Nasal tracheal tube

[stonemd]

Dental procedure on pediatric patients using a nasal RAE tracheal tube.

Do have a recommendation for best tube that comes with a short length high vol low pressure cuff that comes in small sizes?

We are using more cuffed tubes to minimize leak
I know proper placement is more difficult as tube tip and prox end of cuff must both be between cricoid and carina.
Current tubes we use only go down to 4.5 ID

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[propadope]

Dental procedure on pediatric patients using a nasal RAE tracheal tube.

Do have a recommendation for best tube that comes with a short length high vol low pressure cuff that comes in small sizes?

We are using more cuffed tubes to minimize leak
I know proper placement is more difficult as tube tip and prox end of cuff must both be between cricoid and carina.
Current tubes we use only go down to 4.5 ID

Why short length? As far as I know, the cuffed tubes are longer than uncuffed of the same size.

 

[propadope]

You could go 0.5 size smaller but it doesn't make sense from a resistance perspective

 

[stonemd]

Why short length? As far as I know, the cuffed tubes are longer than uncuffed of the same size.

I mean short cuff length. Longer cuff lengths require even greater precision to place properly.

 

[propadope]

I mean short cuff length. Longer cuff lengths require even greater precision to place properly.

Thanks for the clarification. How come the need to minimize leaks? Are they on a vent?

 

[propadope]

I thought the high volume/low pressure cuffs are oblong by design. A round cuff would be shorter but would be more pressure, no?

 

[stonemd]

We do lots of 3-4 cases and some providers are not as comfortable with spont vent and higher etco2
We also see some leaks with spont vent for reasons I don't understand
I

 

[propadope]

We do lots of 3-4 cases and some providers are not as comfortable with spont vent and higher etco2
We also see some leaks with spont vent for reasons I don't understand
I

Usually with the throat well packed the leaks are minimal with spontaneous ventilation How do you size your tubes?

 

[IlDestriero]

We use cuffed tubes on all the kids.
I can see what brand they are.
I can say for sure that they are not the fancy (expensive) micro cuff (high volume low pressure) tubes.
The only time we use the microcuff tubes are for under a year. And usually only for longer cases. We also use them for one lung ventilation.

 

[IlDestriero]

These are our Microcuff tubes. They're made by Kimberly Clark
http://www.infomed.bg/images/Files/microcuff brochure_pediatric.pdf

They don't make nasal tubes, but you can use them in the nose and than place one of the bent metal reusable connectors.
One of the faculty does that with regular tubes as she doesn't like the nasal tubes for some reason.
That would probably be the only way to use these microcuff tubes as nasal tubes for dental.
I have no idea who manufactures the metal connectors.

 

[Noyac]

We do lots of 3-4 cases and some providers are not as comfortable with spont vent and higher etco2
We also see some leaks with spont vent for reasons I don't understand
I

A couple thoughts.
First, i hope you are talking about crnas when you say "providers". Secondly, tell those crnas to stop putting them on the vent. Thirdly, 4.5 should be as small as you need for dentals. You shouldn't be doing these cases under 2yo but this is just my opinion. Oh and the opinion of the rest of my group.

I use the Nasal RAE tubes by Covidien. The Mallinckrodt tube.
http://www.covidien.com/rms/product...l-rae-endotracheal-tubes-with-taperguard-cuff

I don't always put air in the cuff on these kiddos. But I don't paralyze them either, they are breathing from the get go.

 

[propadope]

These are our Microcuff tubes. They're made by Kimberly Clark
http://www.infomed.bg/images/Files/microcuff brochure_pediatric.pdf

They don't make nasal tubes, but you can use them in the nose and than place one of the bent metal reusable connectors.
One of the faculty does that with regular tubes as she doesn't like the nasal tubes for some reason.
That would probably be the only way to use these microcuff tubes as nasal tubes for dental.
I have no idea who manufactures the metal connectors.

Oh I see. The cuff material is thinner. Interesting. Are they super expensive?

 

[IlDestriero]

I believe that we were told that they were 2-3 times more and to "only use them when actually appropriate."
Which could be for every case if you felt strongly enough about it, but we use them sparingly and do 30k+ cases a year, most with standard tubes without problems. The NICU however is opposed to all cuffed tubes and will change them out for patients that are expected to remain intimated for many days. Unless they're a difficult airway, they're not that stupid. Lol.

