Chapter 19

Tracheal Tubes and Associated Equipment

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The t racheal tube (endot racheal tube, i nt ratracheal t ube, t racheal catheter) i s a
device that is i nsert ed through the l arynx i nt o t he t rachea to convey gases and
vapors t o and f rom the lungs.
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General Principles
Resistance and Work of Breathing
A tracheal tube pl aces a mechanical burden on the spont aneousl y breathi ng pat ient
(1,2,3). I t adds resi stance and i s usual l y a more i mportant factor i n determi ning t he
work of breat hi ng than the breathi ng system (4). Thi s is part i cul arl y import ant in
pediatric pati ents (5). Several f actors hel p t o determine the resi stance t o gas fl ow
i mposed by a t racheal t ube.
Internal Diameter
The single most import ant f actor i n det ermining the resi stance t o gas fl ow i s the
i nternal di amet er (ID) of the t ube and i ts connector. A tube wi t h a t hi ck wal l wi l l
of fer more resi st ance than a t hi n-wal l ed tube wi th the same out er di amet er (OD).
The wal l t hi ckness to tube di ameter rat i o i s great er i n smal l tubes, leadi ng to a
great er i ncrease i n resi stance (6). Resi st ance wi l l be i ncreased i f a sucti on
catheter, f iberscope, or other devi ce i s passed through the t ube or i f secreti ons l i ne
t he i nner wal l .
Length
Decreasi ng tube l ength l owers i ts resi stance, but t he decrease i s much less than
could be accompli shed by increasi ng the I D (5, 7, 8). Most disposable tubes are
suppl ied l onger t han necessary and may be cut t o a more sui tabl e length to reduce
resi st ance.
Configuration
Curves i n the t ube or connector i ncrease resi st ance, but if the curve i s gentl e, t he
i ncrease i s smal l (5,6). Ki nki ng i ncreases resi st ance. The resi stance of swi vel
connectors is simi lar to that of curved connectors (9).
Dead Space
The t racheal tube and connector consti tute mechani cal dead space, whi ch was
di scussed i n Chapter 7. Because t he vol ume of a t racheal tube and i ts connector is
usual l y l ess than that of the natural passages, dead space i s normal l y reduced by
i ntubat ion. I n pedi at ri c pati ents, however, long tubes and connectors may i ncrease
t he dead space. Special low-volume pedi at ri c connectors are avail abl e.
Tracheal Tube System
Tube
Materials
The materi al f rom whi ch a tracheal tube i s manuf actured shoul d have the f ol l owi ng
characteri st ics (10,11):
Low cost
Lack of t issue toxi ci ty
Transparency
Easy steri l i zati on and durabi l i ty wi th repeated steri li zati ons (unl ess
di sposabl e)
Nonf l ammabi l i t y
A smooth, nonwet t abl e surface inside and outsi de to prevent secreti on
bui l dup, al low easy passage of a suct ion cat heter or bronchoscope, and
prevent t rauma
Suf f ici ent body t o mai ntain i ts shape duri ng i nserti on and t o prevent
occl usi on by torsion, ki nki ng, or compressi on by the cuf f or external pressure
Suf f ici ent st rength t o al l ow t hi n wal l construct ion
Thermopl asti ci t y to conform t o the pati ent' s anatomy when i n pl ace
Lack of react i on wi t h l ubri cants and anestheti c agents
Latex-f ree
To date no substance wi t h all of the above trai ts has been f ound.
Red rubber tubes are sti l l avail abl e. These can be cl eaned, st eril i zed, and reused
mul ti pl e ti mes. However, t hey are not t ransparent, they harden and become st icky
wi th age, have poor resi st ance to ki nki ng, become clogged by dri ed secret i ons
more easi l y t han pl asti c tubes, and do not sof ten appreci abl y at body temperature.
Latex al l ergy is another possi bl e problem (Chapt er 15).
Pol yvinyl chlori de (PVC) is the substance most wi del y used i n disposabl e t racheal
t ubes. It i s rel ativel y i nexpensi ve and i s compat ibl e wi th t issues. Tubes made f rom
PVC are l ess l i kel y to kink t han rubber tubes. They are st if f enough f or intubat ion at
room temperature but sof t en at body t emperat ure, so they tend to conform to t he
pati ent 's upper ai rway. Pri or t o use, a PVC t ube may be cool ed to make i t more f i rm
duri ng intubati on or warmed t o facil i tate pl acement over a f i berscope (12). PVC
t ubes have a smooth surface that f aci l i tates passage of a suct ion catheter or
bronchoscope. Thei r t ransparency permi ts observati on of the ti dal movement of
respi ratory moi sture as wel l as materi al s i n the l umen.
Si l i cone is used in some tracheal tubes. Al though more expensive than PVC, tubes
made f rom i t can be steri l i zed and reused.
Tube Design
The i nt ernat ional /U.S. standard (11) cont ai ns requi rements and recommendati ons
f or tracheal t ubes, i ncl uding the mat eri al f rom whi ch t he tube is const ructed, t he
i nsi de di ameter, l ength, i nf l at i on system, cuf f , radi us of curvature, markings,
packagi ng, and l abel i ng (10).
A typical t racheal tube is shown i n Figure 19. 1. The int ernal and external wal l s
shoul d be ci rcul ar. A tube
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whose lumen is oval or el l i pti cal in shape i s more prone t o kinki ng than one that i s
round.

View Figure

Figure 19.1 Cuffed Murphy tracheal tube.

The machi ne (proxi mal ) end receives the connector and proj ects f rom the pati ent . I t
may be possi bl e to short en the tube at this end. The pati ent (t racheal or di st al ) end
(ti p) i s inserted i nt o the t rachea. It usual l y has a sl anted porti on cal l ed the bevel .
The angl e of the bevel is the acute angle bet ween the bevel and the l ongi tudinal
axis of t he t racheal tube (Fi g. 19.1). Most commonl y, the openi ng of the bevel f aces
t o t he l ef t when vi ewi ng the tube f rom i ts concave aspect . Thi s is because the tube
i s usual l y i ntroduced f rom the right, and the l arynx i s easi er to vi sual i ze wi th t he
bevel f aci ng to t he l ef t.
The desi gn or ori entati on of t he pati ent end i s i mportant when t he tube is advanced
over a fi berscope or i nt roduci ng cathet er. I nserti on i s easi er i f the bevel f aces
backward or t he ti p is speci al l y desi gned t o minimi ze the distance bet ween the
scope and t he tube' s l eadi ng edge (13,14,15, 16,17,18,19,20,21,22,23,24). A
hemi spherical bevel reduces nasal morbi di ty duri ng nasotracheal i nt ubati on (25).
During nasal intubat ion, turni ng t he tracheal t ube so that the bevel f aces up may
avoid t he ti p f rom becoming i mpi nged on t he epigl ot ti s (23).
Fi gure 19. 1 shows a hol e through the tube wal l on the si de opposi te to the bevel .
Thi s i s known as a Murphy eye, and a tube wi th t hi s f eature is cal l ed a Murphy or
Murphy-type tube. The purpose of the eye is to provide an al t ernate pathway f or
gas f l ow i f t he bevel becomes occl uded (26,27). Forceps, t ube changers, and
f iberscopes may i nadvert ent ly advance through a Murphy eye and become caught
(28,29,30, 31). Usi ng a tube wi t h a Murphy eye wi l l reduce trauma duri ng nasal
i ntubat ion (32). A theoreti cal di sadvantage i s that secreti ons may accumul at e in the
eye. Some tubes have an addi t i onal eye above the bevel . This may provi de an
addi ti onal measure of safety i f the tube acci dental l y advances i nto a mainstem
bronchus.
Tracheal tubes l acki ng the Murphy eye are known as Magi l l or Magi l l -t ype tubes. If
a Murphy eye i s not present , the cuf f can be pl aced cl oser to t he ti p. This may
decrease the ri sk of i nadvertent bronchi al intubat ion.
The Ameri can Society f or Testi ng and Materi als/Internati onal Standards
Organi zat i on standard (11) requi res t hat a radi opaque marker i s pl aced at the
pati ent end or al ong the ent i re length of t he tube t o ai d in determinati on of tube
posi t i on af ter i ntubati on.
Special Tubes
Cole Tube
The Cole t ube i s shown i n Figure 19.2. It i s an uncuf fed t ube. The pat i ent end has a
smal l er di ameter t han the rest of the shaf t . This provi des some protecti on against
i nadvert ent bronchi al int ubati on. Col e tubes are si zed accordi ng to t he I D of the
t racheal porti on. The tube should not be i nserted f ar enough f or t he shoulder t o
contact the l arynx, as thi s coul d damage the l arynx (33). It has been recommended
t hat thi s tube i s used for neonatal resusci t at i on but not for l ong-t erm i ntubat i on
(33). The resi st ance of f ered by t he Col e tube is l ess than that of a comparabl e tube
of constant l umen (8). A di sadvant age i s that i t cannot be i nsert ed through the
nose.
Preformed Tubes
Some t racheal tubes are pref ormed to f aci l i tat e surgery about the head and neck
(34). One of these i s the Ri ng-Adai r-El wi n (RAE) t ube (Fi g. 19.3), whi ch has a
pref ormed bend that may be t emporari l y
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st rai ghtened duri ng i nserti on. Frequentl y, t here i s a mark at the bend. The external
port ion of the oral versi on is bent at an acute angl e so that when i n pl ace, i t rests
on the pat ient' s chin wi th t he connect or over t he pat ient' s chest . The nasal versi on
has an opposi te curve f rom the oral tube so that when i n place the out er porti on of
t he tube is di rected over the pati ent ' s f orehead. This helps t o reduce pressure on
t he nares. The oral tubes are shorter than nasal tubes.

View Figure

Figure 19.2 Uncuffed pediatric tracheal tubes. The top tube
is a Cole tube, which is sized by the French scale, according
to the intratracheal portion. The middle tube is a Magill
tube, while the bottom tube has a Murphy eye. The dark
color is the part of the tube that the manufacturer
recommends to be below the vocal cords. (Courtesy of
Rusch, Inc.)

The nasal and oral versi ons are avail able i n vari ous si zes and i n cuf fed and
uncuf fed versions. Uncuf fed RAE t ubes are short er t han cuff ed RAE tubes (35). As
t he di ameter i ncreases, the l engt h and di stance f rom the distal ti p to t he curve al so
i ncreases. In the maj ori t y of cases, when t hi s mark i s at the teeth or nares, t he
t ube wi l l be satisf actori l y posi ti oned i n the t rachea i f t he proper si ze t ube f or t he
pati ent was sel ected. Thi s i s onl y a gui de and shoul d not be used as the sol e
cri teri on f or j udging correct tube posi t ion. Unf ort unatel y, the l ength f rom the angl e
t o t he t ip of the tube vari es (36,37).
These tubes are easy to secure and may reduce the ri sk of uni ntended ext ubati on.
The curve al l ows t he breathing system connect i on to be pl aced away f rom the
surgi cal fi el d duri ng surgery around the head wi t hout use of special connectors
(38). The l ong l engt h may make t hem usef ul f or i nsert i on t hrough a supragl ott i c
ai rway devi ce (39,40, 41) (Chapter 17). The nasal t ube may be usef ul f or oral
i ntubat ion of pat i ents who are t o be in t he prone posi ti on (42) or who are
undergoi ng otolaryngol ogy procedures (43).
A di sadvantage of pref ormed tubes i s t he di f f i cul ty i n passi ng a suct i on cat heter
t hrough them. I n cri ti cal si tuati ons, sucti oning can be accompl ished by cutt ing the
t ube at t he curvature and t hen reinserti ng the connector i nto the cut end (43).
These tubes of fer more resi stance t han comparabl y si zed conventi onal tubes (6).
Si nce t hey are desi gned to f i t the average pat ient, a t ube may be ei ther t oo l ong or
t oo short f or a gi ven pati ent (35,44). When selecti ng t ube si ze, ref erence to hei ght
and wei ght may be more usef ul than age i n years, and the user should al ways be
al ert to t he possi bi l i ty of bronchi al i nt ubati on or acci dental extubat i on.
Spiral Embedded Tubes
The spi ral embedded (f lexometal l i c, armored, rei nf orced, anode, met al spi ral ,
woven, wi re-rei nforced) t ube has a met al or nyl on spi ral -wound rei nf orci ng wi re
covered internal l y and ext ernal l y
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by rubber, PVC, or si l icone (Fig. 19. 4). The spi ral may not extend i nto t he di stal
and proximal ends. The connector i s f requent l y bonded to the tube.

View Figure

Figure 19.3 Preformed tubes. At left are two nasal tubes,
one cuffed and one uncuffed; at right are two oral tubes.
(Courtesy of Rusch, Inc.)


View Figure

Figure 19.4 Spiral embedded tracheal tubes. A: Note the
reference marks near the patient end of the tube to aid in
positioning with respect to the vocal cords. (Courtesy of
Mallinkrodt Medical, Inc.) B: Note that the tube on the left
has a single reference mark. (Courtesy of Rusch, Inc.) C:
The middle tube has a reinforcing covering over the bite
area. Note again the referencing marks. (Courtesy of
Kendall Healthcare Products Co.)

Spi ral embedded t ubes are especi al l y usef ul i n si tuati ons where t he tube is l ikel y to
be bent or compressed, as i n head and neck surgery. Anot her use is f or surgery on
t he trachea. The tube can be pl aced by t he surgeon.
The pri mary advantage of these t ubes i s resistance to ki nking and compression.
The port i on of the tube outsi de t he pati ent can be angled away f rom the surgical
f iel d wi thout ki nking. Thi s makes them useful for
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i nsert i on i nto t he pati ent wi t h a t racheostomy (45), f or subment al i nt ubati on
(46,47,48, 49, 50), and ret romol ar posi ti oning (51). A spi ral embedded tube may
pass more easi l y over a f i berscope t han a convent ional t ube (52,53, 54,55).
There are a number of probl ems wi t h these t ubes. A f orceps and/ or a st yl et wi l l
of ten be needed for i ntubati on. The tube may rot at e on the styl et during i nsert ion. I t
i s dif f icul t and someti mes i mpossi bl e to pass the tube through the nose. Because of
t he spi ral , t hese tubes cannot be shortened. The elastic recoi l f orce may increase
t he tendency to unint ent i onal ext ubat i on. They are di f fi cul t t o i nsert through the
i ntubat ing l aryngeal mask ai rway (56). Spi ral embedded t ubes t hat have been
resteri l ized have a hi gh i nci dence of probl ems (57, 58, 59). For t hi s reason, reuse is
not recommended. Even si ngl e-use tubes may devel op probl ems (60). Cases have
been report ed where a pat ient bi t t he tube, causi ng i t to be severed or permanentl y
deformed (61,62,63,64,65, 66,67,68). A bi t e bl ock between the mol ar t eeth, not an
oral ai rway, shoul d be used to prevent this. Some spi ral embedded tubes have an
external rei nf orced covering over the bi te port i on (Fi g. 19. 4C). Ki nki ng as a resul t
of compressi on between a ret ractor and t he teeth has been reported (69). The
absence of a Murphy eye may resul t i n obstructi on i f the bevel abuts t he wal l of the
t rachea (70).
Hunsaker Mon-J et Ventilation Tube
The Hunsaker t ube (Fi g. 19. 5) i s l aser-resi st ant and desi gned f or subgl ot ti c j et
venti l ati on. It i s compati bl e wi th carbon dioxi de, neodymi um-ytt ri um al umi num-
garnet (Nd-YAG), and argon l asers. The OD i s 3 mm, and i t has an i nt egral l umen
f or moni tori ng ai rway pressure and respi ratory gases. The pat ient end has a
basket -shaped distal extension desi gned to center t he t ube. Thi s tube has been
used to admi ni ster one-l ung vent i l at ion (71).
Laryngectomy Tube
Laryngectomy t ubes have a J conf i gurati on at the pati ent end (73) (Fi g. 19. 6,
l ef t ). They are desi gned to be i nsert ed into a tracheotomy. Thi s al l ows t he part of
t he tube external t o the pati ent t o be di rected away f rom the surgical f i el d. The ti p
may be short and/ or wi thout a bevel to avoid advancement i nto a bronchus.

View Figure

Figure 19.5 Hunsaker Mon-Jet ventilation tube.


View Figure

Figure 19.6 Left: Laryngectomy tube. Middle: Injectoflex
tube, which is used for procedures on the larynx. The tube
has an embedded metal spiral. The insufflation lumen and
cuff inflation tube are combined in one sheath with the
malleable introducer. Right: Spiral embedded tube.
(Courtesy of Rusch, Inc.)

