Endotracheal Tubes

Department of Anesthesiology Makati Medical Center

Endotracheal tubes
Designed to provide a secure channel through the upper airway used to deliver anesthetic gases directly into the trachea and allow the most control of ventilation and oxygenation

Imposed work of breathing

Resistance to airflow depends primarily on tube diameter, tube length and curvature Poiseuille's equation: resistance is inversely proportional to radius to the 4th power
Secretions within the endotracheal tube: the effective lumen cross section is narrowed and the imposed work of breathing increases.

Material
Most commonly made from polyvinyl chloride Other materials; red rubber (cuffs), nondisposable silicone rubber, latex rubber, stainless steel or polyurethane (LPHV cuffs)

 Oral or nasal tubes Preformed or RAE (Ring, Adair and Elwyn) tubes Reinforced or armored tubes with embedded coil minimizes kinking of the tube when subjected to angulation
head and neck procedures and prone position

Double-lumen tracheal tubes pulmonary or thoracic operations

Parts of an endotracheal tube

 Valve prevents air loss after cuff inflation Pilot balloon provides a gross indication of cuff inflation Inflating tube connects the valve to the cuff and is incorporated into the tube's wall Beveled end visualization and insertion through the vocal cords Murphy eye a hole in the wall of a firm tip opposite the bevel, provide a patent airway if the tracheal tube became occluded at the bevel Cuff seal between the tracheal tube and the wall of the trachea

Cuffs
Significance
creates positive-pressure ventilation protects the lungs from pulmonary aspiration ensure that the tidal volume delivered ventilates the lungs rather than escapes into the upper airway

Types of cuff:
High pressure, low volume associated with more ischemic damage to the tracheal mucosa and are less suitable for intubations of long duration Low pressure, high volume conform to the D-shaped cross section of the trachea and provide a seal at a lower cuff pressure, thereby reducing the risk of tracheal/mucosal damage
May increase the likelihood of sore throat (larger mucosal contact area), aspiration, spontaneous extubation, and difficult insertion (because of the floppy cuff)

Cuff pressure
Maintain cuff pressure at a range of 25 to 30 cm H2O (justseal volume volume that just prevents an air leak) Cuff pressure depends on several factors:
Inflation volume Diameter of the cuff in relation to the trachea Tracheal and cuff compliance Intrathoracic pressure (cuff pressures increase with coughing). Inhaled N2O diffuses into tracheal tube cuffs increases the volume and pressure within the cuff cause tracheal lesions and an increased incidence of sore throat

Cuff
A leak in the cuff or valve or a reduction in trachealis muscle tone can lower cuff pressure and increase the risk for pulmonary aspiration Uncuffed tubes are usually used in children (<8 years old) to minimize the risk of pressure injury and post-intubation croup cricoid cartilage the narrowest portion of the pediatric airway, often provides an adequate seal for mechanical ventilation

Sizes
Described as the internal diameter (ID) in millimetres, but the relationship of the ID to the external diameter varies between different designs and manufacturers Less commonly, it is described in the French scale external diameter in millimeters multiplied by 3.
Oral tracheal tube guidelines
Age Full-term infant Child Adult Female Male 7.0 7.5 7.5 9.0 24 24 Internal diameter (mm) 3.5 4 + (age/4) Cut length (cm) 12 14 + (age/2)

Proper positioning
Orotracheal technique: at the corner-of-the-mouth
Female: 21-cm tube mark Male: 23-cm mark

Nasotracheal technique:
Female: 26-cm tube mark Male: 28-cm mark

Complications
Excessive cuff pressure (>40cm H20) can cause postextubation pain, tracheal damage or rupture, vocal cord dysfunction from recurrent laryngeal nerve palsy, sore throat after surgery, bleeding, stenosis Micro-aspirations silent aspiration (micro-aspiration) of pharyngeal contents occurs along channels between folds in the cuff and is a major contributor to ventilator-associated pneumonia in intensive care Post-intubation croup Hoarseness, stridor and other signs of respiratory obstruction due to subglottic edema that generally appear within 30 min of extubation
Factors: age, trauma during intubation, tight-fitting endotracheal tube, cough, changing patients position while intubated, duration of intubation, operations in the neck region