New grads and ETT's

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Noyac

Noyac

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can someone please explain to me why new grads put such small ETT's in pts these days?
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Can someone explain to me why garden-variety GERD *in and of itself* prompts people to put in an ETT?

(Also to give Bicitra and Reglan and Pepcid preop?)
 
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Noyac said:
In my opinion a smaller ETT requires great cuff volume/pressure. Therefore great risk of sore throat.
Click to expand...

I do not agree with routinely using ETT sizes under 7.0 for adult patients. Of course, a 6.5 ETT for a tiny adult female from time to time may be acceptable but in general I insist on a 7.0 ETT size or greater for all adult patients.

As for cuff pressure being greater with smaller ETT sizes the evidence isn't there:

"We similarly found that the volume of air required to inflate the cuffs to 20 cmH2O did not differ significantly as a function of endotracheal tube size. These data suggest that tube size is not an important determinant of appropriate cuff inflation volume."

Endotracheal tube cuff pressure in three hospitals, and the volume required to produce an appropriate cuff pressure

http://www.tandfonline.com/doi/pdf/10.1080/22201181.2015.1056504

Please note that all the ETT sizes used for these studies were at least a 7.0 ETT.
 
Here is my typical approach to ETT sizes:

slide_89.jpg
 
I don't mind a 1/2 size smaller ETT from time to time but I would not tolerate them on a routine basis. 7.0 ETT for a female and 7.5 ETT for a male should be the minimum ETT size used on a routine basis IMHO:

et-tube-suctioning-ppt-10-638.jpg
 
FFP said:
His reasons for that (bronchial toilet, bronchoscopy, biofilm, less need for tube exchange, easier weaning) sound convincing.
Click to expand...

If I think the patient is likely to be on a vent postop for more than 24 hours I prefer at least an 8.0 ETT for females and an 8.5 ETT for males.
 
For very Morbidly Obese Patients I use a 7.5 ETT for females and an 8.0 ETT for males:


"The results support our hypothesis that obese patients do not have larger airways. Moreover, the results indicated a trend toward smaller airways as BMI increased. Specifically, as BMI increases, tracheal width appears to decrease. This information should help medical professionals avoid the tendency to use a larger tube to intubate an obese patient. Hopefully this will result in fewer airway injuries in a society where obesity has become an epidemic."

SAGE Journals: Your gateway to world-class journal research
 
I go 6.5 for females and 7 for males. If ICU bound then upsize to 8ish to facilitate bronchs/suction/etc.

What's the concern with using tubes on the smaller end for routine surgical cases?? Maybe I could see the point if you were gonna let 'em breathe spontaneously all case but even then PSV is your friend.

Noyac said:
In my opinion a smaller ETT requires great cuff volume/pressure. Therefore great risk of sore throat.
Click to expand...

We've had this discussion recently, and that's not true. I'd explain it again in terms you might be able to understand, but I don't have enough crayons. 😉😀
 
SaltyDog said:
I go 6.5 for females and 7 for males. If ICU bound then upsize to 8ish to facilitate bronchs/suction/etc.
Click to expand...

This is exactly what I do.

I don't see any reason to use a larger tube for a short case that's going to be extubated. My general vague philosophy is to use the smallest tube I can get away with. Particularly when it comes to double lumen tubes.

I think most sore throats are caused by laryngoscopes and the act of intubation, not endotracheal tubes per se. Gentle technique is probably the most important factor, and smaller tubes are sometimes technically easier to place.
 
I use 7s for everyone unless I expect postop ventilation. This is again one of those things that we can debate endlessly and doesn't make any difference in reality.
 
nimbus said:
I use 7s for everyone unless I expect postop ventilation. This is again one of those things that we can debate endlessly and doesn't make any difference in reality.
Click to expand...

Probably a true statement. But, for a group practice it helps to have some uniformity to the process. Maybe, 7.0 ETT for females and 7.5 ETT for males? Of course, we can all ventilate a patient with a 6.5 ETT in place but that's not my preference on a routine basis.
 
pgg said:
This is exactly what I do.

I don't see any reason to use a larger tube for a short case that's going to be extubated. My general vague philosophy is to use the smallest tube I can get away with. Particularly when it comes to double lumen tubes.

I think most sore throats are caused by laryngoscopes and the act of intubation, not endotracheal tubes per se. Gentle technique is probably the most important factor, and smaller tubes are sometimes technically easier to place.
Click to expand...

Endotracheal tubes with inner diameters of 6 or 7 mm can be used safely together with artificial ventilation by flow cycled ventilators (flow generators) during anaesthesia.

https://watermark.silverchair.com/a...kB_fZFIqy8oIdyJ4W68JCsAcCjtmzEgVoTEMnUoyE0tWV



Size matters: choosing the right tracheal tube
 
nimbus said:
I use 7s for everyone unless I expect postop ventilation. This is again one of those things that we can debate endlessly and doesn't make any difference in reality.
Click to expand...