The curve may need to be strai ght ened to faci l i tate i nsert i on. The t ube can be
secured by suturi ng or tapi ng i t to the chest wal l (72).
A case of obstruct ion of this t ube has been reported (73). The sof t cuf f and short
di stance between the cuf f and di stal t ip of the tube may cause the bevel t o abut the
t racheal wal l .
Microlaryngeal Tracheal Surgery Tube
The mi crol aryngeal tracheal surgery (LTS or MLT) tracheal tube (Fig. 19.7) i s
avai l able wi th an ID of 4, 5, or 6 mm (74). The l arge cuf f di amet er is the same as
t hat f ound on a standard 8-mm-ID tube. This helps t o keep the t ube centered i n the
t rachea. One versi on has a yel l ow-col ored cuf f .
Thi s tube is desi gned f or mi crol aryngeal surgery or f or pati ents whose ai rway has
been narrowed t o such an extent that a normal -si zed t racheal tube cannot be
i nsert ed. The smal l tube diameter provi des better vi si bi l i t y and access to the
surgi cal fi el d. I ts l ength al lows i t t o be used f or i ntubati on vi a a l aryngeal mask
ai rway (LMA) or ot her supragl ott i c ai rway device (76). Possi bl e problems wi t h a
t ube having such a smal l bore i ncl ude i ncompl ete exhal at ion and occl usion. Thi s
t ype of t ube i s not saf e f or use wi t h lasers. I t can be used f or sel ect i ve bronchi al
i ntubat ion (75) (Chapter 20).
Endotrol Tube
The Endot rol (t ri gger) t ube (Fig. 19.8) has a pul l ri ng loop (t ri gger) t hat is
connected t o the t ip of the t ube wi th a cabl e embedded i n the tube wal l . Pul l i ng on
t he ri ng decreases t he tube' s inside radi us and moves
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t he ti p anteri orl y. When used wi t h a styl et, the ti p al one can be cont rol l ed (77). The
Endotrol tube has been used f or bl ind i ntubat i ons, i ncludi ng bl ind nasal i ntubati on;
i ntubat ion uti l i zi ng a l ighted i ntubati on st yl et ; and i ntubat ion usi ng a l aryngoscope
(78,79,80, 81, 82,83,84, 85,86).

View Figure

Figure 19.7 Tubes for microlaryngeal tracheal surgery.
Top: The cuff on this tube is colored yellow for greater
visibility. (Courtesy of Sheridan Catheter Corp.) Bottom:
Similar tube with an uncolored cuff.

I n one report ed case, obst ructi on t o gas f l ow was noted af t er the tube was inserted
nasal l y (87). The pul l ri ng exert ed tensi on on the pul l wi re, causi ng the ti p of t he
t ube to abut t he tracheal wal l . Cut t ing the pul l ring all evi at ed t he tensi on and the
obstruct i on. Ki nki ng duri ng prol onged i ntubati on has been reported (88).
EndoFlex
The EndoFl ex tube i s desi gned to ai d i ntubati on when t he pati ent has an anteri or
l arynx. Pull i ng the whi t e bar t oward the connector causes the tube to f lex at the
cuff and the t ip t o move ant eriorl y.
Parker Flex-Tip Tube
The Parker Fl ex-Ti p tube (Fig. 19.9) has a hooded curved, fl exi bl e tapered t i p that
poi nts
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t oward t he center of the di stal l umen on t he concave surf ace of the t ube so that t he
bevel f aces post eriorl y during i nsert ion. There are Murphy eyes on t he right and l ef t
si des of the t ube. Thi s tube is f i t ted wi t h a very t hi n cuf f . Thi s t ube i s easier to
advance over an i ntubati ng cat het er or f l exi bl e endoscope than a conventional tube
(13,19,89, 90, 91). It is al so l ess l ikel y to i mpi nge on the side of the ri ght vocal cord
t han i s a tube wi th t he poi nt of the bevel on the right. The tube is avai lable i n a
vari et y of shapes wi th and wi t hout a cuff .

View Figure

Figure 19.8 Endotrol tracheal tube. The ring is attached to
the tip by a cablelike mechanism that allows the tip to be
maneuvered. (Courtesy of Mallinckrodt Anesthesiology
Division, Mallinckrodt Medical, Inc.)


View Figure

Figure 19.9 Parker Flex-Tip tracheal tube. Note the two
eyes and the hooded curved, flexible tapered tip that
points toward the center of the distal lumen on the concave
surface of the tube so that the bevel faces posteriorly during
insertion.

Tubes with Extra Lumen(s)
Tubes wi th one or more separate l umens termi nati ng near the t i p are avai l abl e (Fig.
19.10). They are usef ul f or respi ratory gas sampl ing, sucti oning, ai rway pressure
moni tori ng, f l ui d and drug i nj ecti on, and j et venti l ati on. A number of probl ems are
associ ated wi th t hese t ubes (92). Secret i ons, bl ood, or moi sture can obst ruct the
extra l umen. The sampl i ng t ube must be securely st abil i zed to mi ni mi ze t ension on
t he tube. Moi st ure may enter the gas lumen and cause probl ems wi th t he gas
moni tor (Chapter 22).
The LITA (l aryngotracheal i nsti l l at i on of topi cal anesthesi a) (Fi g. 19.11) has an
addi ti onal smal l -bore channel i ncorporated wi thi n t he concave surf ace of the tube.
Ten small hol es at t he di stal 13 cm of t he t ube al l ow t he injected medi cat ion to be
sprayed both above and bel ow the cuf f . St udi es show that this can provide a
smooth emergence f rom anesthesi a wi t hout coughi ng in most cases (93).
Tubes with Embedded Fiberoptics
Tubes wi th f i beropti c channel s embedded i nto t he tube wal l are avai labl e. When
connected t o a video system, the f iberopti c channel al lows t he l arynx and t rachea
t o be visual i zed. This t ype of tube can be used to confi rm t racheal i ntubati on and
rul e out bronchial intubati on. These tubes may be useful for dif f icul t i ntubati ons.
Laser-resistant Tubes
A number of t racheal tubes have been designed t o be used when l aser surgery i s
perf ormed. The manufacturer' s instructi ons shoul d be consul ted t o det ermi ne whi ch
t ubes shoul d or shoul d not be used wi th a parti cul ar l aser. It i s import ant t o
understand that these t ubes are laser-resi stant but may catch f i re i f the l aser power
i s too great or the l aser appl i cati on too l ong. Lasers and f i res are di scussed in
more det ai l in Chapter 32.
Laser-Shield II Tube
The Laser-Shield I I (Fi g. 19.12) i s made f rom si li cone wi t h an i nner al umi num wrap
and an outer Tef lon coat ing (94). I t i s desi gned f or use wi t h CO
2
and potassi um-
t i t anyl -phosphate (KTP) l asers. The cuf f is not l aser-resi stant and contai ns
methyl ene-bl ue crystal s. I t shoul d be infl ated wi t h wat er or a sal i ne sol uti on. There
i s 1 cm of unprotected si li cone tubing above t he cuf f . The part of the tube di stal to
t he cuf f i s also unprotected. Cottonoi ds f or wrappi ng around t he cuff are suppl ied
wi th each tube. These must be moistened and kept moi st duri ng t he enti re
procedure.
St udi es show t hat the wrapped porti on of t he shaf t i s not penet rated by a CO
2
or
Nd-YAG l aser, but t he overl yi ng Tef l on may be vapori zed (95). Exposure of t he
unprotected part s of t he tube proxi mal and di stal to the cuf f can resul t i n rapid
combust ion. The methyl ene-blue cryst als may not f ul l y di ssolve and may obstruct
t he pi l ot tube, maki ng i t i mpossibl e t o def l ate (96).
Laser-Flex Tracheal Tube
The Laser-Fl ex tube (Fig. 19.13) i s a stai nless steel t ube wi t h a smoot h plasti c
surf ace and a mat te f inish to ref l ect a l aser beam. It i s desi gned for use wi th CO
2

and KTP l asers. The wal l of the tube i s thi cker t han that of most ot her t ubes (97).
The adul t versi on has t wo PVC cuf fs and a PVC t ip wi th a Murphy eye. The t wo
cuff s are i nf l ated by usi ng separat e inf l at ion t ubes that run along the i nsi de of t he
t ube. The di stal cuf f can be
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used i f the proxi mal one is damaged by t he l aser. Smal l uncuf fed tubes are
avai l able.

View Figure

Figure 19.10 Tubes with additional lumen(s). These tubes
have a main lumen for ventilation of the patient and one or
more additional lumens for monitoring, irrigation, pressure
monitoring, suctioning, and/or ventilation. A: These tubes
have two additional lumens. The clear lumen is used for jet
ventilation and administration of oxygen during suctioning
and bronchoscopy. The opaque lumen can be used for
irrigation and sampling of gases from the trachea. (Courtesy
of Mallinckrodt Anesthesiology Division, Mallinckrodt
Medical, Inc.) B: Pediatric tubes with monitoring lumens.
(Courtesy of Kendall Healthcare Products Co.) C: Tube
with lumen designed for subglottic suctioning. (Courtesy of
Mallinkrodt Medical, Inc.)

The cuff s shoul d be f i ll ed wi th sal i ne col ored wi th methyl ene bl ue (98). The di st al
cuff shoul d be f i l led f i rst unti l seal i ng occurs, then the proxi mal cuf f should be
f il l ed.
St udi es show t hat the shaf t hol ds up wel l when exposed t o a CO
2
or KTP laser but
not the Nd-YAG l aser (97, 99,100,101,102). Bl ood on t he outsi de of the tube renders
i t l ess resi stant t o combusti on wi th t he CO
2
l aser (103). The cuf f and t i p are
vulnerable t o al l l asers. Thi s tube is l ess l i kel y to ref l ect CO
2
l aser radi at ion than
are other t ubes (104).
The Laser-Fl ex tube i s somewhat st i ff and has a rough surf ace. The double cuff
adds to t he ti me of i ntubat ion and extubati on. The large external di amet er can be a
P. 571

probl em in smal l pati ents. In one report ed case, great dif f i cul t y was experi enced i n
removi ng the tube because of a subgl ot ti c mass (105). I n another case, dif f i cul t y
i nsert i ng an ai rway exchange cathet er (AEC) occurred (106). The Laser-Fl ex t ube
wi l l not f i t over ei t her of the Bul l ard st ylets (Chapter 18), so thi s l aryngoscope
cannot be used wi th t hi s tube. The tube wi l l f i t t hrough the Upsher Scope (Chapter
18).

View Figure

Figure 19.11 LITA (laryngotracheal instillation of topical
anesthesia) tube. Small holes at the distal 13 cm of the tube
allow the injected medication to be sprayed both above and
below the cuff. The black reference bar indicates the
position of the uppermost opening. (Picture courtesy of
Kendall Healthcare Products Company).

Sheridan Laser Tracheal Tube
The Sheri dan l aser tube (Fi g. 19.14) i s a red rubber tube wrapped wi t h copper f oi l
t ape. Thi s i s overwrapped wi t h wat er-absorbent f abric that should be saturated wi th
wat er pri or t o use. There i s a copper band at the cuf f -tube junct ion. Radi opaque
pl edgets t hat are desi gned t o be moistened and pl aced above the cuff are provi ded
wi th each tube. I t i s desi gned f or use wi t h a CO
2
or KTP l aser. A di sadvantage i s
t hat i t has a thi ck wal l (107). It has a hi gh-pressure cuf f .

View Figure

Figure 19.12 Laser-Shield II tracheal tube. (Courtesy of
Xomed-Trease.)

Norton Tube
The Nort on tube is a reusable, f l exibl e, spi ral -wound metal t ube wi th a st ai nl ess
steel connector and thi ck wal l s (108). The exteri or of the tube has a matt e f i ni sh to
decrease refl ecti on of t he laser beam. I t has no cuff . A separate cuf f may be
at tached, or packi ng around t he tube can be used to achi eve a seal . Studi es show
t his tube i s accept abl e for use wi th KTP, Nd-YAG, and CO
2
l asers (102).
There are a number of probl ems wi t h this tube. Its f l exi bl e coi l s are not ai rt i ght, and
angul ati on can resul t in a l arge l eak (109). The t ube' s exteri or i s somewhat rough
and may have sharp edges that coul d cause t i ssue damage (110). The l arge
external di ameter and st i ff ness can make surgi cal exposure di f f icul t (111). The tube
t ends to twi st on a st yl et duri ng i nt ubat i on (102). I t requi res special venti l ati ng
t echni ques when used wi thout a cuf f . If i t i s used wi t h a cuff , t he cuf f and i ts
i nf l at i ng tube can be i gni ted and may or may not remain at tached to the t ube.

View Figure

Figure 19.13 Laser-Flex tracheal tubes. The adult tube has
two cuffs. The distal cuff can be used if the proximal one is
damaged. (Courtesy of Mallinckrodt Medical, Inc.)

P. 572



View Figure

Figure 19.14 Sheridan Laser tracheal tube. The outer fabric
should be saturated before use. (Courtesy of Kendall
Healthcare Products Co.)

Bivona Fome-Cuf Laser Tube
The Bi vona Fome-Cuf l aser tube (Fi g. 19.15) has an alumi num and sil i cone spi ral
wi th a si l i cone coveri ng. It has a sel f -i nfl ating cuf f that consi sts of a pol yurethane
f oam sponge wi t h a si l i cone envel ope. The cuff must be defl ated bef ore i nt ubati on
or extubat ion (112). The cuf f shoul d be f i l l ed wi th sal i ne duri ng use. The cuf f
retains i ts shape and keeps a seal when i t i s punctured, but i t can no longer be
defl ated for removal (77,102). The i nf lati on t ube runs al ong the exteri or of the tube
and i s col ored bl ack so t hat i t can be posi t ioned away f rom where the l aser wi l l be
used (113). It i s market ed for use wi th t he CO
2
l aser.
The t ube i s poorl y resi st ant to al l l asers (99, 100,102). When burned, the si l i cone
coveri ng f orms an ash that sl oughs of f and i s lef t i n the t rachea, but most of the
t ube stays i ntact (102). A hi gh i nci dence of sore throat has been noted wi th this
t ube (114).
Lasertubus
Thi s tube (Fig. 19.16) i s made of whi t e rubber and has a cuf f -wi thi n-a-cuf f design.
I f the outer cuf f i s perforated by the l aser beam, the t rachea wi l l st i l l be seal ed by
t he i nner cuff . The manuf act urer recommends t hat the i nner cuf f be f i l l ed wi t h ai r
and the out er cuff wi t h wat er or sal i ne. The shaf t above the cuf f i s covered by a
corrugated si l ver f oi l , whi ch i s covered by a Merocel sponge that should be
moi st ened wi t h sal ine before use. Thi s tube i s recommended f or use wi t h argon,
Nd-YAG, and CO
2
l asers (115). Bendi ng the t ube i n the area above the sponge
coveri ng can predi spose the tube t o kinki ng (116,117).
EMG Reinforced Tracheal Tube
Thi s tube (Fig. 19.17) i s desi gned to moni tor recurrent l aryngeal nerve
el ect romyogram (EMG) acti vi t y during surgery (118). The tube i s wi re-rei nf orced
and has four stai nless steel electrodes above t he cuff . The el ectrodes are
connected t o a moni t or (Fi g. 19.18).
Manuf acturi ng def ects wi th t his t ube have been report ed (119,120,121). I t shoul d
be checked caref ul l y for def ects bef ore use.
Intubating Laryngeal Mask Tracheal Tube and Tube
Stabilizer
The i nt ubat i ng l aryngeal mask (I LMA, I LM, LMA-Fastrach) tracheal t ube (Fi g. 19. 19)
i s desi gned to be i nserted through the i ntubat ing l aryngeal mask (Chapt er 17) but
can be purchased separatel y. I t i s a strai ght , wi re-rei nf orced si l icone tube wi th a
t apered pat i ent end, bl unt ti p, short bevel , and Murphy eye. It has a hi gh-pressure,
l ow-vol ume cuf f (122,123) (Fi g. 19.20). I t i s reusabl e and can be aut ocl aved. I t is
avai l able i n si zes 6, 6.5, 7, 7. 5, and 8.
Fi gure 19. 21 shows the tube stabi l izer. It i s used to st abi l i ze the tube whi le t he
LMA i s bei ng removed.
Thi s tube has been found to be easi er t o advance over a f i berscope than a plasti c
t ube duri ng both oral and nasal i ntubat i on (14,15,20,21,24). It has been used for
subment al i ntubat i on (124) and t racheal resecti on and reconst ructi on af ter the t ip
has been removed (125).
Probl ems reported wi th t hi s tube i nclude eccent ri c cuf f inf l at ion, i nternal
deformi ti es, and the t i p f ol di ng during i nsert i on (126,127,128,129). As wi t h other
spi ral wi re-rei nforced t ubes, bi t ing can def orm t he spi rals or cause
P. 573

a leak (130). Thi s tube should be used wi t h cauti on i f prolonged i ntubat i on is
anti ci pat ed because of the hi gh-pressure characteri st i cs of t he cuf f
(122, 123,125,131). Cuf f inf l at ion shoul d be l i mi ted t o the mi ni mum vol ume that
seals the t rachea. When exposed to t he magnet ic resonance i magi ng (MRI )
envi ronment, the t ube poses no di rect risk t o the pat ient or other personnel .
However, MRI qual i ty may be compromi sed.

