Tracheal Introducer Sheath

Abstract

According to the CDC, the same month (March, 2020) they declared COVD-19 a pandemic, nearly 25% of confirmed COVID-19 hospitalized patients required intubation, or ventilator use. More recently, in the US, during the summer of 2021, child intubations more than quadrupled, when the Delta variant predominated.

Description

CROSS-REFERENCE TO RELATED APPLICATIONS

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BACKGROUND OF THE INVENTION

Severe and critical cases of COVID-19 raise clinical concerns for progression to respiratory failure and a need for airway protection with endotracheal intubation. [What is endotracheal intubation? A procedure typically requiring utilization of a laryngoscope blade in one hand to help visualize the vocal cords (“cords”) and glottic opening for passage (with the opposite hand) of an endotracheal tube into the tracheal space.]

Since nearly 20% of past COVID-19 cases were considered severe or critical, according to a large 2020 study in the Journal of the American Medical Association, the U.S. healthcare system must be prepared for spikes in COVID-19 incidence and related increases in frequency of airway failures. The pediatric COVID-19 population characteristics underscore this point: Among 20,714 hospitalized children and adolescents diagnosed with COVID-19, 31% experienced severe COVID-19.

There is an additional problem that proceduralists (emergency medicine physician, anesthesiologist, ambulance personnel, etc.) face: the so-called “difficult airway”, or those that pose technical challenges.

Difficult airways represent up to nearly one-quarter of all intubations and according to the American Journal of Respiratory and Critical Care Medicine, are due mostly to a difficulty placing the endotracheal tube. This can be for many reasons including difficulty visualizing the cords due to edema (a well described complication with COVID-19-associated acute respiratory distress syndrome, or ARDS), foreign body, a malignant mass, or simply patient's baseline anatomy. The outcomes of COVID-19-associated ARDS patients are especially grim, with a mortality of 45%, and thus this population deserves special attention in the U.S. research and development spaces.

Regardless of the cause, complicated intubation procedures that take excessive time (with multiple “passes” or attempts at passing an endotracheal tube) are associated with diminished central nervous system oxygenation and potential neurologic disease.

As such, much effort has been put towards improving likelihood of first attempt (“first pass”) success during expectedly and unexpectedly difficult intubations. The most notable of airway adjuncts for this purpose is the Bougie Device, patented in 2007 (U.S. Pat. No. US20100307489A1).

Introducers, like the Bougie Device, tend to be helpful because of their relatively small size and (depending on device) kinked and malleable distal tip as compared to an endotracheal tube. Once an introducer is passed through the cords, sometimes blindly (again, due to severe pathology such as edema, or anatomy, or both), tracheal positioning of an introducer is confirmed by feeling tracheal rings as vibratory feedback in the hand operating the introducer. Subsequently, an endotracheal tube is passed over the introducer, and the introducer removed from the patient, for endotracheal tube securing and then attachment to a mechanical ventilator.

Given strong evidence on first-attempt intubation success being significantly higher when using an introducer, intubation proceduralists will likely be continuing to utilize introducers.

The most notable problem with existing introducers, including the Bougie Device, is its limited ability to maintain desired contour and, once they have been placed beyond the oral cavity and oropharynx, take a sharp angle around an often obstructing epiglottis to move through the cords. A kinked or angled introducer tip is extremely limited in taking steep angles because it is pushed by the proceduralist with a force vector driven mostly external to the patient. Sometimes the proceduralist is controlling the introducer within the patient's oropharynx, but this still is relatively external and angled away from the deeper glottic opening. Thus, curving the tip of an introducer that is deep in the patient's airway confers only so much ability to take a steep angle. However limited, an operator can also move the introducer along a curved plane to add some improved angular control.

With both the TIS and STIS, and relatively stiff sheath through which an introducer can move allows the introducer to move along the axis created by the sheath itself, which can be molded quickly to the desired angle, regardless of steepness, up to ninety degrees.

