safer and easier to perform using the
entubator of the present invention than entubment using instruments
such as the laryngoscope.
Such an entubation is possible with the entubator of the present
invention because the entubator includes a means, in the form of a
flexible coherent fiber optic bundle within the endotracheal tube
itself, for viewing the anatomy of the patient as the endotracheal
tube advances into the nasopharynx and a means for directing and
controlling the course of travel of the endotracheal tube to avoid
obstructions which are made visible through the fiber optics bundle
and thus enable the operator to navigate the tube through the
natural passageway formed by the nasopharynx.
The medical literature is replete with references disclosing
medical devices which include coherent flexible fiber optic
bundles, or fiberscopes as they are often called.
Representative of such devices is the well known fiber optic
bronchoscope which is a diagnostic instrument and which comprises a
rubber tube containing light guides in the form of flexible fiber
optic bundles and a tip which is remotely controllable to increase
the field of view once the instrument is inserted into a patient.
Although this instrument includes a flexible fiber optic bundle,
that bundle's function begins once the tube is inserted. In this
regard, the manufacturers of these instruments recommend that the
instrument be inserted through a straight metal tube bronchoscope
or through an endotracheal tube which has been inserted into a
patient with a metal laryngoscope. Thus, the flexible fiber optic
bundle is not intended to facilitate the insertion of the
instrument.
Although the fiberscope portion of the fiber optic bronchoscope was
not designed nor intended to function as a means for facilitating
insertion of the instrument, applicant has devised a procedure for
performing bronchoscopies where the fiberscope portion of the fiber
optic bronchoscope does in fact function as a means for
facilitating the insertion of the instrument. Since this procedure
has many similarities to the present inventive method of entubing
endotracheal tubes, it is amplified below in connection with the
entubment procedure of the present invention.
Although the literature contains many publications disclosing
medical instruments which include fiberscopes, very few instruments
are disclosed or are shown in which the fiberscope system of the
instrument actually is utilized as an aid to facilitate insertion
of the instrument itself.
A patent which discloses an instrument where a fiber optic system
is utilized to facilitate insertion of the instrument is U.S. Pat.
No. 3,572,325 to Bazell et al. entitled "Flexible Endoscope Having
Fluid Conduits and Controls." The device disclosed in the Bazell et
al. patent is an adaptation of a sigmoidoscope which is flexible
and which includes a fiber optic system and a control assembly to
navigate the distal tip of the instrument into a patient's colon.
It should be noted, however, the the instrument disclosed in the
Bazell et al. patent is an adaptation of a previously existing
instrument, a sigmoidoscope, and unlike the instrument of the
present invention is designed and intended to enter into a
patient's body through the same anatomical passageway as the
sigmoidoscope of which it is an adaptation would enter.
Furthermore, the advantages of providing a flexible sigmoidoscope
had been long recognized, particularly since the colon into which
the instrument is inserted has a natural configuration which
renders straight rigid instruments undesirable.
In the device disclosed in the Bazell et al. patent, the fiber
optic system and control assembly facilitate the insertion of this
flexible instrument. As stated above, however, providing
flexibility features on this type of instrument were known to be
desirable.
It should, of course, also be noted that although there is some
similarity between the device of the present invention and the
Bazell et al device in that the Bazell et al device, as well as the
device of the present invention, includes a fiber optic system for
viewing the passageway during the insertion of the instrument and
control means for navigating the instrument in response to the view
of the passageway made visible by the fiber optic system, the
device of Bazell et al could never serve as a means for entubing an
endotracheal tube through any opening in the body let alone through
the nasopharynx. In this regard, it is the entubment of the
endotracheal tube through the nasopharynx and into the trachea
toward which the present invention is directed.
Also representative of prior art medical instruments which include
fiberscopes as a part of the instrument are the devices disclosed
in U.S. Pat. No. 3,434,775 to N. R. Gosselin entitled "Flexible
Fiber Optic Borescope" and the device disclosed in U.S. Pat. No.
3,494,354 to Ryosuke Yokota et al. entitled "Flexible Endoscope for
Use in Cancer Diagnosis." These patents, however, are not believed
to be pertinent to the present invention.
