Endotracheal Tube Size Research Articles

The Academic Highway between the United States and Japan

The Academic Highway between the United States and Japan

Prospective assessment of guidelines for determining appropriate depth of endotracheal tube placement in children*

To determine whether multiplying the internal diameter of the endotracheal tube (ETT) by 3 (3x ETT size) is a reliable method for determining correct depth of oral ETT placement in the pediatric population. Prospective, observational. University-affiliated, 12-bed pediatric intensive care unit. Orally intubated pediatric intensive care unit patients of < or =12 yrs of age. Demographics, ETT size, and depth of ETT placement measured from the lip were obtained. Correct placement, defined as the tip of the ETT below the thoracic inlet and > or =0.5 cm above the carina, was determined by chest radiograph. Suggested ETT size based on the Pediatric Advanced Life Support (PALS) age-based formula and the Broselow tape-length-based guidelines were determined. A total of 174 of 226 ETTs (77%) were correctly positioned. If practitioners utilized the 3x ETT size for the actual tubes chosen, 170 of 226 (75%) would have been accurately placed. More accurate were the 3x PALS-based ETT size (81%) and 3x Broselow-suggested ETT size (85%). The use of the Broselow ETTs to determine the depth would have led to a significantly improved ETT position (p = .009) compared with the actual ETT. The commonly used formula of 3x tube size for ETT depth in children results in 15-25% malpositioned tubes. Practitioners can improve the reliability of this formula by utilizing the recommended ETT size as suggested by the Broselow tape. A more reliable method is necessary to avoid ETT malposition.

L’usage d’un Aintree intubation catheter® dans un cas d’intubation difficile imprévue

To present a case where the Aintree intubation catheter (AIC) was used in conjunction with the Laryngeal Mask Airway (LMA) and a fibreoptic bronchoscope (FOB) in a patient with an unexpected difficult airway. A 38-yr-old 90 kg man scheduled for nasal endoscopy with ethmoidectomy under general anesthesia was found, unexpectedly, to be difficult to intubate using both a Macintosh laryngoscope (#4 blade) and a GlideScope video laryngoscope despite having an airway examination that was unremarkable except for slightly decreased mouth opening and a large tongue. Intubation was achieved by inserting a size 5 disposable LMA into the upper airway, introducing a FOB into an AIC inserting the FOB/AIC assembly into the trachea via the LMA, removing the LMA, and then passing a regular size (7.5 mm) endotracheal tube into the trachea over the AIC. In this patient, the AIC provided an effective alternative to other methods for intubating through a regular LMA.

Effect of lung compliance and endotracheal tube leakage on measurement of tidal volume

IntroductionThe objective of this laboratory study was to measure the effect of decreased lung compliance and endotracheal tube (ETT) leakage on measured exhaled tidal volume at the airway and at the ventilator, in a research study with a test lung.MethodsThe subjects were infant, adult and pediatric test lungs. In the test lung model, lung compliances were set to normal and to levels seen in acute respiratory distress syndrome. Set tidal volume was 6 ml/kg across a range of simulated weights and ETT sizes. Data were recorded from both the ventilator light-emitting diode display and the CO2SMO Plus monitor display by a single observer. Effective tidal volume was calculated from a standard equation.ResultsIn all test lung models, exhaled tidal volume measured at the airway decreased markedly with decreasing lung compliance, but measurement at the ventilator showed minimal change. In the absence of a simulated ETT leak, calculation of the effective tidal volume led to measurements very similar to exhaled tidal volume measured at the ETT. With a simulated ETT tube leak, the effective tidal volume markedly overestimated tidal volume measured at the airway.ConclusionPrevious investigators have emphasized the need to measure tidal volume at the ETT for all children. When ETT leakage is minimal, it seems from our simulated lung models that calculation of effective tidal volume would give similar readings to tidal volume measured at the airway, even in small patients. Future studies of tidal volume measurement accuracy in mechanically ventilated children should control for the degree of ETT leakage.