View Figure

Figure 19.15 Bivona Fom-Cuf laser tube.


View Figure

Figure 19.16 Lasertubus. The inflation tubes have
stopcocks.

Hi-Lo Evac Tube
The Hi -Lo Evac tube (Fig. 19.22) i ncorporates a dedicated channel that can be
used to cl ear secret ions bel ow the vocal cords but above the cuff . Resul ts were
mi xed when usi ng thi s tube to prevent or del ay pneumoni a
(132, 133,134,135, 136, 137,138). The l umen may become bl ocked by secreti ons
(139).

View Figure

Figure 19.17 Electromyogram reinforced tube. Note the
surface electrodes and electrode leads. (Courtesy of Xomed
Surgical Products, Inc.)

Hi-Lo J et Tube
The Hi -Lo Jet t ube i s an uncuff ed tube wi th an addi t i onal l umen that can be used
f or j et venti l ati on, moni tori ng ai rway pressure, sampli ng respi ratory gases,
admi ni stering l ocal anest het ics, or i rri gat i ng t he ai rway (77,140). One problem wi th
t he tube is t hat a sucti on catheter may bi nd i n t he smal l t racheal tube lumen (141).
Tube Size
Current standards desi gnate t racheal tube si ze by the I D i n mi l l imeters. The French
scal e size (three t i mes the external di amet er i n mi l l i met ers) may st i l l be l i sted i n
catal ogs and on packages and is used on some tubes (Fi gs. 19.2, 19.23). Because
of vari at i ons i n wal l thi ckness, tubes having the same ID may have dif ferent
external di ameters (142,143,144). The st andards also speci f y that tubes si ze 6 and
smal l er show the external di ameter i n mi l l i met ers (Fi g. 19.3B). Many manufacturers
al so mark thi s on l arger t ubes.
The ASTM/I SO standard (11) requi res tube si ze to be marked bet ween the cuf f and
t he take-off poi nt of the i nfl ati on tube for cuf f ed tubes. For uncuf f ed tubes, t he si ze
marki ng should be toward the pati ent end. Some manuf acturers also put t he tube
si ze on t he pi lot bal l oon so that t he si ze can be determi ned when t he tube is i n
pl ace (Fi g. 19. 24).
Tube Length
The ASTM/I SO standard (11) specif i es minimum tube length, whi ch i ncreases as ID
i ncreases. Most manufacturers suppl y t ubes l onger t han the mi ni mum requi red by
t he standard. Most tubes can be short ened. The l ength of a tube may vary (145).
Tube Markings
Typical t racheal tube markings, shown in Fi gure 19.23, are si tuat ed on the beveled
si de of the t ube above the cuf f and are read f rom t he pat i ent t o the machi ne end.
The f ol lowi ng are requi red by the ASTM/ ISO standard (11):
The word oral or nasal or oral /nasal .
Tube si ze in I D i n mi l l i meters. Thi s may al so be marked on t he pi lot bal l oon
(Fi g. 19.24).
The OD for tubes si ze 6 and smal l er.
The name or trademark of the manufacturer or suppl ier.
P. 574



View Figure

Figure 19.18 Monitor for use with EMG reinforced
tube. (Courtesy of Xomed Surgical Products, Inc.)

Graduated marki ngs showi ng the distance in centi met ers f rom t he pat i ent
end. These al low t he depth of i nsert ion to be determined and moni tored. On
some tubes, the name of t he manufacturer may repl ace the l engt h marki ngs
(146). Thi s can l ead to probl ems wi t h correct pl acement .
A cauti onary not e such as Do not reuse or Si ngl e use onl y if t he tube i s
di sposabl e.
A radiopaque marker at t he pati ent end or al ong the ful l l ength.
Ot her marki ngs not in conf li ct wi t h t hose ment ioned in t he l i st may be appl i ed.
Some t ubes have marki ngs (gui de marks) to hel p posi ti on t he tube wi t h respect to
t he vocal cords (147,148,149,150,151,152,153,154) (Fi gs. 19.2, 19.4, 19. 23).

View Figure

Figure 19.19 ILM-ETT. The black circle near the middle of
the tube will be at the end of the connector when the tip of
the tube is at the entrance to the bowl of the mask.
(Courtesy of LMA North America.)

Cuff Systems
A cuf f system consi sts of t he cuf f pl us an i nf lat i on system, which i ncl udes an
i nf l at i on tube, a pi lot bal l oon, and an inf l at ion valve (Fi g. 19.1). An i nf lati on l umen
i n the tube wal l may al so be present . The purpose of t he cuf f system i s to provi de a
seal bet ween t he t ube and t racheal wal l to prevent passage of pharyngeal contents
i nto t he trachea and ensure that no gas l eaks past t he cuf f duri ng posi t i ve-pressure
venti l ati on. The cuff also serves to cent er the tube i n the t rachea.
Cuff
The cuff is an i nf lat abl e sl eeve near t he pati ent end of the tube. The cuff materi al
shoul d be strong and tear-resistant as wel l as t hi n, sof t , and pl i abl e. Cuff materials
are subj ect to t he same t issue-testi ng requi rements as the tube i tsel f .

View Figure

Figure 19.20 Tip of ILM-ETT. Note how the high-pressure
cuff lies flat against the tube.

P. 575



View Figure

Figure 19.21 ILM-ETT with Stabilizer.

The ASTM/I SO standard (11) specif i es the maxi mum di st ance f rom t he t ip of the
t ube to t he pat i ent end of the cuf f . This vari es wi th t ube si ze. It also requi res t hat
t he bonded edge of the cuf f does not encroach on the Murphy eye, i f present ; that
t he cuf f does not herni at e over the t ube t i p under normal condi ti ons of use; and that
t he cuf f i nf l at es symmetrical l y.
Cuff Types
The cuff type depends on i ts const ructi on. The constructi on largel y determi nes i f
t he pressure needed to i nf late the cuf f i s high or l ow.
Low-volume, High-pressure Cuff
Description
The l ow-vol ume, hi gh-pressure (smal l resti ng di amet er, l ow resi dual vol ume, l ow
volume, smal l , standard, convent ional , low-compl iance, high-pressure) cuf f has a
smal l diameter at rest and a l ow residual vol ume (t he amount of ai r t hat can be
wi thdrawn f rom the cuf f af ter i t has been al l owed t o assume i ts shape wi t h the
i nf l at i on tube exposed to atmospheric pressure). It requi res a hi gh int racuf f
pressure to achi eve a seal wi th t he trachea. I t has a small area of contact wi th t he
t racheal wal l and di stends and def orms t he t rachea to a ci rcul ar shape (Fi g. 19. 25).

View Figure

Figure 19.22 Hi-Lo Evac tube. (Picture courtesy of Tyco
Healthcare.)

Most of t he pressure insi de this t ype of cuf f i s used to overcome cuf f wal l
compl i ance. The pressure exert ed lateral ly on the tracheal wal l wi l l be l ess t han t he
i ntracuff pressure. The i nt racuf f pressure does not change when the t racheal wal l i s
contacted and does not bear a consi stent rel ati onshi p t o tracheal wal l pressure.
Advantages
These cuf f s off er better protect ion agai nst aspi rati on and better visi bi l i t y during
i ntubat ion t han l ow-pressure cuff s. They may be associ ated wi t h a l ower i nci dence
of sore t hroat (114,155). Because they are usual l y reusabl e, t hey are less
expensive. They have been recommended for use i n adol escent pati ents (156).
Disadvantages
The pressure on the t racheal wal l exert ed by such a cuf f is di f f i cul t t o determi ne but
wi l l l i kel y be wel l above mucosal perf usion pressure (157). I nt racuf f pressure and
t he l ateral pressure on the t racheal wal l i ncrease sharpl y as i ncrements of ai r are
added to the cuf f . If the l argest t racheal tube possi bl e i s used, t he cuf f wi l l be
mi nimal l y inf l ated when a seal i s created.
The most seri ous ri sk associated wi th hi gh-pressure cuf fs i s i schemi c damage to
t he tracheal wal l mucosa f ol l owi ng prol onged use. Whether t hey shoul d be used f or
short peri ods of general anesthesi a is more cont roversi al . If a t ube wi t h a hi gh-
pressure cuff i s used i nt raoperat i vel y and the tube must be l ef t in pl ace f ol lowi ng
surgery or t he surgery is expected to last more than a f ew hours, i t shoul d be
repl aced wi t h a t ube wi th a l ow-pressure cuf f .
P. 576



View Figure

Figure 19.23 Typical tracheal tube markings. The dark
marking at the patient end of the bottom tube and the mark
above the cuff on the top tube are to aid in proper placement
with respect to the vocal cords.The internal and external
diameters as well as the size in French scale are shown. For
example, on the top tube, the ID is 5.0, the external
diameter is 6.7, and the French scale size is 20). Z-79 and
IT both indicate that the tube material has passed the tissue
toxicity test. Length from the patient tip is marked in
centimeters. (Picture courtesy of Rusch, Inc.)


View Figure

Figure 19.24 The tracheal tube size is marked on the pilot
balloon.

High-volume, Low-pressure Cuff
Description
A hi gh-vol ume, l ow-pressure (l arge resti ng diameter; l arge residual volume; l arge;
hi gh-vol ume; hi gh-compl i ance, low-pressure; f l oppy; l ow-pressure, HVLP) cuff has
a large rest i ng vol ume and di amet er. A thi n compl i ant wal l al l ows a seal wi th t he
t rachea to be achi eved wi t hout stretchi ng t he tracheal wal l . As t he cuf f i s i nf lated, i t
f i rst t ouches the trachea at the wi dest part of the cuff or the narrowest poi nt in the
t rachea under t he cuf f . As the cuff conti nues to i nf l ate, the area of cont act becomes
l arger and the cuf f adapts i tsel f to the t racheal surface (Fi g. 19.25). If cuf f i nf l at ion
i s cont i nued, the area i n contact wi t h the cuff wi l l be subj ect t o i ncreasi ng pressure,
and the t rachea wi l l be distort ed.
Di ff erent shapes have been used f or t he l ow-pressure cuf f (158). A cuff wi t h a short
t racheal contact area may have f ewer f ol ds and wri nkl es when i nf lat ed and may be
associ ated wi th a lower i nci dence of postoperat ive sore t hroat . When hi gh ai rway
pressures must be used, a short cuf f requi res higher i nt racuff pressures than a cuf f
wi th a l arger vol ume. The larger vol ume provi des a greater reservoi r of gas wi thin
t he cuf f , al l owi ng addi ti onal gas to be mi l ked i nto the proxi mal end of the cuf f
wi thout i ncreasing t he rest ing cuff pressure (158).
The i nt racuf f pressure vari es during the venti l atory cycl e. Duri ng spontaneous
breat hi ng, ai rway (and cuf f ) pressure wi l l be negative duri ng i nspi rati on and
posi t i ve during exhalat i on. Wi th control led venti lat i on, when ai rway pressure
exceeds i nt racuf f pressure, posi t ive pressure wi l l be appl ied to the l ower f ace of
t he cuf f . I f the cuf f wal l i s pl i able, i t wi l l be unabl e to resi st thi s pressure and wi l l
be def ormed i nto a cone shape as the di stal
P. 577

port ion i s compressed and the proxi mal porti on i s di stended (158). The ai r in t he
cuff wi l l be compressed unti l i ntracuff pressure equals ai rway pressure. Duri ng
exhal ati on, the i nt racuf f pressure wi l l decrease unt i l i ts resti ng pressure i s reached.
A leak wi l l devel op i f the diameter of t he expanded t rachea becomes great er t han
t he di ameter of t he proxi mal end of the cuf f . At that poi nt , more gas must be added
t o t he cuff to abol i sh the l eak. Unf ortunat ely, this addi ti onal cuf f i nfl ati on wi l l
el evate the basel i ne cuff pressure.

View Figure

Figure 19.25 Relation of different types of cuffs to the
trachea. A: Side view. At the left, the high-volume, low-
pressure cuff has a large area of contact with the trachea.
The cuff adapts itself to the irregular tracheal wall. At the
right, the low-volume, high-pressure cuff has a small area
of contact with the trachea. It distends the trachea and
distorts it to a circular shape. B: Cross-sectional view. At
the left is the normal trachea. At the top, the low-volume,
high-pressure cuff distorts the trachea and makes the
tracheal contour the same as the shape of the cuff. At the
bottom, the soft high-volume, low-pressure cuff conforms
to the normal tracheal lumen.

I nserti ng a gastri c t ube or esophageal st ethoscope may i ncrease i nt racuf f pressure
(159, 160).
I t i s desi rable t hat cuff ci rcumference at resi dual vol ume be at l east equal to t he
ci rcumf erence of the trachea (161,162). I f the cuf f is smal l er, i t must be stretched
beyond i ts resi dual vol ume to create a seal . At this point , i t wi l l act l ike a high-
pressure cuff (158). On the other hand, i f t he residual cuf f di ameter is much greater
t han the diameter of t he trachea, cuff inf ol di ng may occur, wi t h the possi bi l i t y of
aspi rat ion al ong the f ol ds.
Advantages
A si gni f i cant advant age of high-vol ume, l ow-pressure cuf fs i s that provi ded the cuff
wal l i s not stretched, the i nt racuf f pressure cl osely approxi mates the pressure on
t he tracheal wal l (162). Thus, i t i s possi bl e t o measure and regul ate the pressure
exert ed on t he tracheal mucosa. Wi th proper use, t he ri sk of signif i cant cuf f -
i nduced compl i cat i ons foll owi ng prol onged i nt ubati on i s reduced.
Disadvantages
Tubes wi th these cuff s may be more dif f i cul t t o i nsert, as the cuff may obscure t he
vi ew of the tube ti p and l arynx. The cuf f i s more l ikel y to be torn duri ng i ntubati on,
especi al l y i f f orceps are used. There may be a great er l ikel i hood that the t racheal
t ube wi th t his t ype of cuf f wi l l be disl odged (163).
The i nci dence of sore t hroat may be greater wi t h l ow-pressure than wi th hi gh-
pressure cuff s, unless the cuf f is speci al l y desi gned so that the t racheal contact
area is smal l (114,155).
A maj or drawback of this t ype of cuf f i s t hat i t may not ef fect ively prevent f luid f rom
l eaki ng i nt o the l ower ai rway even at cuf f pressures as hi gh as 60 cm H
2
O
(157, 164,165,166, 167, 168,169). Fl ui d l eakage i s increased wi th spont aneous
respi rati on and i s reduced wi t h cont i nuous posi ti ve ai rway pressure, posi t ive end-
expi ratory pressure (PEEP), and pressure-support ed venti l ati on (166). I nt ermi ttent
posi t i ve-pressure venti l ati on adds some prot ect ion. Lubri cat i on wi t h a water-sol ubl e
gel wi l l reduce fl ui d l eak for a l i mi ted peri od of ti me (166,170,171,172). It has been
shown that a si li cone cuf f wi thout f ol ds prevents the l eakage of f l ui d when used
wi th a const ant -pressure i nf l ati on system (168,169,173,174, 175).
I t i s rel ativel y easy to pass devices such as esophageal stet hoscopes, t emperature
probes, and enteri c tubes around l ow-pressure cuf fs (176,177,178,179,180).
Sucti on appl i ed t o t he gastri c t ube wi l l resul t i n negat i ve pressure i n t he l ungs.
P. 578



View Figure

Figure 19.26 Tube with deflated foam cuff.

