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ETT sizing.

Discussion in 'Anesthesiology' started by Noyac, Sep 4, 2014.

  1. Noyac

    Noyac ASA Member
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    I have noticed a trend over the past few year towards using smaller ETT's. What are you guys being taught in residency theses days? When I trained it was 7.5-8.0 for most males and 7.0-7.5 for females. Is this still the current thinking in academic centers?
     
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  3. Triple AAA

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    That's what I had been taught as well. How small are we talking here?
     
  4. anes

    anes ASA Member
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    Yea 8 for males 7 for women on average. We had some people in residency say that we should do 7 for males and 6 for women.
     
  5. Hawaiian Bruin

    Hawaiian Bruin Breaking Good
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    Standard where I trained was 7.0 for women, 7.5 for men, unless there was a chance of remaining intubated postop. If so, upsize by half.
     
  6. twoliter

    twoliter ASA Member
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    I was taught 7.5 for males and 7.0 for females. (Keep in mind I'm still a resident, so taught, though past tense, is still pretty recent.) Obviously, it depends on the patient and situation (e.g., will stay intubated, need bronchoscopy, etc.). But I'm hearing of some other people using 0.5 smaller for routine ambulatory cases with the hope of less sore throat. I plan to start trying that myself when I'm back in the OR.
     
  7. sevoflurane

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    If you are going to bronch or need serious plum. toilet hole 8.0-8.5. Multifactorial tho.
     
  8. Triple AAA

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    While we're on the topic, does everyone use 39F DLT for males, 37F DLT for females?
     
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  9. sevoflurane

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    Gender isn't always predictive. Neither is height or weight in adults.
     
  10. sevoflurane

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    37 fr. Most of the time. Height does a factor in dlt.
     
  11. Gimlet

    Gimlet Cardiac Anesthesiologist
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    We had a grand rounds given by an ENT once who opined that our 8.0 tubes were putting our patients at risk of vocal cord injuries. Because of that someone decided it would be prudent to take all tubes 8.0 and larger out of our anesthesia carts without any further discussion. Needless to say that didn't go over so well with the cardiothoracic guys. Fwiw, I go 7.5 on most adult males now, but anyone staying intubated after the procedure gets an 8.0 in case they need to be bronched later on.
     
  12. Planktonmd

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    7 for females and 8 for males.
    DLT: 39 or 37 for males depending on patient's size, and 37 for most females but occasionally 35, I always attempt the bigger size first.
     
  13. Gimlet

    Gimlet Cardiac Anesthesiologist
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    No science to back this up but I'd bet a half size smaller isn't going to significantly impact your rate of sore throat. I would guess paying better attention to the cuff pressure and using the truly minimal occlusive volume would have a greater impact on your sore throats. I was pleasantly surprised to see that my new gig has cuff manometers in every OR. I'm amazed at how much I was probably over inflating my cuffs during residency by just putting 5-7cc of air in for everyone, which seems to routinely result in a cuff pressure waaaayyyy higher than 20cm H2O now that I am actually checking.
     
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  14. dhb

    dhb Member
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    Bigger tube size = less tracheal stenosis according to a cardiothoracic surgeon but i haven't looked it up.
    8 for males sometimes 8.5 for a laparoscopic case in a big guy, 7.5 for females
     
  15. anes

    anes ASA Member
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    My guess is that ett size probably doesn't matter in terms of vocal cord damage. I think lubricating the tube is probably more important. Its probably just personal preference with no evidence to back it up, but I always lubricate any ett I place.
     
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  16. Gimlet

    Gimlet Cardiac Anesthesiologist
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    I think it's a great idea to lube any and all hunks of PVC you are going to ram into any orifices! I do remember reading during residency that, counterintuitively, using lidocaine jelly to lube your endotracheal tube actually is associated with a HIGHER risk of postop sore throat than using plain old lube. So something to keep in mind I guess.
     
  17. pgg

    pgg Laugh at me, will they?
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    I use 6.5 for most women and 7.0 for most men. You don't need anything any bigger and maybe it reduces postop sore throat pain.

    If they're going to stay intubated postop I go for an 8 to facilitate bronching and suction.
     
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  18. urge

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    That sounds counter intuitive. I wouldn't trust a CT surgeon for tracheal pathology. I know the thoracic guys do trachs and tracheal resections but I would rather go to an ENT. My experience has been that ENT surgeons tend to be faster and smoother, with minimal drama, compared to CT surgeons.
     
  19. Noyac

    Noyac ASA Member
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    Ok, I bring this up because I seem to see more sore throats with the smaller tubes that younger anesthesiologist put in. I use 8.0 for males and 7.5 for females. This is obviously my impression though and is not supported as far as I know. My thinking on this goes something like this. Smaller tubes require great cuff volume to get an adequate seal while the larger tubes require less volume, hence less pressure. I liked Gimlet's post because we also have a manometer for cuff pressure. My pressures are usually around 10cm H2O when I check. I am assuming this but it seems to me the pressure is greater with the smaller tubes therefore leading to more sore throats. It could just be a individual related effect as well but I'm pretty sure it's not.

    Now if you are doing a FOB, what size do you use? In other words, are you downsizing or up sizing for FOB?

    As far as Dbl-lumen tubes. I start with a 39Fr. If a small female then I might use a 37 or large male a 41. But this is very subjective and I could be found to change it up for no real reason sometimes.
     