SUMMARY
Many of the disadvantages of the prior art entubators for
endotracheal tubes are overcome by the method and device of the
present invention which involves an entubator for an endotracheal
tube which enables insertion of an endotracheal tube into the
trachea through the patient's nasopharynx.
Accordingly, it is an object of the present invention to provide a
new and improved entubator for placing an endotracheal tube into
the trachea.
A further object of the invention is to provide an entubator with
which an endotracheal tube can be inserted into the trachea without
the use of a laryngoscope.
A further object of the present invention is to provide an
entubator for an endotracheal tube which can entube an endotracheal
tube into the trachea through the patient's nasopharynx.
Another object of the present invention is to provide an entubator
for an endotracheal tube which enables the entubation of the
endotracheal tube while the patient's head rests in a natural
position.
Another object of the present invention is to provide an entubator
for an endotracheal tube which enables the entubation of the
endotracheal tube without tilting the patient's head backwards.
Another object of the present invention is to provide an entubator
for an endotracheal tube which can entube an endotracheal tube into
patients who have fractures of the cervical spine without
performing a tracheostomy.
A further object of the present invention is to provide a new and
improved device for the examination and evacuation of the
trachea.
Still another object of the present invention is to provide a new
method for entubing an endotracheal tube into the trachea.
A further object of the present invention is to provide a method
for entubing an endotracheal tube without the use of a
laryngoscope.
Another object of the present invention is to provide a method for
entubing an endotracheal tube while the patient's head rests in a
natural position.
Another object of the present invention is to provide a method for
entubing an endotracheal tube without tilting the patient's head
backwards.
Another object of the present invention is to provide a method for
entubing endotracheal tubes in patients who have fractures of the
cervical spine without performing a tracheostomy.
Still another object of the present invention is to provide a
method for entubing an endotracheal tube into a patient's trachea
through the patient's nasopharynx.
A further object of the present invention is to provide a new and
improved method for the examination and evacuation of the
trachea.
BRIEF DESCRIPTION OF THE DRAWING
FIG. 1 is a side elevational view partially in section of an
entubator in accordance with the present invention positioned
within an endotracheal tube;
FIG. 2 is a transverse sectional view, on an enlarged scale, taken
along line 2--2 of FIG. 1;
FIG. 3 is a longitudinal sectional view taken along line 3--3 of
FIG. 2;
FIG. 4 is a perspective view showing entubment of an endotracheal
tube with the entubator of FIG. 1 in a patient through the
patient's nasopharynx; and
FIG. 5 is a side elevational view of an embodiment of an entubator
in accordance with the present invention positioned within an
endotracheal tube.
DESCRIPTION OF THE PREFERRED EMBODIMENTS
As stated above, the insertion of tubes into patients through the
patient's mouth has resulted in a number of significant
problems.
After considering these problems, applicant concluded that one way
to provide greater safety and less discomfort for the patient
during entubment would be to utilize a flexible entubator with a
built in viewing system. However, even with such a flexible
entubator, complications still occur when the flexible instrument
is inserted into the patient through the patient's mouth.
In particular, when any instrument, whether flexible or not, is
placed on the back of a patient's mouth, a strong gagging sensation
results. Furthermore, it is difficult to anaesthesize against this
gagging sensation. This complication creates problems because a
patient's normal response to this gagging sensation is a motion of
the tongue which displaces the instrument. It, of course, can be
easily appreciated that such displacement of the instrument is
undesirable.
Another complication resulting from passage of an instrument
through the mouth is that a patient has a tendency to bite the
instrument. This tendency has a deleterious effect on fiberscopes
in that biting disturbs the transmission of an image through the
fiberscope and can damage the fibers in the fiberscope. Thus, a
fiberscope which is inserted into a patient's mouth is normally
shielded against possible damage from biting. Such shields,
however, can reduce the advantage gained by the flexibility
properties of the fiberscope since such shields are not normally as
flexible as the fiberscope.
After considering these problems, applicant conceived of by-passing
the mouth completely by inserting a flexible instrument into the
trachea through the nasopharynx. To test this procedure, applicant
passed a fiber optic bronchoscope into the trachea through the
nasopharynx and has repeatedly utilized this technique involving
transnasal passage of this instrument for the diagnosis of
pulmonary disease.
