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Ask HN: Is anyone working on a less painful intubation tube?

81 points by sigmaprimus 6y ago

I just had lapriscopic surgery and was put under anesthesia for the procedure, upon waking up my throat and voice are totally messed up. My normal deep voice now sounds like Mickey Mouse's and it hurts to swallow. With all the advancements in medicine and especially during the current pandemic it would seem an opportune time to develop a less damaging breathing tube which I suspect currently is just a piece of vinyl or silicone. After my experience I would be more than happy to kick in a few dollars to support the development of a better tube, possibly made of a more natural material grown in a lab. I figured I would ask if anyone is working on this problem. Thanks.

arthurcolle 6y ago
I'm really sorry you are experiencing this. How did they perform the procedure? I'd love to hear more about your experiences, because I have first-hand experience on how surgical procedures can feel really overwhelming.
bombcar 6y ago
I suspect other materials wouldn’t help much - that the main pain and irritation is having anything shoved in there.
- mattigames 6y ago
  No, your body perceiving something in there is the main problem, if even 10% of the effort spent on finding the covid vaccine was spent on understanding how nerves work and how can we modify/intercept nerve signals we could tackle this issue among many others to make pain a thing of the past.
  - gruez 6y ago
    >if even 10% of the effort spent on finding the covid vaccine was spent on understanding how nerves work and how can we modify/intercept nerve signals I find it hard to believe that pain isn't a well studied area of medicine. But to answer your question, we already do know how to "modify/intercept nerve signals", they're called painkillers.
    - apatters 6y ago
      I'm not a doctor but if you've ever had to deal with nerve pain or neurological conditions in general, there's a ton of stuff we don't know. Doctors will readily admit this. Not sure that the question of whether we've "tried hard" to understand it is a productive one but there's a ton of stuff where we have only a vague idea of what is going on, we prescribe drugs that sort of work but we don't know how they work, conditions that they can't even nail down a diagnosis for, etc. It's probably one of the least well understood areas of medicine.
      - solveit 6y ago
        > Not sure that the question of whether we've "tried hard" to understand it is a productive one The point is that more effort isn't likely to dramatically change things on the margin. Whether we know much about pain in an absolute sense is really quite orthogonal to the question.
        mattigames 6y ago
        >The point is that more effort isn't likely to dramatically change things on the margin. Citation needed; I think is completely possible to modify nerve communication in real time and its within our reach but the resources to do all the research and experiments just aren't there; the causes with the big bucks are things like cancer research (nothing worng with that, just pointing it out); plus many artificial obstacles to make lab-grown nerves such as religious organizations against stem cell research.
    - redis_mlc 6y ago
      Western medicine is great when you can X-ray something, but quickly loses certainty when you can't. Pain is something where acupuncture and other related methods might be better.
    - calvano915 6y ago
      Well-studied perhaps but often not effectively given due attention, except for modalities that are easy to apply (medication, TENS, ultrasound, etc) despite insufficient or quickly diminishing effectiveness. The US healthcare system isn't oriented around more time consuming approaches (highly individual; hard to "dose" and ensure adherence) for chronic pain such as stretching, stress relief, postural improvements, etc. For acute pain such as the OPs experience, painkillers are/should be first line when treatment is indicated.
randycupertino 6y ago
It may have been a technique issue as well - the RT or pulmonolgist or anesthesiologist (whoever put your tube in- it varies between hospitals) may have made multiple attempts and/or scratched your larynx. Every second they spend placing the tube in your throat is a second you're not getting ventilation, so they prioritize speed (and accuracy!) over comfort. Also tubes come in different sizes so perhaps they used a large one for your anatomy. You say you "just" had surgery- you probably still have a lot of inflammation on your palatine tonsils and vocal fold area, making your throat scratchy. It should go back to normal in a few days. It's not really the "tube" that hurts- what hurts is the removal. While it's in during surgery your anatomy gets used to the tube there and kind of all settles in place around it, getting comfy. When it's pulled out, it feels like it's being ripped out and it's kind of a shock to your system. Imagine if you hiked the Appalachian Trail for a few months and never changed your boots or your socks and the skin kind of melded