 

[IlDestriero]

A couple thoughts.
First, i hope you are talking about crnas when you say "providers". Secondly, tell those crnas to stop putting them on the vent. Thirdly, 4.5 should be as small as you need for dentals. You shouldn't be doing these cases under 2yo but this is just my opinion. Oh and the opinion of the rest of my group.

I use the Nasal RAE tubes by Covidien. The Mallinckrodt tube.
http://www.covidien.com/rms/product...l-rae-endotracheal-tubes-with-taperguard-cuff

I don't always put air in the cuff on these kiddos. But I don't paralyze them either, they are breathing from the get go.

This is the one we use. With the distinctive tapered cuff, which I don't understand, but that's irrelevant.

 

[propadope]

A couple thoughts.
First, i hope you are talking about crnas when you say "providers". Secondly, tell those crnas to stop putting them on the vent. Thirdly, 4.5 should be as small as you need for dentals. You shouldn't be doing these cases under 2yo but this is just my opinion. Oh and the opinion of the rest of my group.

I use the Nasal RAE tubes by Covidien. The Mallinckrodt tube.
http://www.covidien.com/rms/product...l-rae-endotracheal-tubes-with-taperguard-cuff

I don't always put air in the cuff on these kiddos. But I don't paralyze them either, they are breathing from the get go.

+1 on no paralytics. No need. Also if you are running vapour and they are breathing spontaneously the CO2 does not get very high.

 

[Sublimazing]

Rusch has preformed nasal RAE cuffed down to 3.5 and uncuffed down to 3

Was in a very busy dental surgery center and even on the kids that are 1-2yo you can usually get a 3 down because of the cephalocaudal growth trend

Most of our patients were 2yo and the rusch cuffed 4 was our go-to

 

[propadope]

Rusch has preformed nasal RAE cuffed down to 3.5 and uncuffed down to 3

Was in a very busy dental surgery center and even on the kids that are 1-2yo you can usually get a 3 down because of the cephalocaudal growth trend

Most of our patients were 2yo and the rusch cuffed 4 was our go-to

I find Rusch tubes stiffer and more traumatic than Mallinkrodt

 

[Sublimazing]

I find Rusch tubes stiffer and more traumatic than Mallinkrodt

well continue working with your flaccid tube then, i never had a problem

 

[stonemd]

I prefer preformed nasal tubes as Our hospital is not into reprocessing equipment like the metal right angle connector

Mallinckrodt make tapered cuffed nasal RAE only down to 6.0!
Kimberly Clark has nice sort cuff down to 3.0 but not preformed nasal
Rusch goes to 3.5 preformed nasal but standard cuff
Sheridan preformed down to 6.0
Parker standard cuff nasal down to 4.0

so i guess the best option for me is Rusch

If anyone knows of a short low pressure cuff, preformed nasal RAE
please let me know

 

[Arch Guillotti]

I have used a cuffed tube on every one of these cases I have ever done. What's the big deal with a short low pressure cuff? I inflate the cuff until I am satisfied with the leak around it.

 

[Planktonmd]

I have used a cuffed tube on every one of these cases I have ever done. What's the big deal with a short low pressure cuff? I inflate the cuff until I am satisfied with the leak around it.

Agree!
That non cuffed tubes dogma is ancient, it made sense with the old tubes but it's obsolete now with the use of high volume/low pressure cuffs.

 

[stonemd]

there is a large variation in the distance between the proximal (oral) end of the cuff to the tracheal tube tip. With a greater distance there is more precision required to insure the entire cuff and tube tip is between the cricoid and the carina. So the shorter the cuff tip distance the lower chance of main stem intubation or cricoid mucosal injury. The companies also claim that the newer cuff designs (tapered, microthin, ultra low pressure) allow seal with lower cuff pressure.

That said, I cannot find a preformed nasal tube at small ID that uses the cuff described above.
may not make a big difference so I will use Rusch with standard low pressure cuff as they offer the smallest preformed nasal RAE

I agree that the routine use of uncuffed tubes seems to be going away.

We do pass a red rubber catheter in first to direct the tracheal tube thru the nose. It has reduced the incidence of nosebleeds and keeps blood out of the tracheal tube where it sometimes clots and leads to obstruction.