Congenital cervical fibrosacroma with hydrops fetalis

Congenital cervical fibrosacroma with hydrops fetalis

Aerosolization of perfluorocarbons during mechanical ventilation: an in vitro study.

Inhalation of perfluorocarbons (PFC) has been suggested as a new and promising technique of PFC delivery in animal models of severe lung injury. However, no in vitro data were available on the efficacy of PFC aerosolization during mechanical ventilation. Therefore, the aim of the in vitro study was to investigate the influence of physical properties of PFC and the ventilatory settings on the amount of PFC delivered into the lung. In vitro lung model study. University research laboratory. Two different PFC (PF 5080 and PFOB) were aerosolized with a PariBoy jet nebulizer. Using a PFC selective adsorber, the effect of endotracheal tube size (2 mm and 3 mm diameter) on delivery of PFC was investigated. PFC delivery was estimated by continuous measurement of weight gain of the adsorber (adsorption rate). Finally, the influence of respiratory rate and tidal volume on adsorption rate (AR) was studied. AR was significantly reduced by a decreasing tube diameter and ranged from 1.45+/-0.03 ml/min (no tube) to 0.93+/-0.03 ml/min (2.0 mm) for PF 5080 (vapor pressure 51 mmHg) and from 0.49+/-0.06 ml/min to 0.32+/-0.04 ml/min for PFOB (11 mmHg). PFC-aerosolization into a ventilatory circuit with simulation of spontaneous tidal breathing (minute volume 600 ml) reduced AR to 0.16+/-0.02 ml/min. During mechanical ventilation, changes in respiratory rate and tidal volume, which reduce minute ventilation, caused a decrease in AR. The amount of PFC that can be delivered into the lung by aerosolization is very small and is influenced by PFC properties, tube size, and ventilatory settings.

Airway Considerations for Professional Singers—A Survey of Expert Opinion

The objective of this study was to survey physician experts in voice disorders/treatment to establish consensus guidelines for translaryngeal intubation (TLI) and tracheotomy when treating professional singers or other voice professionals. A written survey was sent to all physician members of the Voice Foundation seeking opinions/recommendations about route of TLI, duration of TLI before tracheotomy, size of endotracheal and tracheotomy tubes, and special interventions during patient care as these might differ between professional singers and nonsingers. Fifty-five percent of the physicians responded, of whom 73% classified their experience in voice care as “extensive.” A strong consensus (76%) favored a smaller endotracheal tube for singers (6–7 mm I.D. for males and 6.0 mm I.D. for females) via the oral (46%) versus nasal (36%) route. Intubation/extubation by the most expert/experienced personnel was emphasized so as to minimize direct trauma to the larynx. While intubated, strong recommendations were made to suppress gastric acid production and to minimize motion of the endotracheal tube, including patient sedation. Preferences for an early tracheotomy (6 days) versus their usual time (10 days) were approximately equal (44% vs. 50%, respectively) and most respondents (69%) recommended the same size tracheotomy tube (8.0 mm I.D. for males and 6.0 mm I.D. for females) for singers and nonsingers. Post extubation/decannulation care emphasized voice rest, retraining, continued gastric acid suppression, and the possibility of direct laryngoscopy to assess post-TLI or tracheotomy injuries.

Dangerous Doughty – A quantitative study of disproportion between the size of endotracheal tubes and splits in tonsillectomy gag blades

The Doughty split tongue blade is used routinely with the Boyle Davis mouth gag during tonsillectomy. If the width of the slot in the blade is excessive, then the endotracheal tube may herniate through the slot in the blade and become fixed and inseparable from the blade. We report two cases of paediatric tonsillectomy where this potentially serious complication occurred. The slot widths of disposable and reusable Doughty blades were measured and specifications were obtained from several manufacturers. All disposable paediatric Doughty blades and some of the reusable blades were found to have excessively and potentially dangerously wide slots. Compression testing of endotracheal tubes by the manufacturer demonstrated marked increases in deformability on warming to body temperature. Ensuring that the slot width of the Doughty blade is not excessive for the endotracheal tube used is essential and we give recommendations.