into the socks and then at the end of your hike I quickly whipped your socks off. Your throat right now is like how your feet would feel. The thing with the tubes is they have to be rigid enough to stand up to the insertion which while a delicate process actually takes more force than you'd think so they need to have a pretty solid structure and also can't collapse on themselves while keeping the airway open. There's a lot of "stuff" that can come up in the tube or goes down through them - phlegm, sticky sputum, tonsil stones, "gunk," blood, lasers, cutting tools, biopsy tissue, etc. Can't have risk of the tube having divets or anything where something could get caught on or stuck to and block the airway. They also will have plastic and metal suction tubes and cameras and things inserted down inside the tube, so the sometimes the width of the tube depends on the procedure they're doing and what how big it is based on the things going through it. I'm not a doctor, just a former respiratory therapist but I'd recommend taking ibuprofen and if it's still bothering your sending a message or calling your doctor tomorrow for their input. As far as making a more comfortable tube - they already use water and gel based lubrication to make the insertion and extubation process more comfortable on the airway. Your idea of a lab-grown natural membrane is interesting, but imo too much medical liability around having the tube be comfortable- would way rather have the patient have a stable airway and uncomfortable throat for a week than the airway collapse mid procedure and have brain damage or worse from an occluded airway. Maybe a longer lasting lubricant so it could last through and still be lubed up for the extubation, however maybe they don't do that because of risk of it dripping down the tube into the lungs. Generally anything fluid in the lungs is bad and that's why your cilia along your bronchioles bring up all that gunk we cough up on a daily basis. Anyways- hope you feel better soon! Fwiw, pain on extubation was a very common complaint- it's one of the reasons patients who frequently or need long term ventilation will have a temporary or permanent tracheostomy which goes in through the throat directly and skips the delicate tissue around the vocal anatomy. Edit- here are two good papers I found googling about this that you might want to read for more info: Larger review of 9 studies/775 pts: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7219530/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7219530/ Voice loss following intubation: https://www.arwy.org/article.asp?issn=2665-9425;year=2019;volume=2;issue=2;spage=57;epage=63;aulast=Kotekar https://www.arwy.org/article.asp?issn=2665-9425;year=2019;vo... <-- what I found interesting from this one is it references between 5-90% of patients have some postop symptoms! Oof. > The incidence of laryngopharyngeal symptoms after endotracheal intubation varies between 5.7% and 90%. These are usually mild and transient requiring minimal active intervention or none at all. Most resolve in 12-72 h, with an exception in cases of injury to vocal folds or arytenoids.[2]
glasss 6y ago
I don't have much relevant info directly related to your question, but have some second hand experience with recovering from intubations that I would just like to share. My mom went through this when she was having health issues over a few years before her passing. I think it varies based on how good the person performing the intubation is and how long it is in. The first time her voice ended up like minnie mouse, and it was like that for a long, long time. Probably a year before it became "normal", but definitely not like how she used to sound. It kept slowly getting better. A few years later her voice was mostly back to how she sounded before hand and had been for while, then she had more health issues and was intubated again. This time she was fine - no voice change and no pain that she reported. A few months later, intubation, but this time her voice was pretty bad and it never got better before her passing.
bezalmighty 6y ago
Try and break the problem down with systems thinking. Here's an example of this: ━━1=> The output effect you're trying to eliminate/reduce is pain and swelling in respiratory tract. ┗━━2=> Hypothesis (needs testing): This is caused by physical irritation of the tube ┗━━3=> Hypothesis (needs testing): That irritation is caused by A) friction and B) physical pressure ┣━━4a=> How can we reduce friction? ┃ ┗━━5a=> Would a lubricant on the tube meet engineering constraints and reduce friction? ┃ ┗━━6a=> Would the use of lubricant in practice create added risks or difficulties in the operating room? ┃ ┗━━7a=> Hypothesis: Yes, due to the application of lubricant necessitating a glove-change afterwards. ┃ ┗━━8a=> How can we overcome problems with lubricant application to the intubation tube? ┃ ┗━━9a=> Would passing the intubation tube through a no-mess, easy-to-use "self lubricating ring" mitigate added risks or difficulties in the operating room? ┗━━4b=> How can we reduce physical pressure? ┗━━5b=> Would reducing the diameter meet