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  20. Gimlet

    Gimlet Cardiac Anesthesiologist
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    I cheat down for fiberoptic intubations to minimize play between the FOB and the ETT...less space between the two where the tip of the tube could avulse a vocal fold or corniculate cartilage on the way through the larynx.
     
  21. pgg

    pgg Laugh at me, will they?
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    I suspect DL technique has more to do with sore throats than tube size. Followed by cuff pressure #2.
     
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  22. gasp

    gasp Physician
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    I tend to use a 7.0 for both average sized males and females. Use a 7.5 for bigger males and 6.5 for more petite females.
     
  23. dhb

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    This guy was doing tracheal transplants...
    I never lube the tube especially not with the can of silicone spray that has a flammable sign on it
     
  24. BobBarker

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    9.0. Retrograde wire. In holding. Every time.
     
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  25. FFP

    FFP Wiseguy
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    Are there any decently priced cuff manometers available to buy? A cursory search pointed me to prices of ~$500. I would buy one for less than $100, if available. In the end, it's just a $10-20 manometer with fancy-shmancy healthcare patents.
     
  26. sethco

    sethco Senior Member
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    Anybody have any experience with the Parker Flex tubes? I used them a couple of times for FOIs and found that they are much easier to slide off the Bronchoscope and across the vocal cords. Apparently, it is also designed to be used for Video Laryngoscopy, but I have not had that problem while using the Glidescope.
     
  27. anes

    anes ASA Member
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    KY jelly, not lidocaine jelly , and not silicone spray.
     
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  28. Ronin2258

    Ronin2258 Prometheus Unbound
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    One place I trained at used them as their go-to for video laryngoscopy. They seem to be good for Glidescope, and they were the only tubes in the hospital in half-sizes from 5.5-8.0. Only the Evac tubes for ICU admit patients were in half-sizes from 7.0-8.0.

    The other place didn't use them. While I did notice it was a bit easier to use the Parkers, they aren't essential for video laryngoscopy/intubation.

    While the tip on the Parker is supposed to be soft, it is very sharp. I have seen pictures where the Parker tip had punched through the vocal folds or damaged the cords. They were not pretty pictures to look at.
     
  29. Noyac

    Noyac ASA Member
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    Hurricane spray. I also use it to lube internally for stylets and FOB. Silicone spray is too slippery for my taste.
     
  30. Spinach Dip

    Spinach Dip Delicious with nachos
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    Your patients thank you for those sore throats.
     
  31. Hawaiian Bruin

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    I don't lube the tube either, and my patients don't complain of sore throats afterward. Yes, I do ask them.

    My technique for cuff inflation: do it while lightly pinching the pilot balloon. Gives you tactile feedback on pressure, so you don't overinflate.
     
  32. psychbender

    psychbender Cynical Member
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    Ditto. I don't lube my ETTs, the majority of my patients don't seem to have sore throats when I ask in PACU, and I feel the pilot balloon while inflating. I have never used a manometer, but it would be interesting to see to what pressure my tactile 'normal' corresponds.
     
  33. anes

    anes ASA Member
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    An interesting thing I've noticed. After slightly overinflating the cuff, take the syringe off. Now hook up a 3 cc syringe with the seal broken and plunger all the way down. Let it sit there for 5-10 seconds until the plunger stops being pushed outwards. Now check the pressure with a manometer. Without fail (for me) the pressure is approx 20mmHg every single time. No need for a manometer.
     
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  34. Random Anesthesiologist

    Random Anesthesiologist Random Anesthesiologist
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    7.5-8 male 6.5-7.0 female

    Nim tubes for ent are huge.
     
  35. dhb

    dhb Member
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    What's the correlation with sore throat? it slides in easier? that's BS
     
  36. Oggg

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    I lube the cuff with 2% lido jelly. 6.5 for little adults. 7.0 for laparoscopy. 8.0 for adult males who are going to remain intubated (7.0 for those females). Downsizing for RAE tubes works but sometimes the preformed bend in the tube comes too early.
     
  37. Southpaw

    Southpaw ASA Member
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    i lube cuff with 2% lido jelly. 7.0 for females, 8.0 for males. 37Fr for females, 39Fr for males.
     
  38. Vaporized

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    How long do you feel lidocaine jelly on the cuff and tube remains effective ?
     
  39. btbam

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    Why don't you just do peds style and hold pressure at 20 mmHg and add air til you don't hear a leak?
     
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  40. anes

    anes ASA Member
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    We've all seen those patients with dry tongues and pharynxs (pharngi? Pharynguses?) . my guess is that the vocal cords and trachea might be dry like that. With the dry tongue as your passing the ett tube sometimes it drags along the tongue and gets caught pulling the tongue with it. My thought is that the same process may happen with the vocal cords which may cause pain post op.
     
  41. Southpaw

    Southpaw ASA Member
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    longer than if it weren't there. most of my cases are < 2 hours. very very rarely do i see sore throats from LMAs or tubes. Much less frequently than in residency where we used nothing.
     
  42. RxBoy

    RxBoy ASA Member
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    Used them a lot in residency. Excellent tubes to facilitate railroad intubations. Work excellent with FOB, bougie, and cook catheter exchanges. I dont love them because they are atraumatic, but because they slip in so easily with the seldinger technique. Ive had failed fobi simply because i couldnt get the ETT past the glottis (getting caught on arytenoids). Never had that issue with parker flex.

    [​IMG]
     

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