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ENDOTRACHEAL TUBE (ETT)

Preamble
 Endotracheal Tube (ETT)  general anaesthesia,
intensive care and emergency medicine, for
airway management and mechanical ventilation1

 Provides a passage for gases to flow between a patients


lungs and an anaesthesia breathing system 2
 Allows one to provide positive pressure ventilation 2
 Protects the lung from contamination from
gastric contents and nasopharyngeal matter such as
blood 2

1. Endotracheal tube. Available at http://eng.wikipedia.org/wiki/endotrcheal_tube accessed on 17th October 2009.


2. Endotracheal Tubes in Anesthesia Physics and Equipment mede easy. Available at www.freshgasflow.com Accessed on 17th October 2009
History
 18th century  tubes were passed into the
trachea during resuscitation from drowning 3
 Sir William Macewen (1848–1924) 
the first physician to intubate the trachea
on July 5, 1878  blind oral intubation 3
 Franz Kuhn (1866–1929)  in 1905, perfected
a metal, flexible tube and used blind oral or
nasal intubation 3

3. Gal TJ. Airway Management. In: Miller RD et all eds. Miller’s Anesthesia, 6th ed. Philadelphia, Elsevier Churchill Livingstone, 2005
History (cont…)
 Ivan W.Magill (1888–1986) and Edgar S. Rowbotham
(1890–1979)  in 1920’s technique of blind nasal
intubation  position "sniffing the morning air” 3
 Arthur Guedel (1883–1956) and Ralph M. Waters
(1883-1979)  in 1928 promoted the cuffed
endotracheal 3
 Murphy eye in 1941 on the side distal tip of the
standard ETT 3
 Carlens in 1949  Double-lumen tubes for
Bronchospirometry 3

3. Gal TJ. Airway Management. In: Miller RD et all eds. Miller’s Anesthesia, 6th ed. Philadelphia, Elsevier Churchill Livingstone, 2005
History (cont…)

Figure 1. Magill-type endotracheal tube 5

5. Magill-type endotracheal tube, England, 1981 in Science Museum. Brought to Life: Exploring the History of Medicine. Available
at www.sciencemuseum.org. Accessed on 17th October 2009
Material of ETT
Table 1. Characteristics of materials from which tubes are manufactured 4

4. Mitchell V, Patel A. Tracheal Tubes. In : Calder I, Pearce A eds. Core Topics in Airway Management. New York, Cambridge University
Design of ETT
 Preformed curve 
anatomy of the pharynx 4
 Have 2 end  proximal
end (machine end) and
Figure 2. ETT made from PVC 2
distal end (patient end) 7
 Bevel 2
 Murphy Eye 2
 With cuff or uncuff 2
Figure 3. Murphy Eye 2 Figure 4. ETT cuff and uncuff 2

2. Endotracheal Tubes in Anesthesia Physics and Equipment mede easy. Available at www.freshgasflow.com Accessed on 17th October 2009
4. Mitchell V, Patel A. Tracheal Tubes. In : Calder I, et all eds. Core Topics in Airway Management. New York, Cambridge University Press, 2005
7. Yadav A ed. Anaesthesia Machine and Equipments. Short Textbook of Anaesthesia, 2nd ed. India, Academa Publishers, 2004
Sizing of ETT
 Internal Diameter  Sizing 4
 Eksternal Diameter is limeted 3
* Adult  level of the glottic aperture
* Children  the subglottic (cricoid cartilage)
 French size  circumference 3
 Manufactured in 0.5 mm ID increment from
2.5 – 9.0 mm 3

3. Gal TJ. Airway Management. In: Miller RD et all eds. Miller’s Anesthesia, 6th ed. Philadelphia, Elsevier Churchill Livingstone, 2005.
4. Mitchell V, Patel A. Tracheal Tubes. In : Calder I, Pearce A eds. Core Topics in Airway Management. New York, Cambridge University
Press, 2005
Sizing of ETT (cont…)
Table 2. Comparison of small and large tracheal tubes 4