As mentioned, manually molding a kink of varied angles at the tip of an introducer prior to introduction into the patient is common practice to aid its navigation towards and through the cords, however this corrective action has limited utility, including an inability to manipulate the angle once placed into the patient.

The TIS solves this problem by taking on varied angles (articulating between 10 and 90 degrees), in real time, controlled at the proximal end of the TIS (outside of the patient), whilst the distal introducer is placed deeper in the airway.

While a patent pending articulating device (Total Control Introducer by Through The Cords LLC) includes an articulating mechanism, the device is itself an introducer. Uniquely, the TIS is a sheath through which a broad range of introducers can be controlled. As such, varied introducer size, material, shape and design (ie ones with a central lumen for oxygenation or blunt-closed-end tips) can be chosen on a clinical case-by-case basis for utilization with a TIS. For example, a patient with an especially friable airway can be intubated using a TIS and an especially soft tipped introducer to avoid potentially injuring the soft tissue and causing acute and chronic complications, such as bleeding and fistula creation, respectively. Any number of introducer types can be designed and manufactured for assembly with a TIS.

In addition to a TIS allowing for selection of varied introducer types on a clinical case-by-case basis, it eliminates waste of existing supplies of introducers, and supports continued, specialized and streamlined manufacturing.

Another issue with known introducers, Bougie, Frova and others, are their relative unwieldy form. Given they are composed most commonly of thin (commonly approaching 6 mm), lengthy (often between 50 and 70 centimeters), PTFE, they produce a somewhat flimsy structure. This is of particular concern during acute and emergency settings wherein patient and environmental factors require steadied instrumentation. Introducers of this length will wobble in free space above the patient, which transfers to the distal introducer (inside the patient). This can become a similarly haptic challenge at the proximal end when attempting to place and slide a endotracheal tube over the introducer.

TIS solves the unwieldiness of most introducers by sheathing them in material with relative stiffness (increased elasticity modulus throughout), including but not limited to PTFE with a specified ID/OD ratio (see below).

The invention will be more fully understood by reference to the following descriptions accompanying drawings.

FIELD OF THE INVENTION

Adjunct for airway intubation involving tracheal introducers.

BRIEF SUMMARY OF THE INVENTION

The present invention is an airway adjunct that allows for ease of passage of an introducer through the glottic opening. The placement of an introducer may be utilized to assist with the ultimate goal of endotracheal intubation, or for whatever the primary goal of the proceduralist, including, but not limited to placing an introducer primarily for emergent oxygenation through the introducer with central canula.

An unprecedented benefit of this invention is the ability to select an introducer on a clinical case-by-case basis (of varied size, style, shape and design) for sheathing into the TIS. An introducer sheathed in an TIS offers the proceduralist substantial improvement in haptic control, including improved maneuverability, remote distal articulating control, an improved force vector by sliding an introducer over a relatively stiff distal channel, and thus overall ease of use and safety profile.

This device supports manufacture of introducers by manufacturers who maintain particular knowledge and streamlined operations of introducers of varied material, specialty and function.

BRIEF DESCRIPTION OF THE SEVERAL VIEWS OF THE DRAWING(S)

FIG. 1 is a schematic illustration of a human airway with a tracheal introducer sheath device with introducer placed within (also referred to as ‘sheath-over-introducer assemblage’).

FIG. 2 shows the tracheal introducer sheath device.

FIG. 3 illustrates an introducer device placed within the sheath of the tracheal introducer sheath.

FIG. 4 illustrates an axial view of a TIS (but not a BTIS) from proximal and distal ends (above and below, respectively), showing vertebrated succession rigid annuli.

FIG. 5 is a schematic illustration of a human airway with laryngoscope assisted insertion of a sheath-over-introducer assemblage into the trachea.

FIG. 6 is a schematic illustration of a human airway with laryngoscope assisted advancement of an introducer through the tracheal introducer sheath device until making contact with tracheal rings.