Broadly, this technique is accomplished by spraying local
anaesthetics directly into the nose and throat, lubricating the
distal end of the bronchoscope with an anaesthetic jelly and
thereafter passing the flexible fiber optic bronchoscope through
the nasopharynx into the trachea while the passageway of the
nasopharynx is viewed through the bronchoscope itself.
In the preferred procedure for transnasal passage of the
instrument, the patient's nose and throat are sprayed with
one-quarter per cent tetracaine solution. The distal end of the
instrument is coated lightly with anaesthetic jelly. The instrument
is passed through the nasopharynx under direct visualation. The
instrument is placed over the vocal cords and they are sprayed with
local anaesthetic, after which the instrument is passed on into the
trachea. Examination of all segments of the bronchial tree is
carried out with the patient seated with his head in a resting
position.
Patient acceptance of this procedure has been excellent and there
have been no significant complications. The flexible bronchoscope
is of utmost utility in the performance of diagnostic bronchoscopy
on patients with cervical osteoarthritis; cervical fractures,
aortic aneurysm, bleeding and clotting disorders, hypoxia, and
other situations where standard bronchoscopy with the rigid
bronchoscope might be contraindicated.
Since a skilled physician is familiar with the anatomy of the
transnasal passageway of the nasopharynx, an instrument can be
guided, manipulated, or navigated through the passageway if the
passageway is viewed during the insertion of the instrument. Of
course, this factor presents no problem in the case of fiber optic
bronchoscopes since a fiber optic viewing system is contained in
this instrument.
Applicant has presented this procedure in papers delivered before
several national medical meetings. The first paper on the
transnasal passage of a fiber optic bronchoscope through the
nasopharynx was delivered by applicant at The Thirtieth Veterans
Administration-Armed Forces Pulmonary Disease Research Conference
in Cincinnati, Ohio, on Jan. 26, 1971. A report on the paper
delivered at that conference appears on page 865 of the publication
"American Review of Respiratory Disease," Vol. 103, No. 6, June
1971, the teachings of which are herein incorporated by
reference.
On Oct. 26, 1971, at the Third Fall Scientific Assembly of the
American College of Chest Physicians, applicant delivered a similar
paper directed to the transnasal passage of a fiber optic
bronchoscope. An abstract of the paper delivered at that assembly
entitled "The Utility of the Flexible Fiberoptic Bronchoscope"
appears in the publication "Chest," Vol. 60, No. 3, Sept. 1971,
pages 303-304, the teachings of which are also herein incorporated
by reference.
Having found that transnasal passage of a fiber optic bronchoscope
clearly reduced many of the problems attendant with oral passage of
this instrument, applicant concluded that many of the problems
attendant with oral passage of an endotracheal tube would also be
greatly reduced by transnasal passage of the endotracheal tube
itself.
To demonstrate the foregoing, applicant constructed a test model
entubator for entubing an endotracheal tube through the nasopharynx
and entubed a number of endotracheal tubes in various patients with
this test model entubator by passing the endotracheal tubes through
the patient's nasopharynx into the trachea.
The test model entubator used in these entubments and an
endotracheal tube are shown in FIGS. 1-4 of the drawing. In FIGS.
1-4, an endotracheal tube is generally designated by reference
numeral 10. Endotracheal tube 10 is a standard commercially
available endotracheal tube formed of a flexible hard rubber, is
tubular, arcuate in shape and has a hollow metal connector 12
fitted into the inner wall of tube 10 at its proximal end 14. Once
the tube is positioned in the trachea, the metal connector 12
provides the means for connecting the air line of a mechanical
ventilator (not shown) to tube 10 to deliver air through the
endotracheal tube to the patient.
For most applications, endotracheal tube 10 is fitted with a rubber
cuff (not shown). The rubber cuff, which is inflatable, is slipped
over distal end 16 of tube 10 prior to entubment. The purpose of
the inflatable rubber cuff is to prevent leakage of air around the
outside of the endotracheal tube once the endotracheal tube is
placed in the trachea. Such leakage is prevented by inflating the
cuff after the tube including the cuff is inserted into the
trachea. However, since the features of such a cuff are well known
in this art and since its use has no connection with the present
invention, the cuff is not shown in the drawing, although in the
entubments described below, the endotracheal tubes were fitted with
such a cuff.
