An innovative pediatric Y-connector to minimize dead space, and maximize safety and surgical access.

Sir,

In oral and maxillofacial surgical procedures, it is an unsaid commitment on the part of the anesthetist to provide as much space around the surgical site as possible. This translates, among other things, into keeping the bulky breathing circuits away from the surgical field. In adults, the task is easily accomplished by inserting extension tubing or, more specifically, a catheter mount, between the Y-connector and the universal connector of the endotracheal tube (ETT). Unfortunately, the same technique cannot be extrapolated in infants and young children,[1] and also in adult patients with respiratory diseases,[2] because this can significantly increase dead space ventilation. Commercially available pediatric Y-connecting pieces (VBM Medizintechnik GmbH, Einsteinstrasse, Sulz a. N., Germany; Nuova GmbH, Schmilauer Strasse, Mölln, Germany) circumvent this problem with double tubing, which segregate inspiratory and expiratory flow close to the ETT. Although these commercial pediatric Y-connecting pieces have narrower tubing than their adult counterparts, they still do encroach upon the surgeon's space. Moreover, being corrugated, they can leave pressure marks on the fragile skin of an infant and thus need padding, which again is space consuming. Also, the Y-connecting piece and the breathing circuit are bulky, and there is a constant fear of accidental extubation. Working in a dedicated maxillofacial anesthesia unit, and having faced this problem frequently, we decided to modify the pediatric Y-connecting pieces with locally available material. We used two uncuffed, flexometallic tubes, of internal diameter 5.5 mm, and external diameter 7.8 mm, in place of the corrugated tubing. Interposing the proximal segment of a soft suction catheter fastened the connection of the beveled end of the tubes with the breathing circuits. The other ends of the reversed ETT were simply inserted inside the proximal ends of a pediatric Y-connector. On putting this assembly to clinical use, we realized that the commercial Y-connectors, both straight and right-angled, still had scope for ergonomic recontouring, especially when used on infants. We drilled two holes of 5 mm diameter adjacent to each other on a universal connector of a 4.0 mm ETT. In these, we inserted two intravenous needle caps, whose proximal and distal ends had been cut off by 1 cm each. The distal end was provided with a bevel to prevent obstruction inside the universal connector. The joint between the caps and the universal connector was sealed with 3M™ Scotch-Weld™ Medical Grade Instant Adhesive MG300 FLX (St. Paul, MN, USA). The proximal ends of the flexometallic tubes were then slid over the caps [Figure 1]. The top of the universal connector was covered with a simple rubber seal from a 5 mL drug vial, and sealed, again with the medical grade adhesive. All joints were diligently sealed to allow no leakage up to a pressure of 40 cm water. The maximum width of this assembly was 18 mm at the level of the rubber cap and 15.6 mm at the level of the tubes, when put together. The height at the level of the tubes was 7.8 mm. The flexometallic tubes provided better kink protection than the corrugated tubes. The device had almost nil dead-space. After nasal intubation, the smooth tubes could be easily fixed to the nose and forehead with the help of adhesive plaster, and likewise, onto the cheek, chin, and neck in orally intubated patients. Securing the assembly in this way significantly decreases the chances of accidental extubation. Although, compared with the wide-bore Y-connecting pieces, the airflow resistance of our assembly should be more, we feel it is still acceptable in clinical scenarios due to two broad reasons: First, the maximum resistance to airflow shall come from the ETT (when less than 5.5 mm ID, as would be the case in infants and young children), or more specifically, from the ETT connector; and second, the concern shall be clinically insignificant during controlled ventilation. The fact that we need to have a specific connector for each tube size is a bit of a disadvantage, but all attempts to create a “universal” connector (using a 22 mm - 15 mm breathing circuit adaptor) managed to add bulk to the device, and defeat the basic purpose [Figure 2]. Having used this design in 15 patients so far, we have faced no problems, and are satisfied by its performance. We present this easy-to-assemble device, for use in infants and small children, to prevent rebreathing, accidental extubation, and most importantly, provide adequate space for the surgeons to operate on the face. As we could find no published literature related to this topic, with our simple innovation, we wish to create awareness and stimulate interest for further research.

Figure 1

The assembled Y-connector. The material used has been shown alongside

Figure 2

Attempted “Universal” Y-connector — useful but bulky