A probl em wi t h l ow-pressure cuff s is the bel i ef that si mpl y usi ng t his t ype of cuf f
wi l l prevent hi gh pressures f rom bei ng exerted on t he tracheal wal l . Any cuff can be
overf i l l ed or t he vol ume and pressure can i ncrease duri ng use, resul ti ng i n hi gh
i ntracuff and tracheal wal l pressures. Indeed, tracheal i nj ury can occur even when
t hese cuff s are used properl y. When ni t rous oxi de is used, i t wi l l di ff use i nt o the
cuff . Thi s added vol ume wi l l i ncrease the pressure on the t racheal mucosa
(181, 182,183,184, 185, 186,187).
Foam Cuff
The f oam (sponge, Fome, Kamen-Wi l ki nson) cuff has a large di ameter, resi dual
volume, and surf ace area (182,188) (Fi gs. 19. 15, 19.26). I t i s f i ll ed wi th
pol yuret hane foam that i s covered wi t h a sheath. Appl yi ng sucti on to the infl at i on
t ube causes the f oam t o shri nk. When the negative pressure i s released, the cuff
expands.
The t ube i s suppl i ed wi th a T-pi ece to f i t bet ween the connect or and t he breat hi ng
system (Fi g. 19. 27). When the i nf l at ion tube i s connected t o thi s T-piece, t he
pressure i nsi de t he cuf f wi l l fol l ow proxi mal ai rway pressure during the venti l atory
cycl e (182,188). Bef ore extubat i on, the cuf f shoul d be col l apsed by aspi rat i ng and
t hen cl ampi ng the i nf l ati on t ube.
When i n pl ace i n the trachea, t he amount that t he f oam expands det ermi nes the
pressure exerted l aterall y on the t racheal wal l . The more the f oam expands, the
l ower t he pressure (188). Thus, t he pressure on the tracheal wal l depends on the
rel ati onshi p between cuf f di ameter at residual volume and the diameter of t he
t rachea. If t oo l arge a cuff i s used, t he cuf f :t racheal wal l pressure rati o wi l l be high.
I f too smal l a cuf f is used, t here wi l l not be a seal . The ri sk of f l ui d l eaki ng past the
cuff i s si mil ar t o that wi th most high-vol ume, l ow-pressure cuf fs (166).
Di ff usi on of anestheti c agents i nto t he cuff can occur but wi l l not cause an increase
i n pressure if the i nf l at i ng channel i s open to atmosphere (182, 189). I t i s not
necessary to moni tor cuf f pressure wi th t hi s devi ce. It can provi de a seal at a low
t racheal wal l pressure, provided the rel at ionshi p bet ween the cuf f and t racheal
di ameters is opti mal (112,188). A reduced incidence of tracheal dil atati on has been
reported wi t h i ts use (190).
One study f ound a hi gh i nci dence of sore t hroat associat ed wi th i ts use (114), whi l e
another f ound a low i ncidence compared wi t h ai r-f i l l ed cuf f s (191). In two reported
cases, the i nf lati on tube was accidental ly pul l ed out at the poi nt of i nsert i on on the
t ube, maki ng cuf f def l ati on i mpossible (192,193).
Lanz Cuff
The Lanz pressure-regul at ing val ve (McGi nnis bal l oon syst em) (194,195,196)
consi sts of a
P. 579

very compl i ant lat ex pi l ot bal l oon i nsi de a transparent pl asti c sheath wi t h an
automati c pressure-regul ati ng valve between the bal loon and the cuf f (Fi g. 19. 28).
The pi l ot ball oon has three f unct i ons: (a) an i ndicati on of cuf f i nfl ati on, (b) an
external reservoi r f or the cuff , and (c) a pressure l i mi t ing devi ce. I t i s desi gned to
mai ntai n an i nt racuf f pressure of 20 t o 25 t orr at end expi rati on whi l e preventi ng
overi nf lati on of the cuff .

View Figure

Figure 19.27 Tube with inflated foam cuff and a T-piece.


View Figure

Figure 19.28 Lanz pressure-regulating valve. The pilot
balloon is confined inside a transparent plastic sheath. There
is a pressure-regulating valve between the pilot balloon and
the cuff. Air should be injected into the cuff until the pilot
balloon is stretched, but it should be smaller than the
confining sheath.

The pressure-regulati ng val ve permi ts rapi d gas f l ow f rom the bal l oon to the cuf f
but onl y sl ow f l ow f rom t he cuff to the bal l oon. Thi s prevents gas f rom being
squeezed back i nto the bal l oon when the air way pressure rises rapi dl y, so there i s
no gas l eak around the cuf f duri ng posi ti ve-pressure vent i l at ion. I t al so prevents
i ncreases in cuff vol ume and pressure caused by dif fusi on of ni trous oxi de and
ot her gases i nt o the cuff .
As ai r i s i nj ected, the cuf f and bal l oon are inf l at ed in paral l el . When the bal l oon has
a st retched appearance, a pressure of approximatel y 26 t o 33 cm H
2
O wi l l be
present i n the cuff . As i nject ion cont inues, t he pi l ot bal l oon f il ls pref erent ial l y. The
i ntrabal l oon pressure remai ns const ant and wi l l not i ncrease unti l i t st ri kes the
confi ni ng sheath. Should t he trachea expand, ai r wi l l sl owl y f l ow f rom the bal l oon
i nto t he cuf f . The pressure-regul at ing val ve protects agai nst rapi d l oss of cuf f
volume i nto t he bal l oon duri ng i nspi rati on.
Thi s valve has been f ound by several i nvesti gat ors t o be eff ecti ve i n keepi ng l ateral
t racheal wal l pressure l ow and preventi ng increases i n cuf f pressure due to ni trous
oxide (189,194). I t el i minates the need to measure cuff pressure.
For pat ients requi ring hi gh ai rway pressures, this system may f ai l to f orm a seal
(197). The cuff may l eak, part i cularl y af ter prol onged use (198). I f the bal loon is
compressed or overi nf l ated, the i ntracuff pressure wi l l ri se.
Cuff Pressures
Intracuff Pressure
A hi gh cuf f pressure prevents aspi rati on, vent i l atory l eaks, and eccent ri c tube
posi t i oni ng i n the trachea but can cause damage to the trachea. A l ow cuff pressure
mi nimi zes t racheal damage and can act t o rel i eve excessive ai rway pressure but
may resul t i n aspi rati on, leaks, and eccent ri c tube posi t ioning.
I t i s desi rable t hat the cuff seal t he ai rway wi t hout exerti ng so much pressure on
t he trachea that i ts ci rcul ati on i s compromi sed or t he trachea is dil ated. Most
authors recommend t hat the pressure on the l at eral tracheal wal l measured at end
expi rat ion i s bet ween 25 and 34 cm H
2
O (18 t o 25 mm Hg) i n normotensive adul ts
(77,157,199,200,201,202). A pat i ent who requi res hi gh peak i nf l ati on pressures wi l l
need a higher cuff pressure to prevent l eaks (mini mum occl usive pressure),
i ncreasi ng the ri sk of ischemi c tracheal i nj ury (202).
For chi ldren, no f i rm recommendat ions f or cuf f pressure have been report ed, but i t
seems l ogical t hat l ower pressure should be used because of thei r l ower arteri al
pressures (203).
P. 580


Changes in Intracuff Pressure
The i nt racuf f pressure and vol ume of a cuf f i nf l ated wi th ai r ri se when ni t rous oxi de
i s admi nistered (181,182,183,184,185,186,187). The i ncrease varies di rect l y wi t h
t he parti al pressure of the ni t rous oxi de, the permeabi li ty of the cuff wal l , and ti me.
Heated humidi f icati on sl ows dif f usi on of ni trous oxi de into the cuf f (204). When
ni trous oxi de admi ni strat ion i s di scont inued, t he pressure i n the cuff decreases
rapi dl y (205).
There are a number of other reasons why cuf f pressure wi l l vary. Cuff pressures
are lower duri ng hypothermi c bypass (206,207). I ncreases i n cuff pressure may
resul t f rom pressure f rom nearby surgical procedures (208), i ncreases i n al ti tude
(209), di ff usion of oxygen into the cuf f (210), and changes in head posi t ion away
f rom the neut ral posi t ion (211). Cuf f pressure wi l l al so be af f ected by coughi ng,
st rai ni ng, and changes in t he muscl e tone. Foam-f i ll ed cuf f s do not exhi bi t these
f luctuati ons (191). Duri ng aeromedi cal transport, cuf f pressure ri ses when al ti tude
i ncreases (212). Cert ai n topical anesthetics can i ncrease the cuf f pressure wi t h
some t racheal tubes (213).
Means to Limit Cuff Pressure
Cuf f pressure can be measured cont inuousl y or at f requent i nterval s and
al tered by i nf lati ng or def l at ing the cuff as needed. This i s the onl y way t o
ensure adequate protect i on f rom the threats of aspi rati on and t racheal
i schemia (214). Measurement i s easy, and cuf f moni tors are i nexpensive.
Pressures higher or l ower than recommended are common when the cuf f
pressure i s not measured.
Four hours may be needed t o stabi l i ze cuf f pressure when usi ng ni trous
oxide (215,216). I f the tracheal tube i s to be l ef t i n pl ace and ni trous oxide
has been i n use, t he cuf f shoul d be evacuated and f i l l ed wi th ai r to avoi d a
l eak i n t he postoperat ive peri od (217).
Several methods have been used t o moni tor i nt racuf f pressures conti nuousl y
or i ntermi t tentl y
(197, 198,199,200, 201, 202,203, 204, 205,206, 207,208,209,210,211,212,213,21
4, 215,216,217, 218, 219). Devi ces f or t his purpose are avai l abl e commerci al l y
(Fi g. 19.29). Cuf f pressure can be measured by connecti ng the i nfl at ion t ube
t o t he pressure channel of a moni tor by using an ai r-f i l l ed pressure
t ransducer (220,221,222,223) or di rectl y to a manometer (224).
P. 581



View Figure

Figure 19.29 Device to measure intracuff pressure.
A: Frontal view. B: Side view showing valve used
to reduce the pressure. (Courtesy of Rusch, Inc.)

The cuff can be f il led wi t h a gas mixture contai ni ng oxygen and ni t rous oxi de
or ni t rous oxi de al one (183,225,226,227,228). This i s awkward t o perf orm. A
cuff i nf lated wi t h ni t rous oxi de wi l l l ose vol ume and may al l ow a l eak when
ni trous oxi de admi ni strat ion i s di scont inued or duri ng ext racorporeal
ci rcul ati on (205,217,229).
The cuff can be f il led wi t h water or sal i ne (184,209,229,230, 231, 232). Thi s
resul ts i n a more stable pressure. However, the i ni ti al adjustment of cuf f
pressure i s more di f f i cul t . Fl ui d-f i l l ed cuf f s cannot be def l ated rapi dl y.
The syri nge may be l ef t at tached t o the i nf lati on tubi ng. This has not been
f ound t o be eff ecti ve i n l i mi ti ng pressure increases i n the cuff (233,234,235).
Usi ng a cuf f desi gned to reduce di ff usi on of ni t rous oxi de, a cuf f wi th a hi gh
compl i ance, or a cuff wi t h a l arge t hin-wal l ed pi lot bal l oon has been
recommended (185,186,236,237,238,239,240, 241, 242).
Speci al i zed bal l oon systems such as the Lanz pressure-regulat i ng val ve (see
above) and various other devi ces f or control l i ng cuff pressure have been
devel oped (199,219,242,243,244,245,246,247,248).
Pressure may be assessed by manual pal pati on and pi nchi ng the pi l ot
bal l oon. These methods do not give consistentl y accurate assessments of
cuff pressure (249,250,251,252).
Usi ng a mini mal l eak vol ume, mi ni mal occl usive volume, or a predetermined
volume to inf l ate the cuf f has been f ound t o be unsati sf act ory (252).
Inflation System (Fig. 19.1)
Inflation Lumen
The i nf lati on lumen, which connects the i nf l at i on tube to the cuf f , i s l ocat ed wi thi n
t he wal l of t he tracheal tube. The ASTM/ I SO standard (11) requi res that i t does not
encroach on t he tracheal t ube l umen and recommends that i t does not bul ge
out ward.
External Inflation Tube
The external i nfl at ion t ube (cuf f t ube, pi l ot t ube or l i ne, pi l ot bal loon l i ne, i nf l ati ng
t ube, t ai l ) is external to the tube. The ASTM/I SO standard (11) requi res that i ts
external di ameter does not exceed 2. 5 mm and recommends t hat i t be att ached to
t he tube at a smal l angl e. The standard al so speci f ies t he di stance f rom t he ti p of
t he tube to where the i nf l ati on tube i s attached and requi res that there i s at l east 3
cm bet ween t he machine end of the i nfl at ion t ube and t he pi l ot bal l oon or i nf lati on
valve.
The i nf lati on tube can become obstructed by ki nki ng, crushi ng f rom a cl amp or
external fi xat i on devi ce, methyl ene-bl ue crystal s, or the t racheal tube connector
(96,253,254,255).
Pilot Balloon
The pi l ot ball oon (bul b, external reservoi r, external bal l oon) may be l ocated near
t he midpoi nt of t he i nf l at i ng tube or adj acent t o t he i nf l ati on val ve. Its f unct ion i s to
i ndi cate cuf f i nf l at i on.
Inflation Valve
The i nf lati on valve i s desi gned so that when t he t ip of a syri nge i s inserted, a
pl unger i s displ aced f rom i ts seat and gas can be i nj ect ed into t he cuf f . Upon
removi ng the syri nge, t he val ve seal s so that gas cannot escape f rom the cuff .
Some t ubes may l ack an i nf l ati on valve. If a val ve is not present, cuf f i nf l at ion i s
mai ntai ned by appl ying a cl amp t o t he external inf l at ion tube or by placi ng a plug i n
i ts f ree end.
Tracheal Tube Connector
The t racheal tube connector (uni on) serves t o attach t he tube to the breathing
system. It may be made of plasti c or met al . The di mensions of the connector are
set by an ASTM/ ISO standard (11).
The end that f i ts i nto the t ube i s cal l ed the pati ent end, and the si ze of the
connector is designat ed by t he ID of t hi s end in mi l l i meters. The end t hat connects
t o t he breathi ng system i s cal led t he machine end and has a 15-mm mal e f i tt ing.
The connector should be the same si ze as the tube wi th whi ch i t i s i ntended to be
used. This wi l l resul t in mi ni mal reducti on of t he lumen and make separat ion
unl i kel y.
The most commonl y used connectors are the st raight and 90 curved (ri ght angl e).
Acute angl e connectors wi th l ess than a 90 curve (Fi g. 19.30) and f lexi bl e
connectors are avai labl e. A curved or f l exi bl e connector may f aci l i tate posi ti oni ng
t he breathi ng system away f rom the surgical f ield but i ncreases resi stance and
must be removed f rom the tube when i t i s desi red to i nsert a styl et or sucti on
catheter.
The connector may have prot rusi ons, l ugs, or other feat ures t o whi ch el asti c bands
or other devices may be at tached t o prevent acci dental disconnecti on f rom t he
breat hi ng system. There is controversy as to t hei r desi rabi l i t y, as they may
i ncrease t he ri sk of accidental ext ubati on. Some connectors have a port f or
respi ratory gas sampl ing. Some have f l anges to ai d i n holding the connector.
Many disposabl e t racheal tubes come wi t h t he connector onl y partl y inserted. Thi s
i s done by the manuf acturer t o prevent the tube f rom di lati ng and the connector
f rom fal l i ng out . Bef ore use, the connector shoul d be f ull y i nserted. Removi ng i t
f rom the t ube and wi pi ng t he tube end wi th al cohol wi l l f aci li tate f ul l inserti on and
bond the connector wi t h the t ube. A towel cl i p may be used t o remove a connector
f rom the t racheal tube (256).
Occasi onal l y, when the connector is f i rml y seated, t he pi l ot t ube may be occl uded,
bl ocking t he i nf lat i on tube (253). Thi s onl y occurs when t he pi lot tube enters the
t racheal tube at the end where the connector is i nsert ed.
P. 582



View Figure

Figure 19.30 Method of securing a nasotracheal tube. A: A
skull cap is placed around the head. An acute-angle
connector is used and taped so that it does not exert pressure
on the nasal ala. B: Foam padding is used to keep the
breathing system from exerting pull on the tracheal tube. C:
Tape is added to keep the breathing system firmly in place.