4. Mitchell V, Patel A. Tracheal Tubes. In : Calder I, Pearce A eds. Core Topics in Airway Management. New York, Cambridge University
Press, 2005
Sizing of ETT (cont…)
 Men  7.5 – 9.0 mm ID 6
 Women  7.0 – 8.0 mm ID 6
 Children
* measuring the diameter of the distal joint of the
index finger of the child or lumen external nares 9
* Calculation of tube sizes according to child’s age 7
- Prematures : 2.5 mm ID
- 0 to 6 months : 3 to 3.5 mm ID
- 6 months to 1 year : 3.5 to 4.0 mmID
6. Morgan GE, Mikhail MS, Murray MJ eds. Airway Management. Clinical Anesthesiology, 4th ed. New York, Lange Medical Books, 2006.
7.Yadav A ed. Anaesthesia Machine and Equipments. Short Textbook of Anaesthesia, 2nd ed. India, Academa Publishers, 2004
9. Ramamani M, Mohanty S, Gupta S. Paediatric Anaesthetic Equipment. In : Jacob R et all eds. Understanding Paediatric Anaesthesia, 2nd
ed. New Delhi, B.I.Publication Pvt Ltd, 2008
Sizing of ETT (cont…)
- Penlington’s formula 9 :
1 to 6 years  Age (in years) / 3 + 3.5 mm ID
> 6 years  Age (in years) / 4 + 4.5 mm ID
- Cole’s formula for uncuffed tubes 6 :
Age (in years) / 4 + 4 mm ID

* Calculation of tube size according to child’s length 11


2 + (body length in cm / 30)
6. Morgan GE, Mikhail MS, Murray MJ eds. Airway Management. Clinical Anesthesiology, 4th ed. New York, Lange Medical Books, 2006
9. Ramamani M, Mohanty S, Gupta S. Paediatric Anaesthetic Equipment. In : Jacob R et all eds. Understanding Paediatric Anaesthesia, 2nd ed.
New Delhi, B.I.Publication Pvt Ltd, 2008
11. Ming HS, Chin YC, Bai C, et all. Accuracy of a New Body Length-based Formula for Predicting tracheal Tube Size in Chinese Children.
Chang Gung Med J, Vol.31 No.3. May-June 2008
Sizing of ETT (cont…)
Table 3.Endotracheal tube size and position based on patient age 3

3. Gal TJ. Airway Management. In: Miller RD et all eds. Miller’s Anesthesia, 6th ed. Philadelphia, Elsevier Churchill Livingstone, 2005.
Length or Depth of ETT
 The Length of the ETT 
the end that goes into trachea,
marked in centimeters 2
 ETT have black markings
proximal to the cuff 2
 Single mark  vocal cords at Figure 5. ETT have single mark

black mark 2
 Two marks  keep vocal
cords between 2
 Confirmed by auscultation 2
Figure 6. ETT have 2 mark
2. Endotracheal Tubes in Anesthesia Physics and Equipment mede easy. Available at www.freshgasflow.com Accessed on 17th October 2009
Length or Depth ETT (cont…)
Methods to predict appropriate ETT depth 12
 21 cm (females) or 23 cm (males) at corner of mouth
for orotracheal technique
 26 cm (females) or 28 cm (males) at nares for
nasotracheal technique
 Distance from cricoid to xiphoid

 Distance from right mouth corner to the right


mandibular angle to center of manubrium
 4 + (body height/10 cm) at right upper canine

 [body height (cm)/5] – 13 at right mouth angle

12. Ledrick D, et all. Evaluation of Manual Cuff Palpation to Confirm Proper Endotracheal Tube Depth. Available at
http://pdm.medicine.wisc.edu. Accessed on 17th October 2009
Length or Depth ETT (cont…)
 In children, the length oral tube by formula 7
Age (in years) / 2 + 12 cm
 In children, length for nasal intubation  add
3 cm to oral length 7
Age (in years) /2 + 15 cm

7. Yadav A ed. Anaesthesia Machine and Equipments. Short Textbook of Anaesthesia, 2nd ed. India, Academa Publishers, 2004
Length or Depth ETT (cont…)
 A Chest radiograph (CXR)  most effective
means of confirming ETT depth 12

Figure 7. Tip of endotracheal tube (red arrow) 13

12. Ledrick D, et all. Evaluation of Manual Cuff Palpation to Confirm Proper Endotracheal Tube Depth. Available at
http://pdm.medicine.wisc.edu. Accessed on 17th October 2009
ETT cuff and uncuff
 The cuff and inflation system
 an inflation lumen in the
wall tube, an external inflation
tube, a pilot ballon, and a self-
sealing inflation valve 4

