Armored tubes

[Hork Bajir]

Armored (aka wire reinforced) ETTs.

Can anyone give me a cohesive argument for a situation where using one of these makes good sense? I’m not sure that they’re really any more kink-resistant than a regular ETT- and if you’re worried about tube kinking, a wire reinforced tube is a risky proposition (won’t unkink, and would need to be urgently exchanged).

The other situation where I hear people reflexively suggest armored tubes is when dealing with an anterior mediastinal mass. However, I do a lot of thoracic, and have never found a particular advantage in this situation... If the airways are collapsing from tracheomalacia or mass effect, a regular tube is usually enough to stent them open. More commonly the issue is that the airway obstruction is distal to the tube, or the airways are collapsed to the point that you can’t shove a tube in (in which case you’d reach for a rigid bronch, or a longer tube like a MLT). An armored tube has a bigger OD for the same ID, as compared to a regular tube, making it harder to pass a point of narrowing.

Am I missing something? Why do these tubes exist? Can someone convince me that they have a role in our practice?

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[KENY1]

They are easier to bend and so less in the way of the surgeon's or dentist's way. Armored/ reinforced endotracheal tube | Anesthesia Airway Management (AAM)

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[KENY1]

Here's a case study of its obstruction after incisor bite and an overview stating if there's airway swelling after maxillofacial surgery etc they are not to be left in after surgery into ICU. I guess they expect a change over a Cook tube changer catheter. That of course has its own risks, I just tried to do one in a Covid patient and I couldn't. I managed to reintubate after 45 minutes with a Glidescope..
Also armored tubes can be used for nasal intubation with no incisor bite risk. There also are armored LMAs mostly for dental use.


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[KENY1]

Armored Endotracheal Tube: Concerns in Intensive Care Unit - PMC

www.ncbi.nlm.nih.gov

Reinforced endotracheal tube: A life threatening experience in intensive care unit - PMC

www.ncbi.nlm.nih.gov

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[woopedazz]

Our ICU doesn't allow them. They get immediately exchanged and a "please explain" sent to anaesthesia.
We use them occasionally for prone cases and some ENT/neuro.

 

[dhb]

I also fail to see the reason for using them but i welcome an explanation.

 

[Hoya11]

Armored (aka wire reinforced) ETTs.

Can anyone give me a cohesive argument for a situation where using one of these makes good sense? I’m not sure that they’re really any more kink-resistant than a regular ETT- and if you’re worried about tube kinking, a wire reinforced tube is a risky proposition (won’t unkink, and would need to be urgently exchanged).

The other situation where I hear people reflexively suggest armored tubes is when dealing with an anterior mediastinal mass. However, I do a lot of thoracic, and have never found a particular advantage in this situation... If the airways are collapsing from tracheomalacia or mass effect, a regular tube is usually enough to stent them open. More commonly the issue is that the airway obstruction is distal to the tube, or the airways are collapsed to the point that you can’t shove a tube in (in which case you’d reach for a rigid bronch, or a longer tube like a MLT). An armored tube has a bigger OD for the same ID, as compared to a regular tube, making it harder to pass a point of narrowing.

Am I missing something? Why do these tubes exist? Can someone convince me that they have a role in our practice?

one ortho surgeon we have has had a problem with neck and facial swelling after shoulder scope in the lateral position.

clearly it has to do with patient selection, scope pressure, scope and port placement, and duration of surgery...

most of the time things go ok, but sometimes you look under the drapes and the entire face and neck is rock solid with fluid - pt not extubate-able...

there are some attendings who put in a armored tube for his cases - worried the regular tube will not hold up..

another example: we used them for some craniotomies where the head is in an awkward position

another: we used to use them for fiberoptic intubations on angioedema folks - because you knew the tube wouldnt collapse but also because the tubes if you have ever seen them are so slick and flexible they are sometimes preferable to intubate with from a fiberoptic scope... and also if you had to go THROUGH an LMA with one they are butter also

some people put them in for prone spine cases that will be several hours just in case of any level of kinking..

Do you need an armored tube for all these things? probably not - but nice to have and that mild increase in OD typically isnt a problem..

We have all done lots of cases, enough to where we have seen problems with a tube kinking at least once, its hard to predict, but the armored tubes will indeed prevent this from happening if you think it might

 

[habibimarwan]

I know ENT like armor tubes for placement in trachea stoma, they suture tube, bend it out of the way. Maybe easy to suture without compression of lumen??

 

[deleted162650]

Sometimes I’ll use them in lieu of a RAE tube in a bigger patient where a RAE would end up too short to stay below the cords.

 

[deleted697535]

one ortho surgeon we have has had a problem with neck and facial swelling after shoulder scope in the lateral position.

clearly it has to do with patient selection, scope pressure, scope and port placement, and duration of surgery...

most of the time things go ok, but sometimes you look under the drapes and the entire face and neck is rock solid with fluid - pt not extubate-able...

there are some attendings who put in a armored tube for his cases - worried the regular tube will not hold up..

another example: we used them for some craniotomies where the head is in an awkward position

another: we used to use them for fiberoptic intubations on angioedema folks - because you knew the tube wouldnt collapse but also because the tubes if you have ever seen them are so slick and flexible they are sometimes preferable to intubate with from a fiberoptic scope... and also if you had to go THROUGH an LMA with one they are butter also

some people put them in for prone spine cases that will be several hours just in case of any level of kinking..

Do you need an armored tube for all these things? probably not - but nice to have and that mild increase in OD typically isnt a problem..

We have all done lots of cases, enough to where we have seen problems with a tube kinking at least once, its hard to predict, but the armored tubes will indeed prevent this from happening if you think it might

There's a lot of things to hypothetically worry about.
The pro's of putting one of these things in, don't outweigh the cons in any circumstance that I can see in the literature to a significant degree or in personal experience.

Just a large waste of money, and people trying to be too smart, or overly cautious. Pretty much the same as every invention or' advance' outside of suggamadex in the last ² decades in anesthesia. Just do regular old things, using regular old tubes and things will pretty much always be fine.

 

[Hoya11]

There's a lot of things to hypothetically worry about.
The pro's of putting one of these things in, don't outweigh the cons in any circumstance that I can see in the literature to a significant degree or in personal experience.

Just a large waste of money, and people trying to be too smart, or overly cautious. Pretty much the same as every invention or' advance' outside of suggamadex in the last ² decades in anesthesia. Just do regular old things, using regular old tubes and things will pretty much always be fine.

for the most part i agree, but what are the cons? it goes in pretty easy and isnt a big deal, its actually kind of a nice slick tube, and i dont know about you guys but im not paying for it. that being said i have not used one in >5 years

 

[deleted500612]

There's a lot of things to hypothetically worry about.
The pro's of putting one of these things in, don't outweigh the cons in any circumstance that I can see in the literature to a significant degree or in personal experience.

Just a large waste of money, and people trying to be too smart, or overly cautious. Pretty much the same as every invention or' advance' outside of suggamadex in the last ² decades in anesthesia. Just do regular old things, using regular old tubes and things will pretty much always be fine.

I do also think the widespread adaptation of ultrasound guided nerve blocks has been a pretty big advancement over landmark-based blocks.

 

[anesthesiadoc]

I find they’re helpful in dental/oral surgery cases because they can be bent out of the way. Occasionally saves me from some unnecessary nasal intubations in these cases. (Which is especially nice in anticoagulated folks so we can skip the torrential nosebleed part).

One caveat: agree with above poster in that I would never send somebody to the unit with one of these because “once they’re bit you’re in the ****.”

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