FIG. 7 is an illustration of a human airway with correct placement of an introducer in the trachea after a tracheal introducer sheath device has been removed.

FIG. 8 is a schematic illustration of a human airway with correct placement of an endotracheal tube over an introducer and into the trachea.

FIG. 9 illustrates the resulting position of the endotracheal tube after removal of an introducer.

DETAILED DESCRIPTION OF THE INVENTION

FIG. 2 of the drawings illustrates a preferred embodiment of the invention which has been referred to hereinabove as a tracheal introducer sheath (TIS), since the instrument 6 is applicable to assisting passage of a tracheal introducer 10 into the airway, through the oropharynx 9 and past the glottis, for endotracheal intubation. It is to be understood, however, that instrument 6 is not limited to the aforementioned uses. It may, for example, be used for sheathing an introducer 10 of many types such as but not limited to one with a central lumen, for emergent airway oxygenation.

Instrument 6 comprises a main portion of the body 5, connecting an open-ended sheath (proximal opening 1 and distal opening 4) by a hollowed tube of PTFE, twelve to fifty centimeters long, with varied ID/OD ratios depending on the chosen length.

As a point of clarification, the length of each individual instrument 6 will generally not be modifiable. A notable functional exception would be if an introducer 10 manufacturer produced an introducer 10 with modifiable length. In this case, if the introducer 10 is placed through the instrument 6, length would be modifiable of the sheath-over-introducer assemblage.

For an adult instrument 6 of length between twelve and fifty centimeters long, the instrument 6 is to have an internal diameter (ID) ranging between 4 mm and 7 mm with outer diameter (OD) ranging between 6 mm and 11.5 mm. Tube thickness for an adult instrument 6 is to range from 0.5 to 3 mm. One embodiment for an adult size instrument 6 is 20.5 centimeters long with an ID of 6 mm and an OD of 8.4 mm, with a wall thickness of 1.2 mm.

For the same instrument 6 sized for children, the instrument 6 length is to range from between seven to fifteen centimeters long with IDs ranging between 2.5 mm and 5 mm. Outer diameters will range between 4.5 mm and 7 mm. Tube thickness for a pediatric version of instrument 6 is to range from 0.2 to 2 mm.

For the TIS but not the STIS, operator controlled articulation of the articulating component 3 occurs by applying a pull force to the proximal portion 2 of the instrument 6, which transmits along an internally installed vertebrate succession of rigid annuli 12 from the proximal portion 2 of the instrument 6 through the body 5 and into the articulating component 3 of the tip and distal opening 4, allowing for proximal operating wires (illustrated in FIG. 4) to effect a smoothly operating graduated bending over a substantial length of the instrument's 6 distal portion, without effect upon intermediate portion of the body 5 and proximal portions 2 of the sheath 6. The vertebrate succession of annuli 12 seen in FIG. 4 is installed internally to the smooth internal surface of the sheath, maintaining smooth passage of an introducer. For those interested in greater detail in the construction of a pull-sheath that maintains a uniformly diametrically dimensioned internal hollow cavity throughout a tube within which fiber bundles are extended, allowing simultaneous proximal-to-distal control of an articulating mechanism, see U.S. Pat. No. 3,913,568.

The articulating component 3 allows angulation 7 between five and ninety-five degrees.

The size of the internal diameter of the instrument is constant throughout each individual instrument 6 but can vary between different instruments 6, allowing for passage of different sized introducers 10 when desired by the proceduralist.

FIG. 3 Illustrates a sheath-over-introducer assemblage, emphasizing both the adjunct nature of the instrument 6, to be utilized with an introducer 10, as well as the 360-degree free rotational movement of an introducer within an instrument 6.

The first steps of operating a tracheal sheath introducer 6 are illustrated in FIG. 5, during which a proceduralist uses either direct laryngoscopy or video-assisted laryngoscopy to insert a tracheal introducer sheath device 6 with introducer into the airway.