 Cuffed tube generally in adult


 to seal the airway to protect
it from soiling from above and Figure 8. Inflating the cuff
to prevent gas leaks 6
 Cuff Volume  4 to 8 ml air 7
4. Mitchell V, Patel A. Tracheal Tubes. In : Calder I, Pearce A eds. Core Topics in Airway Management. New York, Cambridge University
Press, 2005
6. Morgan GE, Mikhail MS, Murray MJ eds. Airway Management. Clinical Anesthesiology, 4th ed. New York, Lange Medical Books, 2006.
7.Yadav A ed. Anaesthesia Machine and Equipments. Short Textbook of Anaesthesia, 2nd ed. India, Academa Publishers, 2004
ETT cuff and uncuff (cont…)
Two major types of cuff 6:
 High pressure (low volume)
 more ischemic damage to
tracheal mucosa, less
suitable for intubation of
long duration

 Low pressure (high volume)


 increase the likelihood of Figure 9. Comparison two types of cuffs 2
sore throat, aspiration,
spontaneous extubation, and
difficult insertion
2. Endotracheal Tubes in Anesthesia Physics and Equipment mede easy. Available at www.freshgasflow.com Accessed on 17th October 2009
6. Morgan GE, Mikhail MS, Murray MJ eds. Airway Management. Clinical Anesthesiology, 4th ed. New York, Lange Medical Books, 2006.
ETT cuff and uncuff (cont…)
 Uncuffed tube usually in children 
to minimize the risk of pressure injury and
postintubation croup 6
 Khine, et all  advantages of cuffed ETT: avoid of
repeated laryngoscopy, low fresh gas flow, reduction
of concentration of anesthetics in operating room 10
 Placed of cuffed ETT in pediatric anesthesia and
critical care  still not clear 14
 Children under 8 years of age  uncuffed tube 14

6. Morgan GE, Mikhail MS, Murray MJ eds. Airway Management. Clinical Anesthesiology, 4th ed. New York, Lange Medical Books, 2006.
10. Khine,et all. Comparison of cuffed and uncuffed endotracheal tubes in young children during general anesthesia. Anesthesiology, 1997
14. Mar;86(3):627-31 14. Robin G. Editorial. Should cuffed endotracheal tubes be used routinely in children?. Can J Anesth, 2005
Other Types of Tube
 R.A.E (Ring, Adair and
Elwyn) preformed tube 2,7
- South facing : upper
cleft lip and cleft palate
surgery
- North facing : lower lip
surgery

Figure 10. Preformed ET Tubes

2. Endotracheal Tubes in Anesthesia Physics and Equipment mede easy. Available at www.freshgasflow.com Accessed on 17th October 2009
7. Yadav A ed. Anaesthesia Machine and Equipments. Short Textbook of Anaesthesia, 2nd ed. India, Academa Publishers, 2004
Other Type of Tubes (cont…)
 Spiral embeded (flexometallic
armored tube) : non kinkable,
non collapsible 2,7
 Microlaryngeal and
laryngotracheal surgery tube 7
 Coles tube : for children, distal
end of tubes has narrow
diameter 7 Figure 11. Comparison of armoured
ETT and standard ETT
 Endotrol tube : angle of tip can
be changed  nasal intubasi 7

2. Endotracheal Tubes in Anesthesia Physics and Equipment mede easy. Available at www.freshgasflow.com Accessed on 17th October 2009
7. Yadav A ed. Anaesthesia Machine and Equipments. Short Textbook of Anaesthesia, 2nd ed. India, Academa Publishers, 2004
Other Type of Tubes (cont…)
 Double lumen tubes :
Robertshaw’s and
carlens  thoracic
surgery where one lung
Figure 12. Green gordon tube (right sided)
anaesthesia 7 and Robertshaw tube (left sided) 2

 Combitube : double
lumen tube  patent
airway in emergency and
difficult intubation 7 Figure 13. A. Combitube in esophagus, B. trachea 15
2. Endotracheal Tubes in Anesthesia Physics and Equipment mede easy. Available at www.freshgasflow.com Accessed on 17th October 2009
7. Yadav A ed. Anaesthesia Machine and Equipments. Short Textbook of Anaesthesia, 2nd ed. India, Academa Publishers, 2004
15. Klock PA, Ovassapian A. Airway management. In : Longnecker, et all, eds. Anesthesiology. New York, Mc Graw Hill, 2008