Laser-resistant Tracheal Tube Wraps
The only product approved by the Food and Drug Admi ni st rati on (FDA) for l aser
protect ion i s a two-l ayered sheet of syntheti c surgi cal sponge and adhesi ve-backed
corrugated si l ver f oi l (Merocel Laser-Guard), whi ch i s avai l abl e in several si zes. I t
can be used on rubber or PVC tubes but shoul d not be used on a si l i cone tube.
Bef ore use, t he t ube wi th wrap is saturated wi th sali ne. When wet, the sponge and
ref l ecti ve foil act as a heat si nk and disperse argon, CO
2
, Nd-YAG, and KTP l aser
beams (102,104,247,248,249, 250, 251,252, 253,254,255,256, 257, 258,259). The
wrapped t ube shoul d not be used wi th Nd-YAG contact f i ber ti ps, whi ch may
puncture and damage the wrap. Bl ood on the coati ng does not reduce i ts protecti ve
ef fect (103). I t i s i mportant that the wrappi ng procedure recommended by t he
manuf acturer i s f ol l owed caref ul l y and that t he sponge materi al is kept moi st duri ng
use. The cuff and the area below t he cuf f are not prot ected by t he wrap. The cuff
shoul d be inf l ated wi t h water or sali ne and methylene blue and protected by
moi st ened cotton pat t ies suppl i ed wi t h the t ube. Breaks i n the si l ver foi l wrap when
t he tube was mani pul ated have been reported (260).
Ot her products i ncl uding alumi num f oi l and t ape and copper tape have been used t o
wrap tracheal t ubes. These products are not approved f or protect ing t racheal t ubes
f rom lasers. These wraps have a number of di sadvantages. They reduce t ube
f lexibil i ty, can predi spose to ki nking, and may create a rough surface
(102, 261,262). The OD of the t ube i s increased. Ref l ect ion of the l aser beam f rom
metal l i c tape may cause damage t o non-t argeted t i ssues (104). The wrappi ng
materi al may come of f and obst ruct the ai rway (263). Errors in wrappi ng or sharp
bends could expose t he t ube to the l aser beam (102,264, 265).
Tube wrappi ng, f i res, and l asers are di scussed in more detai l i n Chapter 32.
Use of the Tracheal Tube
Tube Choice
Cuffed versus Uncuffed
Cuf fed tubes are rout inel y used i n adul ts (266,267,268,269,270,271). Tradi ti onal l y,
uncuf fed t racheal tubes were routi nel y used i n
P. 583

young chi l dren, wi th t he practice of adding a cuff begi nni ng at 6 t o 10 years of age
(156). I n recent years, cuf f ed tracheal t ubes have been used more of ten i n smal l
chil dren.
Advantages of cuf fed tubes incl ude i mproved accuracy of moni t oring end-ti dal
gases, t i dal vol ume, compl iance, and oxygen consumpti on; decreased ri sk of
aspi rat ion; abil i t y to use hi gh i nf l ati on pressures and l ow f resh gas f l ows; l ess
operati ng room (OR) pol l uti on; decreased ri sk of f i re; and f ewer t ube changes
(269, 272,273,274, 275, 276). There i s a theoreti cal ri sk t hat i nf ecti ous dropl ets wi l l
be di spersed when venti l ati ng wi th an uncuf f ed tube (271).
Drawbacks of usi ng a cuff ed t ube i n chi ldren i ncl ude the need to choose a sl ightl y
smal l er t ube (whi ch makes suct ioning more di ff i cul t and tube obstruct i on more l i kel y
and i ncreases resi stance and work of breathing); t he risk that overinf l at ion of the
cuff wi l l resul t i n excessive pressure agai nst t he mucosa; t he ri sk of inj ury to t he
vocal cords; and a reduced margi n of saf et y (t he need to avoi d the cuf f impi nging
on the gl ott i s, yet avoidi ng bronchi al i ntubati on) (272, 277,278,279, 280). Rel ati vel y
smal l amounts of i nf lated ai r l ead t o rapi d increases i n cuf f pressure and vol ume
(280). The l arger external di amet er of the cuf f ed tube may lead to probl ems wi th
extubati on (281). I f a cuf fed t ube i s inserted t hrough a pediatri c supragl ott i c devi ce
such as an LMA, i t may be i mpossi bl e to remove the supragl ot ti c devi ce af ter
i ntubat ion (282).
St udi es i ndi cate that usi ng cuff ed tubes i n chi ldren i s not associ ated wi t h i ncreased
compl i cati ons (273,283,284,285,286,287,288). A cuf fed t ube may be used t o
occl ude a tracheo-esophageal f istul a (288, 289,290).
St udi es i ndi cate that an ul trathi n high-volume, l ow-pressure pol yurethane cuff
resul ts i n l ower seal ing pressures than conventi onal cuf fs (203,291,292).
Size
Smal l er-di amet er t ubes are easier to i nsert and requi re l ess reshapi ng f orce to
adapt t o the pati ent ' s ai rway but are associated wi th hi gher resi stance, di f f icul ty
passi ng a f i berscope or suct ion catheter, and increased risk of occlusi on and
ki nki ng (293). Larger tubes are associ ated wi t h l ess ri sk of occl usi on and l ower
resi st ance but are l i nked wi t h a hi gher i nci dence of postoperati ve sore t hroat and
are more di f f i cul t t o i nsert .
Because no syst em of choosi ng t he correct si ze tube i s f ool proof , t he user should
al ways have readi l y avai labl e t ubes that are l arger and smal ler than the t ube
chosen. A smal ler tube shoul d be used when a di ff icul t i ntubati on i s ant icipated.
Cuffed Tubes
Wi th cuf f ed tubes, t he cuf f ci rcumf erence shoul d equal that of t he t racheal lumen. I f
t he tube is t oo smal l , a high cuff pressure wi l l be needed to achi eve a seal ,
i ncreasi ng pressure on the mucosa. If the cuf f i s too l arge in rel ati on t o the t racheal
l umen, i t wi l l have f ol ds when i nf lated t o occlusi on. Aspi rat ion may occur along
t hose f ol ds.
TABLE 19.1 Recommended Tube Sizes for Children
Age Normal Size
14 y 7.58
1213 y 77.5
1011 y 6.57
810 y 66.5
67 y 5.56
45 y 55.5
1.54 y 4.55
918 mo 44.5
Full term to 9 mo 3.54
Premature 2.53

One study f ound t hat the i deal tube i n the average adul t i s a 7.5-mm-I D t ube f or
f emal es and an 8.5-mm-I D tube f or mal es (294). However, there i s great vari ati on
i n sizes and shapes of tracheas i n adul ts. The t ransverse di mensions increase wi th
age, but in general , the correl ati on between age, race, hei ght , wei ght, body surf ace
area, and tracheal shape or si ze is poor. There i s consi derabl e variati on i n t he cuf f
ci rcumf erence of t racheal tubes wi th i dent i cal I Ds.
Age i s recogni zed as the most rel i abl e i ndi cat or of the appropri ate tracheal tube
si ze f or chil dren (Table 19.1).
For cuf fed tubes i n chi l dren, t he foll owi ng formul a may be used: ID i n mm = age/4 +
3 (273). Al t ernatel y, a t ube 0.5 t o 1 mm smal l er t han that calcul ated f or an uncuff ed
t ube may be used. However, t here are consi derabl e di f f erences i n outer t ube
di ameters for a gi ven ID cuf fed t ube f rom di f f erent manuf act urers (278).
A chi l d wi t h Down syndrome has a smal ler t rachea, so a tracheal tube at least t wo
si zes smal l er t han usual shoul d be used (295). Premature babies have relati vel y
el ast i c l aryngeal structures that may al l ow a l arge tube to be i nsert ed (296). Thi s
may resul t i n inj ury to t he posteri or part of the gl ot ti s.
Uncuffed Tubes
Wi th uncuff ed tubes, the si ze should be l arge enough to provi de ef fecti ve
venti l ati on but not so large as to cause pressure on the mucosa. Thi s is commonl y
achieved by al l owi ng a leak bet ween the tube and the wal l of the trachea at hi gh
peak ai rway pressures (20 to 25 cm H
2
O) (143,297,298,299, 300). Many factors
i nf l uence the l eak pressure, and these shoul d be borne i n mi nd when perf ormi ng
t he l eak test (268). Measuri ng t he leak when t he chi ld's head is turned to one si de
or when he is not paral yzed i ncreases the pressure requi red to cause the
P. 584

l eak. The i mport ance of t he presence of a leak has been chal l enged (301).
The f ol lowi ng have been used as general guidel i nes f or sel ect ing the proper si ze
t ube i n chi ldren. There is consi derabl e variati on i n subgl ot ti c si ze i n chi ldren and i n
t he external di ameters of pediatric t racheal tubes (143, 302,303).
For chi ldren below 6 years: age i n years/3 + 3.75
For chi ldren ol der than 6 years: age i n years/4 + 4.5 (277, 304),
I D = age i n years/ 4 + 4 or 3.5 (153,273)
I D = 3 mm f or t hose 3 months of age and younger
= 3.5 mm f or those f rom 3 to 9 months of age
= (age in years + 16)/ 4 over 9 months of age (298,305)
(age i n years + 16)/ 4 (306)
Use of a measure based on body l ength (305, 307,308,309).
Choosi ng a tube whose external di ameter i s t he same wi dt h as the distal
phalanx of t he l i t tl e or i ndex f inger. Studi es i ndi cate t hi s may be l ess
accurate t han other methods (298, 304) but may be usef ul when t he chi l d' s
age i s unknown.
I D = 2.44 + (age 0. 1) + (hei ght i n cm 0.02) + (wei ght i n kg 0.016) (310).
Checking the Tube
Bef ore i nsert i on, the tube shoul d be exami ned f or def ects such as spl i tti ng, holes,
and mi ssi ng sect ions (311,312,313,314). The tube should al so be checked for
obstruct i ons. Wi t h t ransparent tubes, si mple observat i on wi l l suff ice (315). Wi th
ot her t ubes, the user should l ook i nt o bot h ends and/or i nsert a styl et.
The cuff , i f present, shoul d be i nf l at ed and the syri nge removed to check f or l eaks
i n the i nf lat i on val ve. If the syri nge remai ns i n t he val ve, the valve housi ng may
crack and leak (316). The cuf f shoul d be inspected t o make cert ai n that i t i nf l ates
evenl y and does not cause t he tube lumen t o be reduced. I t should be l ef t i nf l at ed
f or at l east 1 mi nute t o check for a slow l eak.
I f the t ube has a sponge cuf f , al l the ai r shoul d be aspi rated. The i nf lati on tube
shoul d then be closed or cl amped. The cuf f shoul d remai n col l apsed. If i t f i ll s, t here
i s a l eak, and t he tube should be discarded.
Preparing the Tube
Af ter the steri l e wrappi ng i s opened, t he tube should be handl ed onl y at the
connector end. The connector shoul d be inserted as f ar as possibl e. Removi ng the
connector f rom t he tube and wi pi ng the tube end wi t h al cohol wi l l make i t easi er t o
i nsert t he connector i nt o the tube and wi l l al l ow i t t o bond t o the t ube. Using steri le
l ubricant j el l y on a l ow-pressure, hi gh-vol ume cuff may decrease aspi rati on by
f il l i ng i n the f ol ds (166,170). For oral intubat i on, onl y the cuf f shoul d be l ubri cated.
I f nasal i ntubat ion i s pl anned, l ubricant shoul d be pl aced along the enti re l ength of
t he tube.
I f a f i beropt ic i ntubat i on or nasal i ntubati on usi ng a standard tube i s i ntended, t he
t ube shoul d be warmed to increase f l exibi l i t y (317).
Inserting the Tube
Techniques
Oral Intubation
Direct Laryngoscopy
Oral i ntubati on i s general l y preferred for general anesthesi a and in emergenci es
because i t can be perf ormed more qui ckl y and easil y t han nasal i ntubat ion. I t
al l ows use of a wi der and short er t ube than can be used for nasal i ntubat ion.
Di sadvantages i ncl ude the possi bi l i t y of oropharyngeal compl i cat i ons. Oral
i ntubat ion i s usual l y not wel l tolerat ed by t he consci ous pati ent . The pati ent wi t h an
oral tube has di f fi cul t y swal l owi ng. Si gni f icant cervical spi ne moti on may be
associ ated wi th di rect l aryngoscopy (318,319).
Obstruct ion f rom bi ti ng can occur wi th oral i nt ubat i on. A bi te bl ock, rol led gauze, or
oral ai rway should be placed bet ween t he teeth to prevent the pati ent f rom bi ti ng
t he tube and occl uding the l umen.
I nserti ng t he tube is usual l y easy once the vocal cords are exposed. The tube
shoul d be int roduced into the ri ght corner of t he mouth and di rected toward t he
gl ot ti s wi th the bevel paral lel to t he vocal cords. If there i s cord movement , t he tube
shoul d be inserted duri ng maxi mum abducti on. Gri ppi ng the tube as shown i n
Fi gure 19. 31 may faci l i tate anteri or movement of the pati ent end of the tube duri ng
i nsert i on (320).
Blind Oral Intubation
A bl ind oral t echni que i s performed wi th t he head f lat, t hen t il t ed back i n maxi mum
extensi on (321,322). A stylet wi t h a bend i s i nserted i nt o the t racheal tube. The
i ntubator appl i es pressure t o the cri coi d cart i l age wi th one hand whi l e the t racheal
t ube i s i nt roduced i nto the mouth wi th t he ot her, fol l owi ng the curve of t he tube.
The t ube i s advanced unti l the i ntubat or f eel s the t ip or f eels the tube advance i nto
t he trachea. I t may be necessary t o mani pul at e the l arynx to the ri ght or l ef t to
advance t he tube i nto t he trachea. The Endot rol tube may be useful in bl i nd oral
i ntubat ions (82,83). If the pat i ent i s breathing spont aneousl y, bl ind i ntubati on may
be perf ormed by usi ng capnography to obt ai n the opti mal CO
2
wavef orm (323,324)
or a whi stl e-t ype devi ce such as the Beck Ai rway Ai rf l ow Moni tor (BAAM) may
assi st pl acement (83). The t racheal tube wi t h di sposabl e whi stl e at tached i s passed
bl i ndl y i nto the oropharynx and advanced sl owl y. When the whi st l e sounds loudest ,
t he tracheal t ube i s advanced. As wi th any bl i nd techni que, bl eedi ng may occur.
Thi s wi l l make
P. 585

f iberopti c techni ques more di f f i cul t i f the bli nd i ntubati on is not successful .

View Figure

Figure 19.31 A: The tracheal tube is gripped as shown in
the picture with the thumb on the shaft near the connector
and two fingers around the tube. B: Pushing forward with
the thumb will cause the tip to move forward.