Once in appropriate proximity to the glottic opening, the tracheal introducer sheath device 6 is held in place, acting as a supporting vehicle through which the introducer is passed and directed towards the tracheal rings 8 (FIG. 6) until a vibratory sensation is felt that reflects tracheal ring 8 resistant forces have been met. Given the need to hold the laryngoscope and the sheath instrument 6, a third person trained in this procedure will advance the introducer 10 at the instruction of the main operator or proceduralist (holding the laryngoscope). Conversely, the proceduralist may ask an appropriately trained assistant to hold the sheath instrument 6 whilst the proceduralist advance the introducer 10.

At this point, the introducer 10 is held in place while the instrument 6 can be removed (FIG. 7) and an endotracheal tube 11 subsequently slid over the introducer 10 as in FIG. 8. The introducer is removed and endotracheal left in place (FIG. 9) for subsequent securing and mechanical ventilation.

Claims

1. Both a tracheal introducer sheath (TIS) device and simplified tracheal introducer sheath device (STIS) are for guiding insertion of a tracheal introducer through the glottic opening of a person's airway, said sheath devices comprising: a hollowed tube of flexible material with (in the case of the TIS but not the STIS) internal wall fiber bundles extended from proximal to distal ends for proximal-to-distal control of an articulating mechanism, through which (with either a TIS or STIS) a tracheal introducer can be easily passed and manually controlled.

2. The said tube of claim 1 in which the hollowed tube is made of polytetrafluoroethylene.

3. The said tube of claim 1 in which the hollowed tube is of sufficient length to provide coverage of distal end of the said tracheal introducer whilst operator handling is over the said hollowed tube but not so long as to limit removal of the said hollowed tube after introducer placement into the trachea.

4. The said tube of claim 1 in which the hollowed tube is a hollowed tube with internal to external diameter ratio creating sufficiently rigid channel for introducer to be guided along the path of the long axis of the said hollowed tube in varied curved forms yet sufficiently flexible to allow operator malleability and shape memory of said hollowed tube.

5. The said tube of claim 1 is with internal diameter that is sufficiently small to allow some contact with said tracheal introducer for vibratory feedback during distal contact with tracheal rings but sufficiently large diameter to allow smooth passage through the said hollowed tube and sufficient stiffness through the body of said hollowed tube.

6. The said internal wall fiber bundles of claim 1 are uniformly diametrically dimensioned and internal to the internal walls of said hollowed tube and throughout the said hollowed tube within which fiber bundles are extended, allowing simultaneous proximal-to-distal control of an articulating mechanism facilitating guidance of said tracheal introducer.

7. A method of guiding insertion of a tracheal introducer through a tracheal introducer sheath beyond the level of the vocal cords for subsequent placement of an endotracheal tube into the airway of a person, the method comprising: providing a tracheal introducer sheath device comprising a hollowed tube;arranging the hollowed tube to comprise polytetrafluoroethylene and to have internal to external diameter ratio creating sufficiently rigid channel for said tracheal introducer to be guided along the path of the long axis of the said hollowed tube in varied curved forms yet sufficiently flexible to allow operator malleability and shape memory of said hollowed tube,inserting the sheath-over-tracheal introducer assemblage into the airway;guiding the said trachea introducer into the trachea through said tracheal introducer sheath and confirmed by vibratory feedback of tracheal rings through said trachea introducer and said tracheal introducer sheath into the operator's hands;positioning the endotracheal tube over the said tracheal introducer and subsequently removing the said tracheal introducer.

8. The method according to claim 7 including arranging said hollowed tube of length allowing grasping but not so long as to limit temporary holding of said tracheal introducer during removal of the said hollowed tube after said introducer placement into the trachea.

9. The method according to claim 7 including arranging said hollowed tube with internal diameter that is sufficiently small to allow some contact along the hollowed tube length with said tracheal introducer for vibratory feedback during distal contact with tracheal rings, but sufficiently large diameter to allow smooth passage through the said hollowed tube and sufficient stiffness through the body of said hollowed tube.