BTW are all modern tracheal tubes hig volume low pressure? IF not is there an indication for low volume, high pressure cuffs?

 

[stonemd]

A couple thoughts.
First, i hope you are talking about crnas when you say "providers". Secondly, tell those crnas to stop putting them on the vent. Thirdly, 4.5 should be as small as you need for dentals. You shouldn't be doing these cases under 2yo but this is just my opinion. Oh and the opinion of the rest of my group.

I use the Nasal RAE tubes by Covidien. The Mallinckrodt tube.
http://www.covidien.com/rms/product...l-rae-endotracheal-tubes-with-taperguard-cuff

I don't always put air in the cuff on these kiddos. But I don't paralyze them either, they are breathing from the get go.

We have priamrily physicians supervising CRNAs but actually 1 of our peds anes doc prefers ppv to spont vent in these 3-4 hour cases.
We have done kids even under 1 yo! They dont consult me regarding the nesscessity for dental work in these kids.

Do you use a leak test to ? 20cm H2O or a manometer to fill the cuffs?

BTW oour last TJC commision wanted a new air syringe for each patient labled and expiration time/date!!

 

[propadope]

Agree!
That non cuffed tubes dogma is ancient, it made sense with the old tubes but it's obsolete now with the use of high volume/low pressure cuffs.

I wonder why Mallinckrodt only has cuffed nasal RAE down to 6.0 on their website and as per stonemd...

 

[stonemd]

Maybe many cut standard tubes and use adapters

 

[propadope]

Maybe many cut standard tubes and use adapters

Perhaps but I feel that the RAE's are more popular due to comvenience.
Maybe because most children (im guessing) are spontaneously breathing for dental and there is no market for a cuffed nasal RAE?

Of course this doesn't explain why Rusch offers them

 

[IlDestriero]

Do you use a leak test to ? 20cm H2O or a manometer to fill the cuffs?

BTW oour last TJC commision wanted a new air syringe for each patient labled and expiration time/date!!

1. We just do a leak test and I'm satisfied if the leak is more than 18 and less than 30.
2. When does room air expire? Haven't we had an atmosphere for billions of years now?

 

[Noyac]

We have priamrily physicians supervising CRNAs but actually 1 of our peds anes doc prefers ppv to spont vent in these 3-4 hour cases.
We have done kids even under 1 yo! They dont consult me regarding the nesscessity for dental work in these kids.

Do you use a leak test to ? 20cm H2O or a manometer to fill the cuffs?

BTW oour last TJC commision wanted a new air syringe for each patient labled and expiration time/date!!

4 hrs? You have got to be kidding. I guess I can see your colleagues point with regards to PPV.

Leak test. I'm shooting for around 20. But I really don't care since they are breathing spontaneously.

We will never understand the TJC and their demands. They just told us we couldn't keep our dbl lumen tubes in the boxes they come in while in our center core storage area. WTF?

 

[propadope]

We have priamrily physicians supervising CRNAs but actually 1 of our peds anes doc prefers ppv to spont vent in these 3-4 hour cases.
We have done kids even under 1 yo! They dont consult me regarding the nesscessity for dental work in these kids.

Do you use a leak test to ? 20cm H2O or a manometer to fill the cuffs?

BTW oour last TJC commision wanted a new air syringe for each patient labled and expiration time/date!!

Under 1 year old? Thats outrageous! I wonder what for?

 

[stonemd]

We use midazolam Preop, nitrous sevo induction. Sometimes add IV fentanyl or propofol for intubation We use sux if laryngospasm.

What do you add routinely to deepen Anes / prevent spasm? Relaxant or topical might be other options.

 

[IlDestriero]

We use midazolam Preop, nitrous sevo induction. Sometimes add IV fentanyl or propofol for intubation We use sux if laryngospasm.

What do you add routinely to deepen Anes / prevent spasm? Relaxant or topical might be other options.

Unless it's a quick extraction, I usually paralyze them for intubation in case it takes longer than expected to secure the airway. I know that they won't be getting light and going into laryngospasm or coughing, etc.

 

[propadope]

We use midazolam Preop, nitrous sevo induction. Sometimes add IV fentanyl or propofol for intubation We use sux if laryngospasm.

What do you add routinely to deepen Anes / prevent spasm? Relaxant or topical might be other options.

I use propofol and remi. Wears off quick and they are back spontaneously breathing