In this review, Karmali & Rose challenge the dogma surrounding endotracheal tube sizing for adult anaesthesia, traditionally sizing based on sex.
What did they cover?
They explored both the functional consequences (good and bad) of ETT size, as well as airway trauma.
Noting that an ETT ≥ 6.0mm ID will accomodate most intraluminal devices, and in fact at these smaller sizes fibreoptic intubation or passage through an LMA is easier, however smaller tubes are more readily obstructed and deformed.
Ventilation through smaller ETTs
While smaller tubes may require slightly higher inspiratory pressures, these are generally not clinically significant with modern ventilators, and importantly do not translate to higher intra-tracheal or alveolar pressures experienced by the patient.
Similarly, expiratory gas flow is not significantly effected by a small ETT (6.0 mm) for most patients even at high minute ventilations (although use cautiously in patients with chronic airway limitation). Significant gas trapping at normal MV will start to occur with ETT < 5.0 mm.
Size and airway trauma?
While the internal diameter (ID) is important for anaesthesia conduct, it is the external diameter that matters for airway trauma (a standard 8.0 mm ID ETT has a 10.5 mm ED!).
They note while there is wide individual variation in tracheal dimensions, the trachea is narrowest at the subglottis – and thus adequate visualisation of the glottis at time of intubation is an incomplete indicator of the tube size suitability for the subglottis.
Not only do some adult women have an airway size at the lower-limit of acceptability for traditional 7.0-8.0 mm ETTs, but there is also correlation between ETT size and airway trauma, hoarseness and sore throat. A large ETT can result in mucosal ischaemia and ulceration after as little as 2 hours.
"Instead of opting for ‘the largest tube that the larynx will comfortably accommodate’, we perhaps should consider using the smallest tube which permits the safe conduct of anaesthesia."
For routine anaesthesia of ASA 1 & 2 patients, an ETT sized 6.0-7.0 mm is probably the best balance between ventilation needs and airway trauma.
But remember, many of the concerns for tracheal tube trauma are based upon critical care experience, not anaesthesia. While a smaller tube is very likely beneficial for most elective adult patients, most benefit will simply be reduction in post-operative sore throat and hoarseness.summary
Randomized Controlled Trial Multicenter Study
Among trauma patients who survive to reach hospital, exsanguination is a common cause of death. A widely practicable treatment that reduces blood loss after trauma could prevent thousands of premature deaths each year. The CRASH-2 trial aimed to determine the effect of the early administration of tranexamic acid on death and transfusion requirement in bleeding trauma patients. In addition, the effort of tranexamic acid on the risk of vascular occlusive events was assessed. ⋯ Early administration of TXA safely reduced the risk of death in bleeding trauma patients and is highly cost-effective. Treatment beyond 3 hours of injury is unlikely to be effective. Future work [the Clinical Randomisation of an Antifibrinolytic in Significant Head injury-3 (CRASH-3) trial] will evaluate the effectiveness and safety of TXA in the treatments of isolated traumatic brain injury (http://crash3.lshtm.ac.uk/).
Randomized Controlled Trial
Randomized Controlled Trial