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New grads and ETT's
Started by Noyac
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deleted87051
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deleted162650
Can someone please explain why old-timers put such large ETT's in patients??
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?)
(Also to give Bicitra and Reglan and Pepcid preop?)
For regular cases I like the go smaller. I imagine less trauma/sore throat. Idk the data though.
The larger the tube the smaller the risk of tracheal stenosis.
smaller balls?
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deleted171991
His reasons for that (bronchial toilet, bronchoscopy, biofilm, less need for tube exchange, easier weaning) sound convincing.
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deleted171991
Defensive medicine.
6.5 males
6.0 female
In my opinion a smaller ETT requires great cuff volume/pressure. Therefore great risk of sore throat.
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:
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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:
I can see choosing a smaller ETT (still a 7.0 or a 7.5 ETT) for a difficult intubation especially a true fiberoptic guided one:
Endoscopic Study of Mechanisms of Failure of Endotracheal Tube Advancement into the Trachea during Awake Fiberoptic Orotracheal Intubation | Anesthesiology | ASA Publications
Endoscopic Study of Mechanisms of Failure of Endotracheal Tube Advancement into the Trachea during Awake Fiberoptic Orotracheal Intubation | Anesthesiology | ASA Publications
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
"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
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deleted162650
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.
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. 😉😀
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.
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. 😉😀
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.
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deleted87051
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.
I ram in 9.0 ETT tubes on all my patients for the hell of it
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.
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
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.
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.
I guess there is data to support me using smaller tubes haha. by small i mean 7f/7.5m
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.
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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.
Arch Guillotti
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Maybe you need to hire better grads?😉
Just kidding, but does it make that big of a difference?
No it doesn't make a big difference. I just don't know where this training is coming from. It seems silly.
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deleted87051
Any variation for gender or height?
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deleted171991
Again, these new grads and their small... tubes. 😀
We were taught 39 for the average male, 37 for the average female.
Yep, 39M and 37F
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deleted87051
Not for me.
I find it hard to believe that a 37 works for all your cases: i've had problems with tube length with 37s
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deleted171991
It's cheaper than your Porsche.
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.
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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.
I like 37 for women 39 for men 41 if really big.
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.
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.
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.