Large tubes were 9 mm (for men) and 8.5 mm (for women), and small tubes were 7 mm (for men) and 6.5 mm (for women). No lubricants were used. The sore-throat incidence in the group intubated with the large tubes was 48%, compared with 22% in the group intubated with the small tubes. No ventilatory difficulties were experienced as a result of using a small tube. Therefore, the use of smaller tubes has the distinct advantage of reducing the incidence of postoperative sore throat


Postoperative sore throat: cause, prevention and treatment - McHardy - 2002 - Anaesthesia - Wiley Online Library
 
Now, I've posted a fair amount of references buy my experience clearly tells me that sicker patients and possibly long cases should not have a small ETT for the case.
You may disagree with me but at my shop I can assure you the vast majority of the patients are not good candidates for a 6.5 ETT.

Still, a good discussion and I can see using 6.5 ETTs on healthy, thin ASA 1 and 2 FEMALE patients on a routine basis.
 
BLADEMDA said:
Large tubes were 9 mm (for men) and 8.5 mm (for women), and small tubes were 7 mm (for men) and 6.5 mm (for women). No lubricants were used. The sore-throat incidence in the group intubated with the large tubes was 48%, compared with 22% in the group intubated with the small tubes. No ventilatory difficulties were experienced as a result of using a small tube. Therefore, the use of smaller tubes has the distinct advantage of reducing the incidence of postoperative sore throat


Postoperative sore throat: cause, prevention and treatment - McHardy - 2002 - Anaesthesia - Wiley Online Library
Click to expand...

I guess there is data to support me using smaller tubes haha. by small i mean 7f/7.5m
 
anbuitachi said:
I guess there is data to support me using smaller tubes haha. by small i mean 7f/7.5m
Click to expand...
7f/7.5m was standard in residency and what I've seen in two PP jobs since.

For those using larger tubes: what's the point unless you're planning a bronch or planning post-op ventilation?

Could maybe see utility in large pts for steep Trendelenburg to reduce peak pressures.
 
I think most sore throats are caused by rough DL. I tell the resident's I work with you don't need a grade I view to intubate. If you see cords and can visualize the tube passing thats all the force you need to exert on the tissues with the blade. Likewise styletted tubes with big tubes rammed through the cords is not going to feel good when they wake up. I use an appropriate sized tube based on the case and likelihood of needing pulmonary toilet and generally never use a stylet. If I need a stylet I grab a bougie and turn it into a fish hook.
 
pgg said:
This is exactly what I do.

I don't see any reason to use a larger tube for a short case that's going to be extubated. My general vague philosophy is to use the smallest tube I can get away with. Particularly when it comes to double lumen tubes.

I think most sore throats are caused by laryngoscopes and the act of intubation, not endotracheal tubes per se. Gentle technique is probably the most important factor, and smaller tubes are sometimes technically easier to place.
Click to expand...

How are ppl sizing their DLTs? Those things are huge and seem to go down fine, which always reminds me that the human trachea can tolerate a big SLT, though it sure does look uncomfortable.
 
MoMoGesiologist said:
How are ppl sizing their DLTs? Those things are huge and seem to go down fine, which always reminds me that the human trachea can tolerate a big SLT, though it sure does look uncomfortable.
Click to expand...


37 for everyone because it's hard to pass a bronchoscope through a 35.
 
dhb said:
I find it hard to believe that a 37 works for all your cases: i've had problems with tube length with 37s
Click to expand...
Really? DLTs are super long. I don’t care if the Y of the DLT is in the mouth.


Klutzes around here were breaking too many fiberoptic scopes so we’re stuck using the disposable scopes for everything, unless we specifically ask for the bronch cart. (Which I don’t unless I need to do a therapeutic bronch.) The small disposable scopes fit down the 35 Fr tubes easy ... a little spray silicone lube or lacrilube grease helps.
 
dhb said:
Not long enough: when you have to hub it, they have a tendancy to move back out especially when moving to lateral.
I like 37 for women 39 for men 41 if really big.
Click to expand...

I will use a 35F for a small woman under 5'2" or so. If the male is 6'4" I prefer a 41F but I've gotten a 39F to work a time or two buried to the hilt.
 
New grad here. I have yet to see anyone pull out a 6.0 ETT for an adult female unless some form of airway obstruction is expected.

For routine cases, I put a 7.5 in everyone, male or female. Sometimes a 7.0 if they're really small. For cases where I expect the patient to stay intubated and go to ICU, 8.0 for everyone. No reason to go much larger than that.
 
thinkorswim said:
New grad here. I have yet to see anyone pull out a 6.0 ETT for an adult female unless some form of airway obstruction is expected.

For routine cases, I put a 7.5 in everyone, male or female. Sometimes a 7.0 if they're really small. For cases where I expect the patient to stay intubated and go to ICU, 8.0 for everyone. No reason to go much larger than that.
Click to expand...


A nice compromise is a 7.0 ETT for females, 7.5 ETT for males. If morbidly obese up-size the ETT by 0.5.
 
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