How reliable is length-based determination of body weight and tracheal tube size in the paediatric age group? The Broselow tape reconsidered

The Broselow tape was designed to estimate body weight and tracheal tube size on the basis of the body length of emergency paediatric patients. The tape was validated previously in US populations. We assessed its accuracy in a sample of European children by reviewing paediatric anaesthetic charts at the Triemli City Hospital for 1999. Age, body length and body weight measured before surgery as well as the size of the tracheal tube used were recorded. The body weight was estimated on the basis of body length using the Broselow tape and was compared with the measured weight. Tracheal tube size selections using the Broselow tape and an age-based formula were compared with the size of the tube used. A good correlation was found between the Broselow weight and the measured weight (r2=0.88). Bland-Altman analysis revealed a mean bias of -0.52 kg for the entire study population. For children < or = 20 kg the mean bias was -0.05 kg, and for children > 20 kg was -1.05 kg. The Broselow weight was found to be within a 10% error of the measured weight in 65% of children. Tracheal tube selection by the Broselow tape method was adequate in 55% but underestimated the actual tube size in 39%. The age-based formula matched the actual tracheal tube size in 41% of children but overestimated it in 57%. The Broselow tape is an accurate means to assess body weight from length in smaller children; in older children it underestimated body weight. Endotracheal tube size selection by the Broselow tape appears to match the size of the tube used better than the age-based formula. The results in a European sample of children are comparable to the US data.

Intubated pediatric patients requiring transport: A review of patients, indications, and standards

Introduction: We could not find any studies of nontertiary care facilities performing intubation for patients requiring transport to definitive pediatric care. The purpose of our study was to determine the current practices of pediatric airway management in the prehospital and transport environments. Methods: A retrospective analysis of all patients youner than 16 years transported by our flight program during a 2-year period served as the population of interest. The flight records (RN and MD documentation) for intubated patients were analyzed for medications, methods, outcomes, and other descriptive endpoints. As a matter of program policy, all pediatric transports are subjected to peer review in the performance improvement committee. Results: During the review period, 732 patients younger than 16 years (range: 30 days to 15 years) were transported by our flight program. Of the 148 (20%) patients intubated for airway control, 81 were boys (55%), and 67 were girls (45%). Sixteen percent were younger than 1 year, 24% were 1 to 2 years old, 18% were 3 to 5, 20% were 6 to 11, and 22% were 12 to 15. Indicators for intubation included unresponsiveness or arrest, 42 (28%); seizures, 38 (26%); respiratory failure, 28 (19%); decreased level of consciousness (LOC), 14 (9%); airway protection, 13 (9%); combativeness, 11 (7%); and other, 2 (1%). Children were intubated most frequently by the referring physician (92 children, 62% of patients). The flight crew performed 49 (33%) intubations, and EMS staff performed seven (5%). Three children were nasally intubated. Significant variation occurred in medications used, endotracheal tube size and position, and nasogratric decompression. No single group performed better or worse than the others in our review. Conclusion: Variability exists in the application of pediatric airway management techniques, including pharmacologic modes and intubation indications.

Post-thyroidectomy sore throat following endotracheal intubation.