Digital Technique
I n a di gi tal (tacti l e) techni que, one hand is placed i n the pat i ent 's mouth, and the
f ingers are sl i d post eri orl y al ong t he tongue. The other hand i nt roduces the t racheal
t ube i nto t he mout h, and the i nt raoral hand i s used t o gui de the t racheal tube ti p.
Several vari ati ons of this technique have been descri bed
(325, 326,327,328, 329, 330,331).
Nasal Intubation
The nasal route i s commonl y used f or surgical procedures invol vi ng the oral cavi t y,
oropharynx, and face where an oral tube woul d hi nder t he surgeon' s access to t he
operati ve fi el d (332, 333). Ot her i ndi cat i ons may i ncl ude a f ractured mandibl e,
l i mi tati on of movement at t he temporomandi bul ar j oi nts, a pat i ent wi t h a neck injury
or cervical spine disease, intra-oral pathol ogy i ncl uding mechani cal obstructi on,
and pati ents who wi l l not t ol erate di rect l aryngoscopy.
I ntubat ion by the nasal rout e has many advantages. Securi ng the tube i s easi er.
The nasal route el imi nates the possi bil i ty of the tube bei ng occl uded by bi t ing.
Nasal i ntubati on may cause less cervi cal spi ne movement than oral i ntubat ion
(318, 334,335). Disadvantages i ncl ude t he fact t hat a small er t ube must be used,
resul ti ng i n increased resi stance and di ff icul ty i n suct i oni ng or endoscopy.
I ntubat ion usual l y takes l onger. Severe bl eedi ng may occur (336). Nasal i ntubat ion
has been shown to resul t i n a high i nci dence of bact eremia, si nusi tis, and ot i ti s
(337, 338,339,340, 341, 342,343).
Contrai ndi cat ions to nasot racheal intubat ion i ncl ude coagul opat hy and any
mechani cal impedi ment of t he nasot racheal route, i ncl udi ng pol yps, abscesses,
f oreign bodi es, and possi bl y epi gl ot t i tis (344). A f racture at the base of the skul l i s
usual l y consi dered a contrai ndi cat i on to nasot racheal i ntubati on (345), al though i t
has been safel y used i n this si t uat ion (346,347,348,349). Fi beropti c-gui ded
i ntubat ion should be used (350). Pneumocephal us has been report ed af ter nasal
i ntubat ion i n a pat i ent who had had a repai r of the cri bi form pl ate (351). Trans-
sphenoidal surgery can l eave a bony def ect i n t he skull t hat is suscepti bl e to
perf orati on by a nasal tube (352).
A tracheal tube one si ze smal l er than woul d be considered opti mal f or oral
i ntubat ion i s pref erabl e to mi ni mi ze trauma. It shoul d be thoroughl y l ubricated along
i ts enti re l ength wi th a steri l e, wat er-solubl e l ubri cant . The cuf f shoul d be f ul l y
defl ated.
I f possi ble, a f i berscope should be passed through the nostri l s t o determi ne the
presence of abnormal i t ies (349,353, 354). Cl i nical t ests such as esti mat i ng the rate
of ai rf l ow by pal pati on when the contral ateral nost ril i s occluded or aski ng f or the
pati ent 's assessment of ai rf l ow through t he nostril s does not correl at e wi t h nasal
abnormal i ti es (355). I nsert i ng progressi vel y l arger l ubri cat ed nasal ai rways wi l l test
t he pat ency of the nost ri l and dil at e i t . Other met hods t o decrease trauma i ncl ude
applying a vasoconst rictor; usi ng a Magi l l -ti pped tube; usi ng a si l icone tube wi th a
hemi spherical bevel ; thermosof teni ng t he tube; passing t he t ube through a nasal
ai rway; using an i nt ralumi nal bal l oon or esophageal st ethoscope; sli ppi ng t he end
of a catheter or gl ove f i nger over t he ti p of the tracheal tube; and i nsert i ng t he tube
over a bougi e, st yl et, or catheter
(25,32,356,357,358,359,360,361,362,363,364,365,366,367,368, 369, 370,371, 372).
Usi ng a bougi e or st ylet wi th an ant erior curve wi l l facil i tate intubati on. Nasal
t reatment wi t h mupi roci n i s ef fective i n preventi ng bacteria f rom being carri ed int o
t he trachea (373).
When t he tube is i nsert ed, t he bevel openi ng shoul d f ace l aterall y (374,375). I t
shoul d be advanced al ong to the f l oor of the nose whi l e sl i ghtl y l i f ti ng the t ip of the
nose (375,376). The t ube shoul d be pul led cephalad as i t i s passed posteri orl y unt i l
i t contacts the posteri or pharyngeal wal l . From this point , t he natural curve of the
t ube and the ant erior body of the cervical spine wi l l usuall y di rect i t anteriorl y. Onl y
gentl e pressure shoul d be used. If excessi ve resi stance i s encount ered, the ot her
nostri l or a smal l er t ube shoul d be t ri ed (376).
Someti mes, the t ube wi l l i mpact the posteri or pharyngeal wal l and resi st at tempts t o
advance i t f arther. The tube shoul d be pul l ed back a short di stance and the
pati ent 's head extended to f aci l i tat e passage beyond this point. I t may be usef ul to
wi thdraw t he tube and pl ace a st yl et wi t h an acute bend i n the di stal 1.5 cm i nto the
P. 586

t ube. The tube is t hen i nsert ed unt i l i t passes t he posteri or nasopharynx, t hen t he
st yl et i s wi t hdrawn. Another t echni que i s to pass a sucti on cat heter t hrough the
t ube and i nto t he oropharynx. The ti p of the cat heter can be brought out through t he
mouth. A f orward pul l on t he catheter wi l l usual l y bri ng the ti p of the t racheal t ube
f orward. Anti cl ockwi se rotat i on may assi st passage at t hi s poi nt (332,377). If t he
t ube deviates l aterall y, i t shoul d be wi t hdrawn t o the upper part of the oropharynx
and redi rect ed af ter a rotati on of 30 or more (333). Ti l ti ng (not rot ati ng) the
pati ent 's head toward t he si de of t he i ntubati on may also be hel pf ul (378).
Direct Laryngoscopy
Af ter the tube i s i n the pharynx, t he larynx i s exposed by usi ng a ri gi d
l aryngoscope. If the tube i mpi nges on the ant erior commi ssure, i t shoul d be twi sted
whi l e appl yi ng gentl e downward pressure (379). The posi ti on of the l arynx relat ive
t o t he t ube ti p may be al tered by f l exi ng or extendi ng the neck and/or external
pressure on the l arynx. If t hese manipulati ons do not al i gn the tube and l aryngeal
openi ng, f orceps can be used to grasp the t i p and di rect i t through the vocal cords.
The cuff should not be grasped, as i t may be damaged by the forceps.
An al ternati ve to grabbing the t ube wi th a f orceps i s t o add 10 to 15 mL of ai r to t he
t racheal tube cuf f (380). Thi s may cause the t ip t o al i gn i tsel f wi t h the vocal cords.
The t ube t i p i s then pushed i nto the trachea unti l t he cuff contacts the vocal cords,
at whi ch poi nt the cuf f i s defl at ed and t he tube is i nsert ed i nto t he trachea.
I f the t i p passes through the vocal cords but t hen encounters resi stance, i t i s l ikel y
t hat the curve of the tube i s di rect i ng the t i p i nto the anteri or wal l of the l arynx.
Wi thdrawi ng t he tube sli ghtl y and f l exing the neck wi l l usual l y al l ow the tube to
advance i nt o the t rachea. Other t echniques i ncl ude rotati ng the tube 180, passi ng
a sucti on catheter or bougi e through the tube into the l arynx as a guide, and
i nsert i ng a st yl et wi t h an anteri or bend near the t ip.
Flexible Fiberoptic Laryngoscopy
Thi s met hod i s of t en pref erred. Bl i nd nasal i nt ubat i on may st i r up bl eedi ng and ruin
t he chance to view t he larynx through a f i berscope. The technique is described in
Chapter 18. A wi re- rei nforced, Parker Fl ex-Ti p, or warmed standard tracheal t ube
may f aci l i tate i ntubati on wi t h a f i berscope (13,19,52,53,54, 55,317). Passage
beyond t he epi gl ot ti s may be faci l i tated i f t he tube is rotated so t hat the bevel i s
f aci ng up (23).
Blind Nasal Intubation
The bl i nd techni que may be usef ul when di rect laryngoscopy or fi beropt ic i ntubati on
woul d be di f f i cul t. There are i nstances where bl ind nasal int ubati on may prove l i fe
savi ng, and t he t echnique is wel l wort h l earni ng (381,382,383).
Bl i nd nasal i ntubati on may be perf ormed under general or l ocal anesthesi a. A
t racheal tube wi t h di rect i onal ti p cont rol may i mprove the success rate (84, 86). The
cl assical techni que of bl i nd nasal i ntubati on requi res a spontaneousl y breathi ng
pati ent and uses breath sounds t o gui de pl acement. The pat i ent i s pl aced i n the
cl assical i ntubat i ng posi t i on wi t h t he neck f l exed and the head extended. Af ter t he
t ube i s i nsert ed through the nost ri l , i t is advanced bl indl y. If the pati ent i s breat hi ng
spontaneousl y, breat h sounds can be heard as the t i p approaches the l arynx. When
t he sounds are at maxi mal i ntensi t y, t he tube is gentl y but swi f t l y advanced duri ng
i nspi rati on. If t he sounds suddenl y cease but the pati ent conti nues t o breat he, t he
t ube has passed i nt o a locat i on ot her than t he t rachea.
Vari ous modi f i cati ons of thi s t echnique have been descri bed
(384, 385,386,387, 388, 389,390, 391, 392). The BAAM and other whi st l e devi ces have
been used to faci l i tat e det ecti ng ai rf l ow duri ng i ntubati on
(330, 393,394,395, 396, 397). These devi ces are att ached to t he machine end of the
t racheal tube and make a sound as ai r passes t hrough the tube.
The presence of end-ti dal CO
2
can al so be used as a gui de t o bli nd i ntubat ion
(398, 399,400,401). If CO
2
ceases to be detected, the tube has entered the
esophagus.
I f the pati ent is not breathi ng, cert ai n l andmarks on the f ront of the neck (hyoi d
bone, notch of the t hyroi d carti l age, and the cri coi d carti l age) can be observed. As
t he tube moves anteri orl y, t he t ip moves these l andmarks. The obj ect is t o move
t he ti p to t he mi dl i ne at t he thyroid angl e, where i t should enter t he l arynx. If t he ti p
i s above the t hyroi d cart i lage, f lexi ng the head wi l l move the t ip caudal l y. I f the ti p
i s bel ow the t hyroi d carti lage, neck extensi on wi l l move i t cephal ad. If the t i p i s
observed l ateral l y, t he tube should be wi thdrawn and twi sted to di rect i t toward the
mi dl i ne. If the tube ti p passes t he laryngeal i nlet but i mpi nges on t he anteri or
t rachea, increasi ng cervi cal f l exi on or rot ati ng the tube through 180 may all ow i t t o
pass into the trachea.
Ot her maneuvers may be empl oyed to ai d bl i nd nasal intubati on. Fl exi on or
extensi on of t he head or mani pul ati ng the larynx by external pressure may l i ne up
t he tube and larynx (402). Rotati ng t he tube may be hel pf ul (332,403). A st yl et can
be i nsert ed into the tube t o hel p to advance the t ip through t he vocal cords. The
cuff may be part i al l y i nf l at ed i n t he oropharynx to el evate t he ti p f rom the posteri or
pharyngeal wal l and center i t (380,402,404,405,406,407,408). The cuf f i s def l ated
before the tube i s advanced i nto the t rachea. A sucti on cat heter or nasogast ri c tube
t hat i s inserted through the tube may faci l i tate passage through t he l arynx
(409, 410,411). A bougi e can be used (412). Bl i nd nasot racheal intubati on f aci l i tat ed
by conti nuous f l uoroscopy has been descri bed (413).
Depth of I nserti on
I n adul ts, the tube shoul d be i nserted unt i l the cuff i s 2.25 to 2.50 cm bel ow the
vocal cords (147,414). Thi s should be regarded as a starti ng posi ti on, as there i s
great vari at i on i n the length of the t rachea. Some manufacturers
P. 587

pl ace a mark above the proxi mal end of t he cuf f and recommend that the tube is
advanced unt i l thi s mark l i es at the vocal cords. If no cuf f i s present , t he tube ti p
shoul d be inserted not more t han 1 cm past the cords i n chil dren under 6 months,
not more t han 2 cm past the cords f or pati ents up to 1 year, and not more t han 3 to
4 cm past the cords i n l arger pat i ents.
I n average-si ze adul t pat ients, securi ng t he tube at t he anteri or i ncisors at 23 cm i n
mal es and 21 cm i n femal es has been shown to be a reasonabl e starti ng poi nt f or
t ube pl acement (415,416). For nasal i ntubati ons, 5 cm shoul d be added to these
l engths f or posi t i oni ng at t he nares (417). However, caut i on should be exerci sed i n
using routi ne depth of i nsert i on, as t racheas vary i n l engt h (418,419,420,421).
Formul as based on the subj ect ' s hei ght or other measurements may be used
(422, 423,424), or the correct length can be est i mated by ali gni ng t he proxi mal end
of t he cuff external l y at t he level of the cri coid cart i l age and angl i ng the tube
anteriorl y toward t he level of the upper incisors or gums (425).
Checking Tube Position
Af ter the tube has been i nsert ed, i ts posi ti on shoul d be checked t o be certai n that i t
i s i n the tracheobronchi al tree and that i t i s nei t her t oo deep nor too shal l ow.
Met hods to detect bronchi al or esophageal i nt ubat i on are di scussed in t he
Peri operat ive Compl i cati ons secti on l ater i n thi s chapter. Af t er correct pl acement i s
confi rmed, the porti on of the t ube external to the pat ient may be short ened to
prevent ki nki ng (426).
Inflating the Cuff
Low-volume, Hi gh-pressure Cuff
A hi gh-pressure cuf f shoul d be inf l at ed wi t h the mi ni mal amount of gas that wi l l
cause i t to seal against the trachea at peak i nspi ratory pressure. Listening wi t h the
unaided ear wi l l of ten mi ss smal l l eaks. These can be detect ed by pal pat i on or
auscul t ati on of t he pret racheal area. I nf l at i on unt il the pi l ot ball oon i s tense and/or
i nf l at i ng beyond seal wi l l resul t i n unnecessari l y hi gh cuf f volume and pressure.
Low-pressure, High-vol ume Cuff
Wi th a l ow-pressure, hi gh-vol ume cuf f , the cuf f should be i nf lated to a pressure of
25 to 34 cm H
2
O (18 t o 25 mm Hg) at end-expi rati on i n adul ts
(77,157,197,200,201,202). No data exist in chil dren about cuf f pressure l i mi ts, but
l ower cuff pressures are preferabl e. The pressure shoul d be measured (Fig. 19.29)
and adjust ed approxi matel y 10 minutes af ter t he tube has been inserted. Thi s del ay
i s necessary to al l ow f or sof teni ng of the cuf f materi al at body temperat ure and for
t he pat ient to become sett led, because the volume necessary for occl usi on wi l l vary
wi th muscl e t one. Not measuri ng t he pressure wi l l usual l y resul t i n a pressure wel l
above that recommended (139).
Af ter cuf f pressure has been adj usted, a check shoul d be made to make cert ai n t hat
t here i s no l eak at peak ai rway pressure. A l eak can be detect ed by a di ff erence
bet ween i nhal ed and exhal ed vol umes, a noi se heard wi t h a stethoscope around t he
cuff , or by moni t oring f or CO
2
i n the upper ai r way (139).
Cuf f pressure shoul d be measured and adj usted f requentl y. Changes i n muscl e tone
i n the t rachea and dif fusi on of gases across t he cuff may resul t i n l arge cuf f
pressure changes. The peak i nspi ratory pressure may also change, so f requent
checks f or l eaks shoul d al so be perf ormed.
When a t racheal tube wi t h a Lanz pressure-regul at ing valve is used, t he cuff shoul d
be i nf l ated unti l a seal is achi eved duri ng peak inspi rat i on. The pi l ot bal loon shoul d
be di stended but smal l er t han the conf i ni ng sheath.
Sponge Cuff
Af ter int ubati on, the i nf l ati on tube should be opened to atmosphere and the cuff
al l owed to f i l l wi t h ai r. The amount of ai r i n t he cuf f shoul d be det ermi ned by
wi thdrawi ng t he ai r wi th a syri nge. The abi l i t y t o remove 2 to 3 mL f rom the
smal l est cuf f or 5 to 6 mL or more f rom t he l argest cuf f usual l y si gni f ies t hat t he
cuff :t racheal wal l pressure rati o wi l l all ow adequat e mucosal perf usi on. If l i tt le or
no ai r can be aspi rated, the cuf f may be too l arge.
I f a l eak is present af ter the cuff has been al l owed to expand, wri nkl es i n the cuff
may be present and may be strai ght ened out by i nj ect ing 2 or 3 mL of ai r int o the
cuff and then al l owi ng i t to def l at e. If the l eak persists, a l arger t ube may be
needed.
Securing the Tube
A securel y posi ti oned t racheal tube is essenti al f or saf e anesthesia. If t he tube is
not wel l f i xed, t here i s danger of acci dental ext ubati on, or the t ube may advance
i nto a bronchus. The techni que used t o f i x the tube must be appropri ate f or t he
nature of t he surgery and al l ow access to the tube. Gentl y pressi ng the chi n toward
t he maxi ll a wi l l hel p to keep t he t ube in posi ti on whi l e i t i s bei ng secured (427).
Adhesi ve tape is most commonl y used to maint ai n the t ube i n the desi red posi ti on.
A variety of t aping met hods have been used (428,429, 430, 431,432,433). The part
of t he t ube to which the t ape i s to be appli ed shoul d be thoroughl y dri ed. Al l tapes
do not adhere t o al l t racheal t ubes equal l y wel l (429,433), so i t is advi sabl e to t est
avai l able t apes t o det ermi ne whi ch works best f or t he chosen tube. Adhesi on t o
both the pat i ent and the tube may be
P. 588

