Endotracheal Tube

General anesthesia:Endotracheal tube intubation is the most commonly used airway during general anesthesia.

Patients may need an endotracheal tube for one of several reasons. An endotracheal tube is needed to mechanically ventilate a patient (or breathe for them by a machine). Each breath is pushed into the endotracheal tube and into the lung. An endotracheal tube is also needed if a patient is unconscious or has a brain injury. The brain controls the reflex in the airway that prevents choking when we swallow or eat. This reflex is called the gag reflex. The top of the windpipe has a special opening called the epiglottis. When we swallow food, the epiglottis closes to prevent food from entering the windpipe. When patients are heavily sedated, unconscious or have a brain injury, this protective response is often impaired. Without a gag reflex, saliva would enter the windpipe. This is called aspiration. Aspiration is a serious complication and one of the causes for pneumonia. A less common reason for intubating a patient is to keep the airway open. This is seen most commonly in patients with tumours or growths in the neck or upper chest. The usual route for inserting an endotracheal tube is through the mouth. This is called an oral endotracheal tube. Less frequently, the endotracheal tube is inserted through the nose. This is called a nasal endotracheal tube.

A soft donut shaped balloon is located around the outside of the endotracheal tube. The cuff is inflated with air, and serves two purposes. First, it reduces the number of oral sections that can travel down the outside of the tube and into the lung. This is important because inserting an endotracheal tube into the airway will "wedge" the epiglottis into an open position. Although the cuff reduces the amount of secretions that can enter the lung, it does not completely prevent it. For this reason, patients on ventilators are at risk for developing pneumonia from secretions. The second reason for the cuff is to keep any mechanical breaths from leaking out of the lung around the tube. When we give a patient a breath with the ventilator, we want the breath to go in and out through the tube. Without a cuff, the breath would go in the tube but part of it would escape around the cuff before it was able to reach the lung. As long as the patient has an endotracheal tube in place, the cuff will need to be inflated. An inflated cuff will prevent the patient from being able to speak. Speech is produced when we exhale air through the vocal cords, causing them to vibrate. Because the cuff blocks the flow of air around the tube, speech is not possible. Once the tube is removed (called extubation), the patient will be able to speak. The voice may sound hoarse and the patient may have some throat discomfort for the first few days.

Because the cuff on the breathing tube only reduces (doesn't prevent) secretions from getting past the cuff, we have a number of other strategies that are part of routine practice: Special breathing tubes call Subglottic Drainage Tubes are used which have a low continuous suction port located above the cuff. Dilignet oral care to reduce the number of oral bacteria. Chlorhexidine oral care routine twice per day to decrease the oral bacteria count. Daily assessment for readiness/attempt to reduce sedation. Daily assessment for readiness/attempt to breath spontaneously (without the breathing machine support). Early feeding within 24-48 hours unless contraindicated. Routine elevation of the head of the bed.

Endotracheal tubes (ETT) are an essential and familiar element of anesthesiology practice. The presence of an ETT maintains airway patency, permits oxygenation and ventilation, allows for suctioning of secretions, lowers the risk of aspiration of gastric contents or oropharyngeal secretions, and facilitates the use of inhalation anesthetics.

The most commonly used ETT material is polyvinyl chloride (PVC), a transparent plastic that allows the visualization of exhalational condensation (“breath fogging”), secretions, and other foreign materials within the tube. PVC is a semi-rigid material at room temperature, but relatively more pliable as it warms following placement in the trachea, which permits easy manipulation of the tube tip during intubation while reducing the risk of mucosal ischemia following placement. Although not used as commonly, ETTs made of other materials, including nylon, silicone, and Teflon, are also available in the United States.

The size of an ETT signifies the inner diameter of its lumen in millimeters. Available sizes range from 2.0 to 12.0 mm in 0.5 mm increments. For oral intubations, a 7.0-7.5 ETT is generally appropriate for an average woman and a 7.5-8.5 ETT for an average man. However, the appropriate tube size is a multifactorial clinical decision based on patient height and weight, type of procedure or surgery, and the presence of pulmonary or airway disease. For nasal intubations, a reduction in size of 0.5-1.0 mm is appropriate. Length is directly proportional to the ETT size. Nasotracheal tubes are approximately 2 cm shorter than orotracheal tubes. Because anatomic variations of tracheas can be difficult to predict, several sizes of ETT should be readily available prior to intubation. The appropriate pediatric tube size can be calculated using the formula ID = age in years/4) + 4. For example, a size of 6.0 ETT would generally be appropriate for an 8-year-old patient.

The patient end, also known as the distal or tracheal end, is placed into the trachea and commonly has an inflatable cuff, which provides a seal that prevents the aspiration of gastric contents and reduces air leakage during positive pressure ventilation. A cuff is inflated through its pilot balloon, which is located at the machine end (or proximal end) of the ETT. The pilot balloon is connected to the cuff by a pilot tube that runs the length of the ETT and contains a one-way valve that maintains the inflation of the cuff once the inflating syringe is removed. Generally, cuffed tubes are used in patients older than 6 years of age. Endotracheal tubes can be beveled or nonbeveled. A bevel allows better visualization of the glottis ahead of the ETT tip while permitting it to more easily pass through the vocal folds. In orotracheal tubes, the bevel faces left and is at a 45 degree.

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