Sore throat is not an uncommon complaint following general anaesthesia (GA) with endotracheal intubation. It has been a source of considerable discomfort particularly in those patients who had thyroid surgery. Driven by the increased number of patients with post-intubation sore throat following thyroid surgery, the aim of the present study was to evaluate the contributing factors of sore throat in patients who had thyroid surgery under general anaesthesia. A total of 57 consecutive patients who had thyroid surgery from November 1998 to April 1999 was included in this prospective study. Factors such as intubation time, number of intubation attempts, size and type of endotracheal tube (ETT) used, gender and age were recorded. The nature and extent of the surgical procedures were also studied. Postoperative symptoms were assessed by questionnaire on the day after surgery and the different parameters were compared and analysed. The incidence of post-intubation sore throat following thyroid surgery was documented in 39 (68.4%) patients. Twenty-seven (47.4%) patients had a mild complaint of sore throat, which resolved after the third day. The data from the present study show that the size of ETT and extent of surgical procedure were significant contributing factors affecting the postoperative recovery. The outcome of the present study demonstrated a substantial increased incidence of sore throat after thyroid surgery under GA. Postoperative sore throat following thyroid surgery under GA may be caused by multiple contributing factors. Nonetheless effort and care should be taken during endotracheal intubation and surgery to reduce this unpleasant complaint arising mainly from pharyngeal irritation or trauma.

Do age-based formulae predict the appropriate endotracheal tube sizes in Japanese children?

Age-based formulae have been widely used to predict the appropriate size of the endotracheal tube (ETT) in children. These formulae are based on old data from Western countries. The current study was undertaken to assess the effectiveness of these formulae in Japanese children. We reviewed data for the past 5 years from children (0-8 years of age) intubated orally with the regular uncuffed ETT or RAE type. The data included the child's age in years and months and the internal diameter (ID) of the ETT. Data from 1301 children were reviewed. The IDs of the most frequently used ETT were 3.0 mm for patients less than 1 month old, 3.5 mm for those 1 to 4 months old, 4.0 mm for those 5 to 17 months old, and 4.5 mm for those 18 to 23 months old. In children 2 to 8 years old, the ID of the most frequently used ETT was in accordance with the ID predicted by the formula ID (mm) = [age in years + 16]/4. However, the ID predicted by this formula applied to only 53.5% of our patients. The age-based formula, ID (mm) = [age in years + 16]/4, is applicable to Japanese children. However, we recommend that three sizes be available before endotracheal intubation.

Appropriateness of endotracheal tube size and insertion depth in children undergoing air medical transport.

Guidelines for pediatric endotracheal tube (ETT) size and insertion depth are important in the helicopter EMS (HEMS) setting, where intubated patients are frequently transported by a non-physician flight crew providing protocol-based care in an environment noted for limitations in clinical airway assessment. The objectives of this study were to characterize, in a HEMS pediatric population, the frequency of compliance with guideline-recommended ETT size and insertion depth, and to test for association between guideline noncompliance and subsequent receiving hospital adjustment of ETT size or insertion depth. This retrospective review analyzed 216 consecutive pediatric (age <14) scene and interfacility HEMS transports, of patients intubated before or during HEMS transport, by an urban two-helicopter HEMS service providing protocol-based care with a nurse/paramedic crew configuration. Patients were transported to one of three receiving academic pediatric referral centers. Pediatric Advanced Life Support (PALS) criteria for ETT size and insertion depth were used to assess guideline-appropriateness of pediatric ETTs. Receiving hospital records were reviewed to determine if post-transport ETT size or lipline adjustment were associated with guideline-appropriateness of size and lipline during HEMS transport. Univariate (chi-square and Fisher's exact) and multivariate (logistic regression) statistics were used to assess and control for the following covariates: intubator group (physician, flight crew, ground EMS), transport year, sex, age, transport type (scene versus interfacility), and receiving hospital. For all analyses, statistical significance was set at the 0.05 level. The initial ETT size was within 0.5 mm of guideline-recommended sizes in 178 (83.6%) of the 213 patients for whom this data were available. Inappropriate sized ETTs were nearly always (32 of 35, 91.4%) too small. Compared to initial ETTs placed by ground EMS personnel, initial ETTs placed by flight crew or physicians were more likely to be appropriate as defined by guidelines (P = .008 and .032, respectively). Receiving hospitals changed the ETT size in 18 (8.3% of 216) cases. Receiving hospital ETT size change was more likely with later transport year (P = .018) and less likely in patients over 2 years of age (P = .03); there was no significant association between receiving hospital ETT size change and intubator group (P > .22) or guideline-appropriateness of ETT size (P = 0.94). The initial ETT insertion depth was within 1 cm of the guideline-recommended lipline in 86 (43.2%) of the 199 patients for whom this data were available. Inappropriate liplines were almost always (109 of 113, 96.5%) too deep. Compared to initial ETT liplines determined by ground EMS personnel, initial liplines determined by flight crew (P = .007), but not physician (P = .47) were more likely to be appropriate as defined by guidelines. Receiving hospitals changed the ETT insertion depth in 72 (33.3% of 216) cases. Receiving hospital lipline change was more likely (P = .03) in patients older than 2 years of age, but was not associated with intubator group (P = .75) or lipline guideline-appropriateness (P = .35). As judged by frequently used guidelines, pediatric ETTs are often too small and commonly inserted too deep. However, this retrospective study, limited by lack of clinical correlation for ETT size and insertion depth, failed to find an association between lack of ETT size or lipline guideline compliance and subsequent ETT adjustment at receiving pediatric centers. This study's findings, which should be confirmed with prospective investigation, cast doubt upon the utility of pediatric ETT size/lipline guidelines as strict clinical or quality assurance tools for use in pediatric airway management.