i mproved by using a t ransparent adhesi ve dressi ng (434, 435,436) or an adhesive
such as ti ncture of benzoi n (434,437). I f possi bl e, the t ape shoul d not be placed
across the connector, because i t may obscure a di sconnecti on and hi nder rapi d
reconnecti on (438,439). Securi ng t he edges of the tape wi t h t ape at a ri ght angl e
wi l l prevent l ooseni ng at the edges (437). A cl ear adhesi ve dressing placed over
t he tape wi l l protect i t f rom oral secreti ons, bl ood, or prep sol uti ons (440). A gauze
pad may be used to protect the pati ent' s f ace f rom the connector, especi al l y when
t he pat ient i s i n the prone or l ateral posi t ion (441).
Many pati ents have beards or mustaches, maki ng i t di f f icul t to at t ach the tape. For
pati ents wi t h suf f i ci ent l y long mustache hai r, t his can be taped to t he tracheal t ube
(442). I f a must ache i nt erf eres wi t h proper f i xat ion, t he pat ient shoul d be i nf ormed
preoperat ivel y that t ri mming or even shavi ng may be necessary. Because hai r i s an
i nsecure medium f or f ixing a tube, a close-f i tt i ng skul l cap, elasti c net , or a towel
t aped around t he head may be used t o provi de a structure to at tach tape or t ies
(Fi g. 19.30). Another method is to use doubl e-sided tape to at tach an el ast ic strap
(443).
Some pati ents have cutaneous responses to adhesive t ape (444,445,446). Fragi l e
ski n i s commonl y present wi th prematuri t y, chronic steroi d treat ment , zi nc
defi ci ency, amyl oi dosis, epi dermol ysi s bul l osa and pati ents recei vi ng cosmetic skin
exf ol i ants. I n these pati ents, ot her materials such as a ti e shoul d be used t o anchor
t he tube (428,447, 448, 449,450, 451,452).
Speci al devices (t ube hol ders, fi xati on devices) f or securing t racheal t ubes wi t hout
use of adhesives or t i es are avai labl e commerci al l y (453, 454, 455,456). A t ube
hol der may be combi ned wi t h a bi t e bl ock and/or nasogast ric tube hol der (457,458).
Speci al methods f or securi ng the t racheal tube in pati ents wi t h trauma or f acial
burns have been descri bed (448, 459, 460,461, 462, 463,464, 465, 466,467,468).
Compl i cated crani of aci al procedures and reconst ructi ve surgery may requi re
securi ng t he t racheal tube t o a stabl e tooth by using a wi re, sut ure, or dental f loss
(448). The t ube may al so be sutured to t he t ongue, between the teet h, to a
mandibular st ructure, or to t he nasal septum (469,470,471).
A nasal bridle may be used for fi xati on of a nasotracheal tube (472,473,474, 475). A
secti on of materi al (e.g., f eedi ng t ube or umbi li cal tape) i s looped around the nasal
septum. The three t ubes (nasot racheal and t wo ends of t he f ixati on mat erial ) are
t hen secured together cl ose to the external nasal septum. Thi s may be especi al ly
useful i n pati ents wi th t ape al lergi es or excessive secreti ons.
Changing the Tube
Replacing a t racheal tube may be necessary i f the tube i s damaged or obst ructed or
a larger tube is requi red (476,477). It may be necessary t o change f rom an oral to a
nasal t ube or vice versa. There are several t echni ques: di rect l aryngoscopy, usi ng
a fl exibl e endoscope, usi ng a l aryngeal mask, and usi ng a tube changer (di scussed
l ater i n thi s chapter). Combi ni ng these methods may conf er addi t i onal saf ety
(478, 479,480,481, 482).
Changi ng an oral t ube to a nasal tube by usi ng an AEC is di scussed l ater i n this
chapter. Another t echni que is to insert a fi berscope loaded wi th a t racheal tube
t hrough the nost ri l and then i nsert the t ip i nt o t he t rachea beside the oral t ube. The
oral tube i s then wi t hdrawn and t he nasal t ube advanced int o the trachea.
Al ternatel y, a f i berscope may be i nsert ed through the nost ri l , retri eved oral ly, then
passed through the exi stent oral tracheal tube (483). The f iberscope and tube are
t hen wi thdrawn ret rograde t hrough t he nasal passage.
Removing the Tube
The oral ai rway or bi t e bl ock shoul d be l ef t i n pl ace unt i l af ter extubati on to avoid
bi ti ng on t he tube (67,484,485,486,487). Li docaine sprayed down t he t racheal tube
wi l l att enuate the ai rway and ci rculatory react ions during emergence and ext ubat i on
(488, 489). Respi ratory and cardi ovascular compl i cat i ons that are commonl y
associ ated wi th extubati on can be decreased by i nserti ng a supragl ottic ai rway
device (Chapter 17) before or j ust af ter removal of the t racheal tube
(490, 491,492,493, 494, 495,496, 497, 498,499, 500,501,502).
Extubati ng a pat i ent i n whom i t may be dif f icul t to re-establ i sh an ai rway i s best
carri ed out i n a staged or reversi bl e manner, permi t t ing rei ntubati on whi l e
al l owi ng oxygen admi ni st rat i on by i nsuf f l at ion or j et venti lati on whi l e the ai rway i s
bei ng secured (503,504,505,506,507,508,509, 510). An AEC that can be connect ed
t o t he breathi ng system or other oxygen source may be usef ul f or t hi s purpose. In
t he very smal l pat i ent , a gui de wi re may be used (509).
Bef ore extubat i on, t he mout h and pharynx should be sucti oned and t he tape or
ot her f i xati on devi ce removed. Wi t hdrawi ng the tube unti l resi st ance i s met bef ore
defl ati ng t he cuf f may push mat eri al t hat has accumul ated above the cuff i nto the
pharynx, where i t can be removed by sucti oni ng. A l arge sustai ned i nf lati on shoul d
be admi ni st ered (504,511). Al ternat el y, t he adj ustable pressure l i mi t i ng (APL) val ve
can be closed and ai rway pressure al l owed t o ri se to 5 to 10 cm H
2
O (512). Whi le
t he l ung is near total capaci ty, the cuf f shoul d be def l at ed and t he tube removed. If
a syri nge cannot be l ocated, the ti p of a pen can be i nserted i nto t he valve
assembl y to defl ate the cuff (513). The practi ce of pul l i ng the pi l ot bal loon and
i nf l at i on val ve f rom the i nf l ati on t ube to defl at e the cuff shoul d be di scouraged, as
t his can cause the i nf lati on tube to seal (514, 515,516). Suct i on should not be
appli ed to t he t ube duri ng extubati on, as thi s wi l l cause oxygen desaturat ion
(511, 517).
I f the t ube cannot be easi l y removed, the i nf lat i ng tube should be checked for
obstruct i on, especial l y at the
P. 589

poi nt where tape was used t o hol d t he t ube i n place. I f the surgery has invol ved t he
mouth, neck, or t horax, a suture may have been pl aced through or around t he tube.
I f the t ube i s forci bl y removed i n these ci rcumst ances, the surgi cal si te may be
di srupted.
Using Open but Unused Tubes
Many cl i ni ci ans f eel t hat i t i s necessary to open one or more t ubes of di ff erent
si zes. Thi s raises the quest i on as to whether i t i s saf e to store t hese t ubes f or
another day. Studi es indi cate that tracheal tubes can be used up to 14 days af ter
bei ng opened (518, 519). However, i f a l ubri cant has been used, i t may dry out and
f orm fl akes (520).
Perioperative Complications
Failure of the Tube to Pass into the Trachea over an
Intubating Device
I t i s somet imes di f f i cul t to pass (rai l road) a t racheal tube over a f iberscope, l i ghted
st yl et , bougie, or ai rway exchange catheter (AEC) and through the glott ic openi ng.
When using a f lexi ble endoscope, this can of t en be prevented by usi ng the l argest
scope that f i ts easi l y insi de an appropri ate size of tracheal tube and keepi ng the
f iberscope i n the mi dl ine (521,522,523,524,525,526,527). A tube wi t h a ti p
designed t o mi ni mi ze the di stance bet ween t he f i berscope and t he leadi ng edge of
t he tube may pass more easil y than a standard tube
(14,15,18, 19, 20,21,24, 90,91,528). A spi ral embedded tube may pass more easi l y
over a fi berscope than a tube wi t h a pref ormed curve (53,54,55,529, 530). Warming
a st andard t racheal tube may faci l i tat e i ts passage (55,317). The tube may pass
more easi l y i f i t i s reverse l oaded (upsi de down f rom i ts natural curvature)
(527, 531).
Ot her maneuvers can be t aken to f aci li t ate passi ng a tracheal t ube i nt o the t rachea
(532). A supragl ot ti c device such as an LMA may f aci l i t ate intubati on (533).
Rotat ing the t racheal tube 90 counterclockwi se may be helpf ul
(18,277,505,524,526,534,535,536,537). Ot her helpful maneuvers are neck
extensi on, using a rigid l aryngoscope t o open up the ai rway, appl yi ng a j aw t hrust,
and appl yi ng external pressure to the l arynx (521,538,539, 540, 541). Another
method i s to i nsert a smal l er t racheal tube beyond the t ip of the t racheal tube
(529, 533,542,543). A stylet may be pl aced wi t hi n t he tube wi th the f i berscope
(544). St i l l another t echnique is to pass an AEC vi a the t racheal tube beside the
f lexible scope unti l the ti p of t he catheter i s vi sual i zed near the cari na (545). A
sl eeve may be pl aced on the f i berscope t o i ncrease i ts di ameter (522,546). I f the
pati ent i s awake, he can be asked to take a deep breath or i n the si t ti ng pati ent t o
l ook upward (547).
Trauma
I ntubat ion i s of ten associ ated wi t h t rauma to t he st ructures i n the upper and lower
ai rways. One study f ound that 86% of pati ents had occul t or vi si bl e bl ood af ter
extubati on (548). Ai rway i nj ury f orms a major subgroup of mal pract ice cl ai ms
(549, 550). Trauma i s of ten associat ed wi th use of excessive f orce or repeated
at tempts at intubati on. It vari es wi t h t he ski l l of t he operator, t he di ff icul t y of the
i ntubat ion, and t he amount of muscl e rel axati on. Damage may be i ncreased i f the
st yl et prot rudes beyond the end of t he tube or t hrough the Murphy eye. Mucosa can
be torn when a metal or foil -wrapped tube is used. A defecti ve tube may have a
barb.
Report ed i nj uri es to t he l arynx incl ude hematomas, contusi ons, lacerati ons,
puncture wounds, cord avul si ons, and f ractures (550,551). Aryt enoi d cart i l age
di sl ocati on may occur (550, 552,553, 554,555,556,557, 558,559).
Wi th nasotracheal i nt ubati on, abrasi on or l acerat ion of the nasal mucosa is common
(560). The nasal sept um may be di slocat ed or perf orated. Fragments of adenoid
t i ssue, nasal pol yps, or t urbinates may be di sl odged
(375, 561,562,563, 564, 565,566). Bl ood cl ots f rom epistaxis may enter the t rachea
and block a bronchus (567,558).
Cases of t racheal , bronchi al , pharyngeal , nasal f ossa, hypopharyngeal , pyrif orm
si nus, esophageal , and l aryngeal perf orati on have been reported, someti mes wi th
f atal consequences
(550, 569,570,571, 572, 573,574, 575, 576,577, 578,579,580,581,582,583,584,585,586,
587,588,589,590,591,592,593,594,595). Esophageal perf orati on can occur
(550, 596,597,598, 599, 600,601, 602, 603,604).
The best way t o avoi d t rauma i s to never use more than gentl e pressure. A styl et
shoul d be fl exi bl e and not ext end beyond the ti p of the tube. Methods to decrease
t rauma to the nose were discussed i n t he Nasal I ntubati on sect i on.
Esophageal Intubation
Esophageal i ntubati on can occur even wi th an experi enced anest hesia provi der
(605, 606,607,608, 609, 610). Recogni t i on and prompt correcti on are necessary to
prevent di re consequences. In most pat ients, recogni zi ng esophageal intubati on i s
not di ff icul t . But in some, t he si gns so cl osel y resembl e t racheal pl acement t hat
t hey can decei ve even a careful , experi enced i ndividual . In many of the report ed
cases of esophageal i ntubati on, one or more of the f ol l owi ng tests were perf ormed
and were mi sl eadi ng.
Direct Visual ization
Di rectl y vi sual i zi ng the tube passi ng between the vocal cords is one of t he most
rel i abl e met hods. Unf ortunatel y, the glot t is of t en cannot be seen wel l . The tracheal
t ube may be posteri orl y di spl aced wi t h the l aryngoscope bl ade st il l i n the mouth,
bri ngi ng the l arynx i nto view (611). However, even af ter t he tube is
P. 590

vi suali zed between the cords, i t may sl i p out as t he laryngoscope or styl et is
removed or the tube i s secured.
Feel of the Reservoir Bag
Normal reservoi r bag compl i ance and ref i l l ing wi t h manual vent i lat i on is another
method to determi ne correct t racheal tube pl acement. This test is unrel i abl e
(605, 606,612). It may be more reli abl e if perf ormed wi th no f resh gas fl ow (613).
A rel ated test i s seeing movement of the reservoi r bag i n t i me wi t h t he pati ent 's
spontaneous respi ratory eff orts. However, ti dal vol umes have been noted wi t h t he
t ube i n t he esophagus (605,614).
Chest Wall Motion
Some users rel y on vi sual and/or manual evi dence of chest wal l movement duri ng
venti l ati on. Unf ort unatel y, movement of the chest wal l si mul at ing lung venti l at i on
can occur wi t h the tube i n the esophagus, especi al ly i n pat ients whose respi rati on
i s pri mari l y abdominal (606,614,615,616). Chest wal l movement may be dif f i cul t to
assess i n the obese pati ent or i n the pat i ent wi t h l arge breasts. Low l ung or chest
wal l compl i ance may resul t i n l i tt le chest movement, even when the tube is i n the
t rachea. Listening through the open end of the tracheal tube whi l e the sternum i s
abruptl y depressed can al so be mi sl eadi ng (606).
Auscultation
Auscul tati on shoul d be performed hi gh in each midaxi l l ary area, not just t he
anterior chest regi on. The qual i ty of t he sounds i s import ant . A gurgl i ng sound
(deat h rat t le) suggests esophageal pl acement . Thi s test i s not al ways rel i abl e
(605, 606,614,615, 617, 618,619). Auscul tat i ng the upper abdomen as wel l as the
l ungs may i ncrease the rel iabi l i ty of auscul tat i on (615,620). These sounds may be
confused wi th breat h sounds that are of t en heard i n the epigast ri c area in thi n
i ndi vi dual s and pedi atri c pati ents (605, 618).
Another method of determi ning tracheal tube l ocat i on is breathi ng system
auscul t ati on (621). A st ethoscope is attached to an adaptor i n the breathi ng system
adj acent t o the t racheal tube. If t he tube is i n the t rachea, loud breath sounds are
heard. If t he tube i s i n the esophagus, squeaks or f l atus-l i ke sounds are heard.
Thi s test i s not t otal ly rel iable.
Epigastric Distention
The abdomen can be observed for gast ri c di stenti on. Unf ortunatel y, the abdomen
does not al ways di stend wi t h i ntermi ttent gast ri c inf l at ion, and gast ri c distenti on
can resul t f rom mask venti lati on bef ore i ntubati on i s attempt ed (606). The presence
of a hi at al herni a or i nt rathoracic gast roi ntest i nal cont ents may resul t i n the
absence of abdominal di stent i on wi t h esophageal i ntubat i on (614). The presence of
a nasogastric tube may make gast ri c f i l l i ng di f f i cul t to disti nguish f rom normal
abdomi nal movements during vent i lat i on.
Moisture Condensation i n the Tracheal Tube
Moi st ure condensat i on in a transparent t racheal tube i s not reli able, because
moi st ure can appear wi th esophageal i ntubati on (605, 606,615,622,623). But if no
condensat ion i s seen, t he tube is al most al ways i n the esophagus.
Gastri c Contents in Tracheal Tube
Gastric contents i n the tube l umen may i ndi cate mi spl acement . However, gast ri c
f lui d may not appear wi th esophageal placement and/or may be dif fi cul t t o
di st ingui sh f rom secreti ons f rom the t rachea (605,606).
Oxygenation
Good pati ent col or or sat isfactory pul se oximeter readings have been advocat ed as
a means to confi rm tracheal placement . However, hypoxemi a may be delayed a
number of mi nut es wi th esophageal intubati on i f preoxygenati on has been
perf ormed. Later onset of hypoxemi a may occur f rom ot her causes besi de
esophageal i ntubati on and must be ruled out. By that ti me, esophageal intubat ion
may not be suspected. If oxygen saturati on i mproves af ter i ntubati on, i t i s l ikel y
t hat the tube is i n the t racheobronchi al tree (624). The pat i ent can be vent i lated by
using a mask pl aced over the open t ube and mouth. Cyanosi s rel i eved by thi s
maneuver is evidence of tube mi spl acement.
Chest X-ray
Chest radi ography i s ti me consumi ng and expensive and may not be def i ni t ive i n
determining i f the tube is i n the esophagus (605, 606,625, 626, 627).
Palpation
During i ntubati on, a washboardl i ke sensat i on can of ten be fel t by t he i ndi vi dual who
i s mani pul at ing t he tube or applying cri coi d pressure as t he tube passes over the
t racheal ri ngs. Af t er t ube pl acement , maneuvers such as inf l ati ng and def lat i ng the
cuff rapi dl y, squeezing the pi l ot ball oon, or moving the tube i n and out may be f el t
when t he neck is palpated at the suprast ernal notch (628). The rol l test invol ves
gentl e backward pressure on the cri coi d cart i l age and simul t aneous si de to side
di spl acement of the carti lage i n an at tempt t o detect a t racheal tube l yi ng behi nd in
t he esophagus (629). None of these tests i s al ways rel i abl e (605,629,630).
Cuff Inflati on Needed to Produce a Seal
Another method is t o not e the amount of ai r requi red t o cause t he cuff to f orm a
seal . An excessi ve amount may i ndi cate esophageal placement . I f the cuf f is at or
P. 591

j ust above the vocal cords or is t orn or fai l s to expand unif orml y, there wi l l also be
a need f or high volumes of ai r t o be added to the t racheal tube cuf f .