engineering constraints and reduce pressure? ┗━━6b=> If there is a minimum diameter requirement needed to deliver oxygen, would dynamically changing the diameter of the tube (e.g. inflating it) after insertion create a reduction in pressure? So that's a very simplified example of how to solve problems with systems thinking (although in reality it would be WAY more detailed and actually test each hypothesis). The problem is very rarely "money" in medical fields, the problem is someone actually identifying the root problem/s, i.e. the "problem behind the problem behind the problem", and applying engineering to solve that, which solves the problem one level above it, etc. If you're interested in this, read up on things like "the five whys", a systems approach to problem solving invented at Toyota.
- mulmen 6y ago
  Meta: Thanks for presenting this in this format, it helped me visualize how this process would work. We use the five whys at work to great effect, to such an extent I actually look forward to COEs. Your comment put a name to this domain. I'd like to learn more about systems thinking. Are there any books you recommend?
  - kkm 6y ago
    I can recommend material from Donella H. Meadows. The book “Thinking in Systems” is a very good one. https://www.goodreads.com/book/show/3828902-thinking-in-systems https://www.goodreads.com/book/show/3828902-thinking-in-syst...
DoreenMichele 6y ago
My normal deep voice now sounds like Mickey Mouse's and it hurts to swallow. Perhaps a more "low hanging fruit" solution for this problem space would be better procedures for helping people recover. Doctors routinely prescribe antibiotics. I never had any of them tell me to eat yogurt afterwards to repair what they do to your gut biome. I learned that elsewhere. No doctor ever told me I needed to taper off of steroids. I learned that from a friend. There are a lot of ways modern follow-up care for medicine seems to be pretty bad and this is probably a much easier thing to improve upon than innovating on intubation tubes (which I'm not trying to discourage -- I see no reason we can't do both).
- robbiep 6y ago
  No doctor is ever going to prescribe steroids that do not end in a tapering dose (necessary for initial durations longer than 5 days). It literally kills and is negligent
  - DoreenMichele 6y ago
    I've been on steroids multiple times, for sometimes months at a time. No doctor ever put me on a tapering dose. So whatever they are supposed to do, that's not what I personally experienced.
  - peteretep 6y ago
    Plenty of doctors prescribing benzos seemingly unaware of the cessation issues with them
    - robbiep 6y ago
      Very few would be unaware of the consequences... it’s a basic tenet of medicine - after all, along with alcohol withdrawal (and because of similar mechanisms) it’s one of the few withdrawals that can actually kill you (along with steroids). Again that’s terrible practice but more often than not, given the prevelance of Benzo knowledge and specific requests from patients, some people end up giving them away (similarly to antibiotics for viral infections). It’s bad medicine but when GPs have 20 minutes for a consult and patients are more and more demanding... corners are cut when harm is considered minimal (ie regular low level Benzo dosing). For example, probably 20-30% of elderly patients in hospital are on temazepam on arrival. They’re taking 10mg every night. That should never happen, but it does all the time.
mft_ 6y ago
Just checking: do you know for sure what type of tube was used? There are two broad types used for general anaesthesia - the endotracheal tube and the laryngeal masked airway, which are very different in design and function.
Ovah 6y ago
It's probably the actual physical metal laryngoscope that is the cause of the throat pain, and not the tube itself. The laryngoscope is used to pry open the throat so the vocal chords can be clearly sen. It's not violent but there is significant force involved and a slight mistake can get a tooth knicked. This visibility is needed so that an air tube can be inserted between the vocal chords to secure the airway. https://en.wikipedia.org/wiki/Laryngoscopy#/media/File:Macintosh_Blades.jpg https://en.wikipedia.org/wiki/Laryngoscopy#/media/File:Macin...
- BjoernKW 6y ago
  If applied properly the laryngoscope should never actually touch the larynx or the vocal cords. The spatula is inserted between the tongue and the epiglottis.
  - Ovah 6y ago
    I agree. OP stated it was painful to swallow and I'm guessing the laryngoscope is likely the culprit there. The idea is that because the laryngoscope compresses the base of the tongue this likely results in pain swallowing.
FiatLuxDave 6y ago
My father is an expert in this field. He is a pediatric anesthesiologist who has done much work on development of entubation systems. I think he has at least six entubation patents, and was also the developer of the light tube entubation method. Back in the early covid days we were discussing possible lung lavage tubing methods, but neither of us had time to work on that. I can put you in touch with him if you are interested.