Effects of Fiberoptic Bronchoscopy During Mechanical Ventilation in a Lung Model

To evaluate the effects of fiberoptic bronchoscopy (FOB) on delivered volumes and pressures during mechanical ventilation, utilizing a lung model. Bench study. Laboratory. Using varying-sized endotracheal tubes (ETTs), we ventilated a lung model at two levels of compliance utilizing different modes and parameters of ventilation. After establishing baseline measurements, the bronchoscope was inserted and measurements repeated. During controlled mechanical ventilation (CMV) with a preset high-pressure limit (HPL), tidal volumes (VTs) were reduced from 700 mL to 0 to 500 mL following insertion of the bronchoscope. Increasing the HPL to 120 cm H(2)O resulted in a VT of 40 to 680 mL. Changing from square to decelerating flow waveform resulted in no consistent difference in VT. Auto-positive end-expiratory pressure (auto-PEEP) of 0 to 41 cm H(2)O was present under most conditions. Higher rates and lower peak inspiratory flows were associated with higher levels of auto-PEEP. In the pressure-control (PC) mode, using a preset inspiratory pressure level (IP), VT was reduced from 700 mL to 40 to 280 mL following insertion of the bronchoscope. Maximum IP (100 cm H(2)O) increased VT to 260 to 700 mL. Auto-PEEP was less in the PC mode. Extreme care must be taken when bronchoscopy is performed on a patient receiving mechanical ventilation. Extremely low VT and significant auto-PEEP may develop unless flow, respiratory rate, mode, and ETT size are carefully selected. The PC mode delivered more volume than did the CMV mode. When performing FOB during mechanical ventilation, the inside diameter of the ETT should be > or = 2.0-mm larger than the outside diameter of the bronchoscope to maintain volume delivery and minimize the development of auto-PEEP.

Safety and efficacy of the rapid four-step technique for cricothyrotomy using a Bair Claw

The Rapid Four-Step Technique (RFST) has been demonstrated to be faster than standard open crico thyrotomy technique, but may have a higher incidence of cricoid injury with tracheal hook traction applied caudad. The “Bair Claw” is a novel device that may help eliminate these complications. This randomized, experimental trial used a fresh-frozen cadaver model of cricothyrotomy to compare speed and safety between RFST using a Bair Claw and standard open technique. Outcome measures included time to definitive airway, size of largest endotracheal (ET) tube able to be passed, and incidence of complications. We observed that RFST using a Bair Claw was significantly faster than standard open technique. There was no significant difference with regard to size of ET tube able to be passed with RFST using a Bair Claw versus standard open technique, and there was no damage to trachea or larynx observed with either technique. We concluded that RFST using a Bair Claw is faster and appears to be equally safe when compared to standard open technique in a fresh-frozen cadaver model of cricothyrotomy. The two techniques were equal with regard to maximal ET tube size.