The test model entubator used in various tests in which tube 10 was
entubed into patients by passing the tube through their nasopharynx
and into their trachea comprised a viewing means for viewing the
anatomy of the nasopharynx as the tube passed therethrough and a
means for directing the course of travel of the endotracheal tube
to avoid obstructions made visible by the viewing means. In the
test models constructed for these tests, the viewing means utilized
was a commercially available fiber optic bronchoscope generally
designated in FIGS. 1-4 by reference numeral 18. The fiber optic
bronchoscope used in these tests was an Olympus Model BF
fiberscope. This instrument has a transmission cable 19 with a
working length of 55.7 cm, an outside diameter of 5 mm and a
remotely controllable tip which moves through a range of
130.degree. upward and 30.degree. downward. The mechanism for
moving the tip of cable 19 which is a tension wire is not shown in
the drawing since the details of this mechanism are well known in
this art. Furthermore, that mechanism is not capable of causing any
useful movement of endotracheal tube 10 because that mechanism is
only designed to move cable 19 which has little resistance or
resiliency. In this regard, endotracheal tube 10 offers too much
resistance to enable this mechanism to move tube 10 through the
distances required to accomplish the objects of this invention.
Fiber optic bronchoscope 18 also contains a lens (not shown)
positioned over the distal end of image transmitting bundle 32.
This lens enables an 83.degree. forward field of view with a depth
of focus of from 5 to 45 mm.
Transmission cable 19 of bronchoscope 18 also contains a 1 mm
suction channel 21. Channel 21 is open at distal end 26 and the
other end is connected to a connector or nipple 23 formed in handle
40 of the bronchoscope. During the entubment procedure, a local
anaesthetic is injected into the patient from a syringe which is
attached to connector 23.
Because of the small diameter of transmission cable 19, it is
easily positioned within cavity or lumen 20 which is formed by
inner wall portion 22 of tubular wall 24 and the inner wall portion
of metal connector 12. As is shown in FIG. 1, cable 19 is
positioned so that it extends into and through the entire length of
the lumen of tube 10, from its proximal end 14 to its distal end
16. Since the diameter of that portion of cavity or lumen 20 formed
by inner wall portion 22 is approximately 9 mm, a reasonably good
fit results when cable 19 with an outside diameter of 5 mm is
positioned within tube 10. In the test models, cable 19 was
positioned within tube 10 so that the distal end 26 of cable 19
extended just beyond the distal end 16 of tube 10, as is shown in
FIG. 1. Thus, the viewing means of the entubator of the present
invention is positioned within the lumen of the endotracheal
tube.
In the test models, the means for directing the course of travel of
tube 10 comprised a thin nylon line 28. Prior to insertion of cable
19 into endotracheal tube 10, line 28 was passed into cavity 20 so
as to run through the inside of the entire length of tube 10. The
two ends of line 28 were then knotted outside of the tube as is
shown at 29 to form a loop, part of which extended through the
lumen of tube 10. Line 28 was knotted in a manner so as to allow
sufficient slack to permit endotracheal tube 10 to remain in its
natural arcuate configuration when no pressure was exerted along
line 28. It should be noted that the size of line 28 is greatly
exaggerated in the drawing. A suitable line is 6 lb. test nylon
monofilament line with a diameter which is less than 0.5 mm.