sigmaprimus 6y ago

I appreciate your method of breaking down the problem. I'm still stuck on the idea of using different materials but after applying your thought process I think a gelatin coating may solve the lubrication issue and possibly allow a topical numming agent like Ambesol or anti inflammatory to be infused in the gelatin layer. It is possible that because my procedure ran longer than expected due to complications, they either had to reinsert a different tube or the tube they used was not designed to be used for that long. I had my gallbladder removed and unfortunately some of the gallstones got stuck in the bile ducts and they had to chase them down. This turned a 45 minute procedure into a 3 1/2 hour operation and once finished it took another 2 hours to wake up.

DoreenMichele 6y ago
I don't know what kind of anesthesia you were on, but a quick google suggests some kinds of anesthesia cause difficulty swallowing. I also can easily pull up a link suggesting that dehydration is a common cause of sore throat following any major surgery. So this may not be entirely about the physical contact of the tube. I am not a doctor, just someone who has seen too many of them over the years for my own medical dramas. Edit: Just to be crystal clear, I am absolutely not trying to suggest anything for you, medically speaking. The above observations are food for thought concerning the problem space under discussion. That's it. That's all it is.
benmaraschino 6y ago
The issue with coatings and lubricants is that you’d need to use a nontrivial amount for them to be effective, and that means the patient is at risk of aspirating the substance. That happens, and boom, you’ve got aspiration pneumonia. Even with some kind of encapsulated or solid gelatin coating you’d have to be very careful to make sure it doesn’t leave any kind of residue or break into pieces that could be aspirated.
- mswann 6y ago
  Considering solid materials with ultralow friction (e.g. fullerene-like nanostructures) might be worthwhile. https://pubmed.ncbi.nlm.nih.gov/21825776/?dopt=Abstract https://pubmed.ncbi.nlm.nih.gov/21825776/?dopt=Abstract https://pubmed.ncbi.nlm.nih.gov/11001049/?dopt=Abstract https://pubmed.ncbi.nlm.nih.gov/11001049/?dopt=Abstract https://doi.org/10.1088/0022-3727/39/18/R01 https://doi.org/10.1088/0022-3727/39/18/R01 https://doi.org/10.1063/1.1366649 https://doi.org/10.1063/1.1366649
- hackeraccount 6y ago
  This is a dumb idea that would presumably cause other problems but ... what if they put the patient upside down? It's certainly make using some sort of lubricant a lot less dangerous. Now presumably it would introduce a host of other problems that would offset this but who knows.

stevegalla 6y ago

TL;DR 1. Consider Ishikawa (“fish bone”) diagrams before applying the 5 whys or as a way to help organize the 5 why process. 2. To improve a system, first determine what is constraining the performance of the system. This is 80/20 thinking and attempting to optimize globally instead of locally. Local improvement may not result in system improvement. Longer explanation and examples follow. 1: The 5 whys are a great problem solving tool. Often there are many potential root causes which need to be investigated. Sometimes there is a single root cause that is responsible for the problem being investigated other times there are multiple factors that interact to cause the problem. An Ishikawa or “fishbone” diagram is a useful tool to help organize many potential root causes. In the example of pain and swelling caused by intubation we could start a little higher before diving into detailed 5 whys. We can start with top level groups, such as: - material - method - person - patient For each group, we determine potential root causes. This can be done through asking the experts performing the process, reviewing SOPs, observing the process, looking at process parameters, literature reviews. Some examples, material could be the material of the tube, the type of coating being used, anesthesia, etc. Method could be how the tube is inserted. Person can be if the person is new to the process or experienced, is the person following procedures... Patient could be if the patient has any allergies to materials or adverse reactions to medication or anesthetic... The above are illustrative. You can decompose the groups in different ways. You can define the groups differently. Of course the above isn’t comprehensive or unique. Try to be MECE or mutually exclusive and collectively exhaustive when decomposing the problem space. We often try to investigate the potential root causes by performing statistical experiments to try and determine cause and effect and which variables significantly impact the outcome. 2: I want to provide an alternative point of systems thinking. The medical procedure is a process. There is a system at work to deliver that medical procedure. There are measurements to determine how the procedure is working. Efficiency (are you using the resources planned) and effectiveness (are you achieving the outcome the procedure was designed to provide) are two high-level ways to look at measuring system performance. Many measurements can be derived from these two. From that perspective, you want to focus improvement on the areas/steps in the process that will most improve the outcome measures. With that in mind, it may have been determined that the combination of intubation materials and procedures that are used provide for the best outcomes as determined by the procedure provider. It may be to reduce cost while keeping recovery, discomfort, risk of infection, etc. at some baseline acceptable level. If you change those variables to reduce discomfort, it’s possible you may negatively impact cost, patient recover, or something else. Note: I’m not a health care professional, so I have no knowledge about medical procedures or the various trade-offs and optimizations that take place. I am speaking from the point of view of someone who works in quality and process improvement.