Measurement of endotracheal tube cuff leak to predict postextubation stridor and need for reintubation

Background: The purpose of this study was to determine the predictive value of an endotracheal tube cuff leak for the development of postextubation stridor and the need for reintubation. Study Design: Consecutive trauma patients who required intubation at a level I trauma center from July 1997 to July 1998 were studied prospectively. Pediatric patients and those who did not meet the standard weaning protocol criteria established by the Division of Trauma and Surgical Critical Care were excluded. Injury Severity Score, endotracheal tube size, reason for intubation, and the number of days intubated before the initial extubation attempt were recorded. At the time of extubation, the difference in exhaled tidal volume from before to after endotracheal tube cuff deflation was calculated. This number was then divided by the exhaled tidal volume before cuff deflation and was recorded as the percent cuff leak. Patients were followed for 24 hours after extubation for the development of stridor or need for reintubation. Statistical analysis to compare subgroups of patients was performed using ANOVA with Scheffé post hoc analysis. Results: Among the 110 patients analyzed, the most common reason for intubation was closed-head injury. Seven patients (6.4%) developed stridor alone and had a mean cuff leak of 58 mL (8.4% of tidal volume before cuff deflation). Six patients (5.5%) experienced stridor that required reintubation and had a mean cuff leak of 68 mL (9.2% of tidal volume before cuff deflation). Patients who developed stridor or needed reintubation had been intubated for a significantly greater length of time than those not developing stridor or requiring reintubation (2.6 versus 3.0 days, p < 0.001). There were no differences in Injury Severity Score, endotracheal tube size, or reason for intubation between these groups. Conclusions: A cuff leak of less than 10% of tidal volume before cuff deflation is useful in identifying patients at risk for stridor or reintubation (96% specificity). It appears that the amount of cuff leak decreases after intubation for more than 3 days, increasing the risk of stridor and need for reintubation. This information may be helpful in identifying those patients who need treatment for laryngotracheal edema, ie, use of steroids or anesthesia during extubation, the efficacy of which remains to be determined.

Prospective study of airway management of children requiring endotracheal intubation before admission to a pediatric intensive care unit

To prospectively identify complications related to airway management in children before pediatric intensive care unit (ICU) admission. A descriptive, prospective study covering an 18-month period. A survey was completed at the time of admission to obtain demographic data, reason for endotracheal (ET) intubation, medications administered, location of and personnel responsible for ET intubation, and major/minor variances associated with airway management. Major variances were defined as technical problems resulting in a significant risk for airway trauma and increased morbidity. Minor variances were problems that should be avoided, but which do not significantly increase the immediate risk to the patient. Additional information obtained included whether a chest radiograph (CXR) was obtained and if postextubation problems occurred, such as stridor requiring treatment or reintubation. Community hospitals, emergency rooms, children's hospital emergency rooms All children < or =18 yrs of age receiving ET intubation before admission to the pediatric ICU, except those in cardiovascular arrest. Data were collected on 250 consecutive patients. Major or minor variances were noted in 135 (54%) patients and in 66% of patients < or =1 yr of age (p = .02865; odds ratio, 2.0). Twenty-six percent of patients < or =1 yr of age received an anticholinergic agent before ET intubation compared with 40% of older patients (p = .04343; odds ratio, 0.504). Eleven patients received a neuromuscular blocking agent (NMBA) without a sedative/analgesic agent. Major variances occurred in 54% of patients who did not receive a NMBA and in 27% of patients who received a NMBA (p = .00002; odds ratio, 0.307). Forty-one patients (16%) were intubated with an inappropriately sized ET tube. Postintubation CXRs were obtained in 65% of patients managed outside of a children's hospital and in 93% of patients in a children's hospital emergency room (p < .00001; odds ratio, 7.199). Variances detectable by CXR went unrecognized in 40% of patients, despite obtaining a CXR. Emergency airway management in children can be fraught with problems. Most variances could be avoided by improved education regarding appropriate ET tube size, appropriate medication use, and improved training for evaluation of ET tube placement.