Since endotracheal tube 10 is arcuate in shape, a downward force
applied at about point 31 in the direction of arrow 33, causes a
downward displacement of the distal end 16 of the arc formed by the
endotracheal tube. With tube 10 positioned as is shown in solid
lines in FIG. 1, such displacement of tube 10 is in the plane of
the drawing and is along the route indicated in FIG. 1 by arrow 35
from the natural position of tube 10 shown in solid lines to the
position shown in dotted lines. To apply such force during
entubment, the operator places his finger at location 31 through
the loop formed by line 28 and applies a gentle force in the
direction of arrow 33, thus displacing the position of endotracheal
tube 10. As suggested above, line 28 enables displacement in one
plane. However, in the tests, such displacement of endotracheal
tube 10 proved to be satisfactory to enable entubment through the
patient's nasopharynx since displacements in directions other than
the one shown in the drawing are possible by turning the
endotracheal tube during entubment to cause the distal end 16 of
tube 10 to point in the general direction toward which displacement
is desired. Thus, by a combination of turning endotracheal tube 10
and applying a force along line 28 in the direction of arrow 33, it
was possible to navigate the endotracheal tube through the
passageway formed by the nasopharynx.
Further details of fiber optic bronchoscope 18 are shown in FIGS.
2-4 and include an image transmitting bundle 32, light source
bundle 34 and a flexible suction channel 21, all of which are
enclosed by a flexible plastic tubular covering 36. Although in
FIGS. 2 and 3 bundles 32 and 34 appear as if they are solid rods,
it should be understood that bundles 32 and 34 are each comprised
of a plurality of minute light guiding fibers. Such fibers have
diameters that may be just one-tenth the diameter of a human hair.
Both bundles 32 and 34 are flexible. The fibers which comprise the
flexible image bearing bundle 32 are arranged to be coherent so
that an image cast upon the face of the bundle at distal end 26 is
reproduced upon the face at the opposite end of the bundle. Since
the light source bundle 34 does not transmit an image, flexible
bundle 34 need not be coherent. It should be understood, however,
that light source bundle 34, if coherent, would function to conduct
light but the cost of manufacturing and assembling coherent bundles
exceeds the cost of manufacturing non-coherent bundles. Since the
only function of bundle 34 is to conduct light, this bundle is not
normally coherent. The fibers which comprise both bundles 32 and 34
are formed of a transparent material such as glass and operate on
the principle of total internal reflection. This principle is so
well known that it requires only a brief description. A transparent
elongated smooth-surfaced body of higher refractive index than its
surroundings can transmit light applied to one end so that it
emerges with little loss at the other end, due to total internal
reflection from its surfaces, of light rays divergent from the
longitudinal axis of the body. To produce total internal reflection
within each fiber, each fiber is formed of a central glass core
surrounded by a thin sheath or cladding of glass having a lower
refractive index than the core. Although glass fibers are
preferred, light guiding fibers may be formed of transparent
plastics. However, the construction of bundles of light guiding
fibers from either glass or plastic is well within the skill of
those in this art.
The transmission cable 19 comprised by covering 36, bundles 32 and
34 and channel 21 extended to and into handle 40 of bronchoscope
18. The image transmitting bundle 32 passes through handle 40 to an
eye piece 42. Light source bundle 34 passes through the side of
handle 40 and is enclosed by a protective plastic covering 41. The
assembly comprised by covering 41 and bundle 34 is connected to a
fiber optic illuminator (not shown). Light from the illuminator is
conducted through the fibers in bundle 34 to the distal end 26 of
cable 19 to enable the scene to be viewed through bundle 32 to be
illuminated.
The first entubment of an endotracheal tube utilizing the foregoing
entubator is shown in FIG. 4 and was performed on a patient who had
suffered respiratory failure and required mechanical
ventilation.
With the patient seated in bed, his head was placed in a
comfortable position and his nose was then sprayed with a local
anaesthetic while he remained seated in an upright position in his
bed. A suitable local anaesthetic which can be used for this step
is a 1 per cent xylocaine solution.
A nylon line was then looped through the lumen of an endotracheal
tube and knotted in the manner which is described above and which
is shown in FIG. 1. The distal end of the endotracheal tube was
lubricated with an anaesthetic jelly and thereafter about one-half
of an inch of the distal tip of the tube was inserted into the
patient's nose. A suitable anaesthetic jelly which can be used to
lubricate the tube is xylocaine jelly. With the tip of the
endotracheal tube inserted slightly into the patient's nose a fiber
optic bronchoscope was then inserted through the lumen of the
endotracheal tube so that the distal end of the bronchoscope
extended just beyond the distal end of the endotracheal tube as is
shown in FIG. 1 so that the passage of the endotracheal tube
through the nasopharynx could be observed.
