title: Efficacy of the self-inflating bulb in confirming tracheal intubation in the morbidly obese.
abstract: BACKGROUND
  This study was designed to determine the incidence of false-negative and false-positive results when the self-inflating bulb (SIB) is used to differentiate tracheal from esophageal intubation in morbidly obese patients using two techniques. In technique 1, the SIB is compressed before it is connected to the tube; in technique 2, the SIB is compressed after connection to the tube.
  
  
  METHODS
  With institutional review board approval, 54 consenting adult morbidly obese patients (body mass index > 35) undergoing elective surgical procedures were included in the study. After anesthetic induction and muscle relaxation, both the trachea and esophagus were intubated under direct vision with identical cuffed tubes. The efficacy of the SIB in verifying the position of both tubes was tested by a second anesthesiologist. The speed of reinflation was graded as rapid ( < 4 s) or none ( > 4 s), using both techniques. In the case of tracheal intubation, the absence of reinflation was recorded as a false-negative, whereas in cases of esophageal intubation, rapid reinflation was recorded as a false-positive. Identification of tube location by the second anesthesiologist was based on SIB reinflation results from techniques 1 and 2, as well as the presence of a flatuslike sound elicited by technique 2 in esophageally placed tubes. All patients were retested by the SIB after receiving three breaths of 400-500 ml each. In all patients exhibiting false-negative results, six obese patients exhibiting true-positive results, and four nonobese patients exhibiting true-positive results, tracheal responses to the SIB maneuvers were observed directly by a flexible fiberoptic bronchoscope incorporating an airtight system, 15-20 min after mechanical ventilation was instituted.
  
  
  RESULTS
  The incidence of false-negative results was initially 30% with technique 1 and 11% with technique 2, but decreased to 4% when technique 2 was used after the delivery of three breaths. The second anesthesiologist initially identified tube location in 92.5% of patients correctly. After the delivery of three breaths, tube location was correctly identified in 96.3% of patients. Fiberoptic bronchoscopic examination of the patients exhibiting false-negative results revealed exaggerated inward bulging of the posterior tracheal membrane during reinflation of the SIB when technique 1 was used.
  
  
  CONCLUSIONS
  Contrary to previous investigations in healthy patients, the current study demonstrates a high incidence of false-negative results when the SIB is used to confirm tracheal intubation in morbidly obese patients. If the SIB is used, the technique should include compression of the SIB after connection to the tube and should be used in conjunction with other clinical signs and technical aids. The mechanism of false-negative results in these patients seems to be related to reduction of caliber of airways secondary to a marked decrease in functional residual capacity, and collapse of large airways due to invagination of the posterior tracheal wall when sub-atmospheric pressure is generated by the SIB.
authors.affiliation: Department of Anesthesiology, Illinois Masonic Medical Center, Chicago 60657-5193, USA.
authors.forename: D J
authors.initials: DJ
authors.lastname: Lang
authors.forename: Y
authors.initials: Y
authors.lastname: Wafai
authors.forename: M R
authors.initials: MR
authors.lastname: Salem
authors.forename: E A
authors.initials: EA
authors.lastname: Czinn
authors.forename: A A
authors.initials: AA
authors.lastname: Halim
authors.forename: A
authors.initials: A
authors.lastname: Baraka
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001999:Bronchoscopy / Q000379:methods; D005188:False Negative Reactions; D005189:False Positive Reactions; D005260:Female; D005336:Fiber Optic Technology / Q000379:methods; D006801:Humans; D007442:Intubation, Intratracheal / Q000295:instrumentation / Q000379:methods*; D007828:Laryngoscopy / Q000379:methods; D008297:Male; D008875:Middle Aged; D009767:Obesity, Morbid / Q000503:physiopathology*; D011446:Prospective Studies