Down syndrome: analysis of airway size and a guide for appropriate intubation.

The purpose of this study is to prospectively evaluate the airway size of children with Down syndrome (DS). Previous studies have observed an increase in postintubation stridor in children with DS. Anesthetic literature suggests using a smaller endotracheal tube in children with DS, but more specific recommendations are not offered. With this study, recommendations are presented for the appropriate endotracheal tube size to use in children with DS undergoing intubation. A prospective, nonrandomized study was performed on a cohort of 42 children with DS and 32 control subjects. Sizing of the airway was assessed through measurement of an air leak around the endotracheal tube at intubation. The size of the airway was also evaluated through measurements of the tracheal diameter at the "tracheotomy point" on magnetic resonance imagine (MRI) studies of the head and neck which were performed on a group of children with DS. These were compared with normative values of the tracheal diameter in children. The proper size of endotracheal tube in a population of children with DS and in a group of normal controls was determined. The "proper size" of an endotracheal tube was defined as that size of tube which allowed an audible air leak around the tube between 10 and 30 cm of H2O pressure. Anesthetic technique was controlled and identical for all study subjects. Participants had no previous history of airway compromise, stridor, or previous intubation. Weight and age were recorded and evaluated for their influence on the results. A retrospective evaluation was made of MRI studies of the neck that were performed on children with DS. Using measurement techniques described by Reed et al., the tracheal diameters at the "tracheostomy point" were compared with normative values for children. Measurements were both obtained by the author and confirmed by a pediatric radiologist. Using this prescribed method to determine the proper size of endotracheal tube, the control group used endotracheal tubes that were predicted from established anesthesia charts and formulas. However, children with DS required endotracheal tubes at least two sizes smaller. Age was found to be a more reliable factor in predicting the endotracheal tube size. A table of endotracheal tube sizes for intubation in children with DS is presented. Evaluation of the tracheal diameter at the tracheotomy point revealed that children with DS have a smaller trachea when compared with control children. It is not only the subglottis that is smaller; the tracheal diameter as well must be assumed to be of a smaller diameter in children with DS. Children with DS have smaller airways than other children. This is because of an overall decrease in the diameter of the tracheal lumens. Initial intubation of a child with DS should be performed with an endotracheal tube at least two sizes smaller than would be used in a child of the same age without DS, to avert potential trauma to the airway.

Anesthesia for Tracheal Resection: A New Technique of Airway Management in a Patient with Severe Stenosis of the Midtrachea

Anesthesia for Tracheal Resection: A New Technique of Airway Management in a Patient with Severe Stenosis of the Midtrachea

Anesthesia for Tracheal Resection: A New Technique of Airway Management in a Patient with Severe Stenosis of the Midtrachea

We report the combined use of a Fogarty catheter (FC), a 3.5-mm fiberoptic bronchoscope (FOB), and a 6.0 endotracheal tube (ETT) to intubate the lower trachea of a patient with a primary upper- and midtracheal tumor causing a 66% stenosis of the tracheal lumen at the level of the thoracic inlet. Initially, the 6.0 ETT, with the FOB and the FC fed to its tip, was placed above the tumor and rotated 90° counterclockwise. The FOB and the FC were advanced through the stenosis, and the FC cuff was inflated just above the carina. The ETT was advanced over the FOB toward the FC cuff, and the ETT cuff was inflated below the tumor and above the FC cuff. After inspection for blood and tumor debris through the FOB’s eyepiece, the FC cuff was deflated, both the FOB and FC were withdrawn, and intermittent positive pressure ventilation (IPPV) was begun.