In this entubment procedure, the endotracheal tube with the looped
nylon line were placed into the patient's nose prior to the
insertion of the fiber optic bronchoscope. Alternatively, the
bronchoscope and nylon line can be assembled within the
endotracheal tube as is shown in FIG. 1 prior to the insertion of
the endotracheal tube into the patient's nose. Whether this
technique is utilized or whether the foregoing technique is
utilized is merely an operator's preference. The important point,
however, is an endotracheal tube cannot be safely inserted very far
into a patient's nasopharynx without the operator being able to see
the natural passageway of the nasopharynx.
With the entubator assembled, the endotracheal tube was then
manually navigated through the nasopharynx while the passage of the
tube was viewed through the fiber optic bronchoscope. As the
natural anatomical passageway formed by the nasopharynx was
observed through the fiber optic bronchoscope, that passageway was
navigated by flexing the distal end of the endotracheal tube by
pulling the looped nylon line, by turning the endotracheal tube so
that the end of the tube pointed in the general direction of the
passageway, or by a combination of turning and flexing the distal
end of the tube. After the distal tip of the tube was pointed in
the desired direction, the operator gently pushed the tube into the
passageway. If any obstructions in the nasopharynx were viewed,
such obstructions were cleared in the same manner.
When the patient's vocal cords were visualized, a local anaesthetic
solution was passed through the channel of the bronchoscope onto
the vocal cords.
To anaesthetize the vocal cords, a 1 percent xylocaine solution is
put into a syringe. The syringe is then connected to the nipple or
connector on the bronchoscope. The xylocaine solution is then
delivered from the syringe and after passing through the channel is
sprayed on the vocal cords.
After allowing sufficient time (about 3 minutes) for the
anaesthetic to take effect, the endotracheal tube was pushed
through the vocal cords while the vocal cords were viewed through
the bronchoscope. After passing the tube through the vocal cords
the tube was positioned in the trachea.
Once the endotracheal tube was positioned in the trachea, the fiber
optic bronchoscope and the nylon line were removed. The
endotracheal tube was then connected to a mechanical ventilator to
provide the ventilation required by the patient.
Endotracheal tubes were positioned in 10 patients by passing the
endotracheal tube through the nasopharynx in accordance with the
present invention. The patients in whom tubes had been inserted in
this manner tolerated the procedure very well. The patients'
response was considered good and there were no complications noted
from this procedure. As compared to the prior art method of oral
entubment with a laryngoscope, by following the present invention
there was an increase in the speed of passage of the tube. Such
increased speed of passage decreased the amount of pain normally
incurred by a patient when endotracheal tubes are entubed with a
laryngoscope.
At this point it should be noted that endotracheal tubes have in
the past been passed through the nasopharynx. Such passage has been
accomplished by using one or two known techniques. The first
technique is to blindly stuff the endotracheal tube through the
nasopharynx into the trachea. This technique is not considered to
be satisfactory since the passage of the tube through the
nasopharynx cannot be observed and is normally performed only in
emergency situations. The other prior art technique for passing an
endotracheal tube through the nasopharynx is to use a laryngoscope
which is placed in the patient's mouth to illuminate the vocal
cords. This technique has many deficiencies when compared to the
method of the present invention. In particular, all the
disadvantages arising from oral passage of the endotracheal tube
with the use of a laryngoscope are still present when a
laryngoscope is employed. Merely by way of example, the patient's
head must be tilted back in order to insert the laryngoscope. In
addition, this procedure is not acceptable because the passage of
the nasopharynx cannot be viewed.
It should be noted that the entubator described above was
constructed to demonstrate that endotracheal tubes could be safely
entubed into the trachea through a patient's nasopharynx. In this
regard, the entubator described above was capable of successfully
entubing endotracheal tubes in a number of patients by passing the
endotracheal tube into the patient's nasopharynx. It is here
emphasized, however, that the entubator described above is merely a
demonstration model constructed from components that were readily
available to enable the foregoing tests. That model, however, was
sufficient to indicate the essential components necessary for
carrying out the objects of this invention. Those components
include a viewing means for enabling the observation of the natural
passageway formed by the nasopharynx, a means for navigating the
endotracheal tube through that passageway and a conduit or channel
for delivering an anaesthetic into the patient as required during
entubment. All of these components are preferably assembled to form
an entubator which can be positioned within the lumen of the
endotracheal tube.
A more sophisticated embodiment of the invention which contains the
foregoing essential elements is shown in FIG. 5 of the drawing. In
FIG. 5 the entubator is generally designated by reference numeral
50 and is shown positioned within the lumen of an endotracheal tube
10. The endotracheal tube 10 shown in FIG. 5 is identical to the
endotracheal tube shown in FIG. 1. The viewing means for entubator
50, like the viewing means of the bronchoscope shown in FIGS. 1-4,
is comprised of a coherent flexible fiber optic image transmitting
bundle and a flexible light source illuminating bundle, both of
which are enclosed in a plastic covering 52. The image transmitting
bundle extends throughout the length of covering 52 to the distal
end 54 of the entubator whereupon it is capped by an appropriate
lens for viewing the anatomy of the nasopharynx. The proximal end
of the image transmitting bundle extends through handle 56 and is
optically connected to an eye piece 58 to enable the operator to
view images focused by the lens on the distal end of the image
transmitting bundle. The light source bundle also passes throughout
the inside of the protective cover 52 to the distal end of the
entubator. The light source bundle then passes through handle 56 of
entubator 50 at 60 where it is protected by a plastic covering 62.
The light source bundle within covering 62 is then connected to a
fiber optic illuminator (not shown), thus enabling the illumination
of the image to be viewed by the image transmitting bundle. Also
extending through the entire length of covering 52 is a conduit or
channel 64. Channel 64 is open at the distal end 54 of the
entubator and passes through handle 56 of the entubator and is
connected to a connector 66 to which in turn is connected a suction
line 68. For delivering local anaesthetic to the patient from the
distal end of the entubator, suction line 68 is removed and a
syringe is connected to connector 66. Delivery of the anaesthetic
with this embodiment is identical to the delivery discussed above
in connection with the embodiment shown in FIGS. 1-4. Running along
the inside wall of covering 52 is a tension wire 70. Tension wire
70 is anchored to the covering 52 at the distal end of the
entubator and runs along the inside wall of covering 52 into handle
56 whereupon it passes through the handle and is connected to a
ring or trigger 72. Tension wire 70 may be constructed in the same
manner as the tension wire used to remotely control the tip of
cable 19 of bronchoscope 18 with the exception that tension wire 70
must be capable of exerting a force sufficient not only to remove
the distal end 54 of the entubator but also be sufficient to move
the endotracheal tubes through the distance required to accomplish
the objects of this invention. It should, of course, be immediately
appreciated that in an alternate embodiment of the invention a
tension wire or any other means for moving the endotracheal tube
may be built right into an endotracheal tube itself.
A transverse sectional view of entubator 50 is not shown in the
drawing but it should be appreciated that such a view would be
similar to the transverse sectional view of bronchoscope 18 shown
in FIG. 2 of the drawing.
With the type of entubator shown in FIG. 5, the working length of
the fiber optic bundles need not be as long as the working length
of the bundles in cable 19 of bronchoscope 18. Preferably, the
length of the entubator should only be long enough so that when
inserted in an endotracheal tube, handle 56 of the entubator is in
close proximity to the proximal end 74 of metal connector 12 with
distal end 54 extending just beyond distal end 16 of tube 10. The
diameter of the assembly enclosed by covering 52 must be small
enough so that the assembly can be positioned within the lumen of
the endotracheal tube as is shown in FIG. 5. However, the fit must
be loose enough to enable easy removal of the entubator from the
tube after insertion of the tube into the patient without
significantly disturbing the position of the tube in the patient's
trachea.
The invention may be embodied in other specific forms without
departing from the spirit or essential characteristics thereof. The
present embodiments are therefore to be considered in all respects
as illustrative and not restrictive, the scope of the invention
being indicated by the appended claims rather than by the foregoing
description, and all changes which come within the meaning and
range of equivalency of the claims are therefore intended to be
embraced therein.
* * * * *