View Figure

Figure 19.32 Adaptor to allow a fiberscope to be inserted
without interrupting ventilation.

Fiberscopi c Vi ew
The t racheal ri ngs can be vi sual i zed by usi ng a f i berscope or an opt i cal stylet . A
speci al adapt or (Fig. 19. 32) wi t h a port wi l l al l ow v ent il at ion whi l e the exami nati on
i s carri ed out . Thi n opti cal f i bers passed through or incorporat ed into a tracheal
t ube can be used to conf i rm the proper placement of the tracheal t ube when a
f iberopti c scope is t oo l arge t o pass t hrough t he tube (631,632,633).
Thi s i s a rel iable method but requi res special instrumentat i on, ski l l , and t i me. If the
t i p of the t ube hangs up on the ant eri or commissure, i t may be possi bl e t o vi suali ze
t he trachea, even though the tube is not in t he trachea (634,635).
Tacti le Confirmati on
Tacti l e conf i rmat ion i nvolves pl aci ng one hand i nsi de the pati ent' s mouth and the
ot her hand on t he neck and conf i rmi ng that t he tube l i es i mmedi ately anteri or to the
i nteraryt enoid groove. Thi s test i s not t ot al ly rel iabl e (636, 637).
Intentional Bronchial I ntubati on
The t racheal tube may intenti onal l y be advanced i nto a mainst em bronchus
(638, 639). The chest is then auscul tat ed duri ng posi ti ve-pressure vent il at i on. If
breat h sounds can be heard on onl y one si de, bronchi al i ntubati on has been
achieved. Wi th esophageal i ntubat ion, the breath sounds are ei ther equal bi l ateral l y
or equal l y di mi ni shed or absent on both si des of the chest. This test i s not foolproof
(638).
Passing a Device through the Tracheal Tube
A nasogastric t ube, i nt roducer, or ot her devi ce can be passed down the t racheal
t ube (605, 640). I f the t ube i s in the trachea, i t wi l l abut the cari na at 28 to 32 cm in
adul ts. If the tube is i n the esophagus, this resi st ance wi l l not be f el t. Other cri teri a
i ndi cat i ng tracheal i ntubat i on include the abi l i ty to maintai n ai r ent rai nment through
t he open end of the tracheal tube whi l e sucti on is appli ed to t he t ube, the ease of
wi thdrawi ng t he tube wi t h sucti on, and the absence of bi l e or gastric cont ents in t he
aspi rate.
Tracheal Il lumination
A l i ght ed i ntubat ion stylet, discussed l ater in t his chapter, can be passed t hrough
t he tube and the i ntensi t y of t he il l umi nat ion used to dif ferenti ate t racheal f rom
esophageal i ntubati on (641). Obesi t y and swel l i ng of the neck make use of t hi s
t echni que di f f icul t , and i t can onl y be used wi t h t ubes l arger than 6.5 mm I D (642).
Thi s test has l i mi ted rel i abi l i ty (619,643).
Pressure- and Fl ow-volume Loops
Pressure- and f l ow-vol ume l oops are di scussed i n Chapter 23. If the t racheal t ube
i s i n the esophagus, t he loops wi l l not have thei r characteristi c shapes. The l oop
wi l l probabl y be open. Al though i t wi l l not detect al l esophageal i nt ubati ons, this
t est has a hi gh l i kel i hood of success.
Esophageal Detector Devi ce
The esophageal detector devi ce (EDD) (Fi g. 19.33) consi sts of an aspi rat ing
component (a l arge syringe or self -i nf lati ng compressi bl e bulb) at tached to t he
t racheal tube usi ng an adaptor (642,644, 645,646,647, 648, 649). The pl unger i s
wi thdrawn, or t he compressed bulb i s rel eased. I f the tube is i n the t rachea and an
ai rt i ght seal has been achi eved,
P. 592

gas wi l l be aspi rated f rom the pati ent ' s lungs wi thout resi stance. However, i f the
t ube i s i n the esophagus, apposi ti on of the esophageal wal ls around the tube t ip
wi l l occl ude t he l umen and cause a negati ve pressure or resistance. As a
confi rmatory test , the devi ce can be used to i nj ect a bol us of ai r i nto t he tube whi l e
l istening over t he epi gastri um. Thi s test wi l l also detect a bl ocked t racheal tube
(646). The EDD shoul d be used i mmedi atel y af ter t ube pl acement , pri or t o
del i veri ng the f i rst breath (608).

View Figure

Figure 19.33 Esophageal detector device attached to a
tracheal tube.

Most studi es show t hat t hi s test has a hi gh degree of accuracy i n i denti f yi ng
esophageal i ntubati on even wi t h i nexperi enced users
(619, 642,646,650, 651, 652,653, 654, 655,656, 657,658,659,660,661,662,663,664,665)
, but one showed poor sensi ti vi ty (666). I t can be used to detect the posi ti on of the
Combi t ube (667). The presence of a nasogast ri c tube or tracheal t ube cuff def l ati on
does not l i mi t i ts eff icacy (668). I ts accuracy i s not af f ected by l ack of pul monary
perf usi on. I t i s faster than most other methods. Thi s devi ce may be bett er t han
exhal ed CO
2
in the cardi ac arrest pat i ent (663,669).
There are a number of false-negat ive resul ts i n which the t ube i s in t he trachea but
t he bul b expands too sl owl y or not at al l (670, 671). Some i nvesti gators f ound that
t here were f ewer f al se-negati ve resul ts i f 10 seconds were al l owed f or rei nf l at ion
(656). There are si tuati ons where this devi ce may not conf i rm placement i n the
t rachea (646,672). The bul b wi l l not re-expand rapi dl y i n pat ients wi t h decreased
expi ratory reserve vol ume as wi t h the morbi dl y obese or pregnant pat i ent , pat i ents
wi th bronchospast ic disease, tracheomal aci a, pul monary edema, bronchi al
i ntubat ion, and upper or lower ai rway obst ruct ion
(642, 656,659,673, 674, 675,676, 677, 678,679, 680). Pat i ents havi ng cesarean
secti ons have been invest i gated by usi ng thi s test, and a hi gh number of false-
posi t i ve and f al se-negati ve resul ts were f ound. The i nci dence of f alse negati ves i s
reduced if the bulb i s compressed af t er connection to the t racheal tube. Another
source of a fal se negat ive is t he bevel l yi ng agai nst the t racheal wal l . Thi s devi ce i s
unrel i abl e i n pat i ents under 1 year of age (681). If the t i p of the t racheal tube is
above the cords, a f al se-negati ve test can occur (663).
Fal se posi ti ves have been report ed where the t racheal tube was not i n the trachea
but the devi ce suggested t hat i t was (656, 676,679,682,683). These may be rel ated
t o an i ncompet ent gast roesophageal j uncti on (obesi t y, pregnancy) or gastri c
i nf l at i on.
Ultrasound
Ul trasound i magi ng of the di aphragm just beneat h the xiphoi d process can ident if y
most esophageal i ntubati ons (684).
Exhaled Carbon Di oxide
I n most cases, an esophageal i ntubat i on can be rapi dl y and rel i abl y determi ned i f
CO
2
i s not present i n the exhal ed gases (605, 606, 619,685). Carbon di oxi de
moni tori ng i s di scussed i n det ai l in Chapter 22. Al though not f ool proof , this i s
generall y consi dered the most rel i abl e method of detect ing esophageal intubati on.
The Ameri can Society of Anest hesi ol ogists (ASA) Standards f or Basi c Anest het i c
Moni tori ng and the Ameri can Associ at ion of Nurse Anest heti sts (AANA) requi re that
when a t racheal tube is i nsert ed, i ts correct posi t ioni ng must be veri fi ed by
i denti f i cat i on of CO
2
i n the expi red gas (686). I t has been f ound t o be rel i abl e in
ci rcumst ances where the esophageal det ector devi ce was unrel i abl e (687).
Carbon di oxide may not be det ected despi te correct placement wi th severe
bronchospasm, cardi ac arrest , no pul monary bl ood f low f rom probl ems such as
pul monary embol i sm, or a one-way obstructi on in t he tracheal tube
(612, 660,688,689, 690). The EDD may be a more rel i abl e devi ce i n these
ci rcumst ances (669). In t he prehospi tal set ti ng, col ori met ri c end-ti dal CO
2
(Chapter
22) may be di ff icul t to use because of i nadequate l ight. Carbon dioxi de may be
detected when the tube t ip i s above the vocal cords (691,692, 693).
There are some ci rcumstances in whi ch CO
2
may be detect ed if the tube is i n the
esophagus (694, 695). Exhal ed gases may have been forced int o the stomach duri ng
mask vent il ati on bef ore i ntubat i on (660,696). Carbon di oxi de can be i n the stomach
as a by-product of antaci ds that have reacted wi t h gast ri c acid or f rom i ngesti on of
carbonated beverages. In these cases, the end-t i dal CO
2
wi l l be l ow. The
capnogram (Chapter 22) wi l l have an abnormal conf i gurati on and be i rregul ar. I n
t his si tuat i on, the CO
2
l evel s wi l l rapi dl y di mini sh wi t h repeated vent il ati on (697).
Inadvertent Bronchial Intubation
Bronchial intubat ion i s a rel at ivel y common probl em (618,698, 699). I t occurs more
f requent l y wi t h emergency i ntubati ons and i n pediat ric and f emal e pat i ents
(700, 701). A short t rachea i s associ ated wi t h a number of pediatric syndromes
(702). One study showed that RAE tubes (di scussed previousl y in this chapter)
were too l ong i n 32% of chi l dren, and bronchi al i ntubati on occurred i n 20% (44).
Bronchial pl acement can l ead to atelectasi s i n t he nonvent i l ated l ung (703). The
l ung that i s venti lated may become hyperinf l ated, l eading to barotrauma and
hypotensi on. If the t ip i mpi nges on t he cari na, persi stent coughi ng and bucki ng may
occur.
Usual l y, the t ube wi l l ent er t he ri ght mainstem bronchus, ei ther because of t he
anatomy of the cari na and the t racheal bi furcat i on or t he ri ght -sided bevel of t he
t racheal tube (704,705,706). Tubes wi t hout bevel s also t end t o enter t he ri ght
bronchus (707).
Bronchial intubat ion can occur af ter correct i ni ti al pl acement . A t racheal tube may
descend i nt o a bronchus
P. 593

as a resul t of the wei ght of t he attachments, suct ioning, movement of the pati ent' s
head, and/or neck or pat ient reposi ti oni ng. It i s i mport ant that the correct tube
posi t i on is conf i rmed af ter t he pati ent ' s posi ti on has been al tered. The t ube wi l l
usual l y move caudall y wi th neck f l exi on, mout h opening, and change i n posi t ion
f rom erect t o recumbent
(148, 154,421,708, 709, 710,711, 712, 713,714, 715,716,717,718). The di stance f rom
t he cords to t he cari na is decreased duri ng l aparoscopy and wi t h the Trendelenburg
posi t i on (719,720,721,722,723,724,725,726). Mani pul at ion of an i nst rument
i ntroduced i nto t he mout h such as a t ransesophageal echocardi ography probe,
gastroscope, or t ongue depressor can resul t i n tracheal tube movement
(713, 714,727).
A number of techni ques and t ests have been recommended to avoi d or det ect
bronchial i ntubat ion. These should be made af ter i nt ubat i on and at i nt erval s during
an anest het ic, especi al l y af ter t he pat i ent i s reposi ti oned or the head and neck are
moved.
Lung Auscultation
Lung auscul tat i on is the most commonl y used method t o detect bronchi al
i ntubat ion. Auscul tati on shoul d be performed bi lateral l y i n the mi daxi l l ary areas. I f
surgery has begun and auscul tat ion woul d di sturb the surgical f ield, the end of the
stet hoscope can be put i n a steri le bag and posi t ioned i n each axil l a by a member
of t he surgi cal team (728). Auscul t ati on may be mi sl eadi ng, as breat h sounds can
be t ransmi t ted to t he opposi te si de of the chest i n the presence of bronchial
i ntubat ion, unless the t ube i s wedged f i rml y i n a bronchus
(700, 729,730,731, 732, 733,734). The presence of a Murphy eye may reduce t he
rel i abi l i t y of chest auscul tat i on i n detecti ng bronchial intubat ion.
Symmetri cal Chest Expansion
Vi sual i zati on of symmetri cal chest expansi on is easi l y perf ormed but i s not rel iabl e.
The chest is not al ways avai l able f or i nspect i on.
Chest X-ray
Chest x-rays are rel i abl e but t ime consumi ng and expensive. The t racheal tube
standard (11) requi res a radiopaque marker at t he pat ient end or al ong the f ul l
l ength of t he tube. The t i p of the tube shoul d be i n t he mi ddl e thi rd of the t rachea,
wi th t he head i n a neut ral posi t ion (mi dway bet ween f ul l extensi on and f ul l f l exi on).
I n adul ts, the tube t i p shoul d be 3, 5, or 7 cm above the cari na wi th t he neck f lexed,
neutral , or extended, respecti vel y (702). The ti p shoul d l i e over t he second to
f ourth thoraci c vertebrae i n the neut ral posi t i on (612,729) or at the l evel of the
cl avi cl e (724).
I n t he neonate, i nf ant , and young chi l d, t he ti p shoul d be 2 cm above t he cari na
wi th t he neck i n the neut ral posi t ion (735). I n chi l dren approaching 5 t o 6 years of
age, this di stance should be i ncreased to 3 cm.
Tube Position at the Lips/Nostril
Adult Patients
I t has been recommended that oral t ubes be posi ti oned at the 21-cm mark on the
t ube at t he teeth (or upper anteri or edge of t he gums i n edentul ous pati ents) i n
normal -si ze f emal es and 22 to 23 cm in normal -si ze males and that f or nasal
i ntubat ion, 2 or 3 cm be added to t hese l engths f or posi ti oni ng at the nostri l
(415, 736,737). Studies show that t hi s i s a bet ter method of preventi ng bronchi al
i ntubat ion t han chest auscul tati on. However, i t wi l l resul t i n mal posi t ioning i n some
pati ents (419,423, 700,701,738).
There i s a correl ati on between ai rway l ength and body hei ght (419,423). For
pati ents whose body l engths l i e outsi de t he normal range, the t ube can be pl aced
al ongsi de the pati ent ' s face and neck. The t i p of the t ube i s al igned to t he
suprasternal notch, and t he tube i s al i gned t o conf orm t o the posi ti on of a nasal or
oral t racheal tube. The place on the tube at whi ch the tube i ntersects wi t h the t eeth
or gums (oral i nt ubati on) or the nares (nasal i ntubat i on) i s noted, and the t ube i s
secured at that point.
Pediatric Patients
The margi n of safet y in chi l dren i s l ess than i n adul ts. A number of f ormulas have
been developed, i ncl uding t he f ol l owi ng:
Oral Intubation
Lengt h i n centi meters = age/2 + 12 cm (700).
Lengt h i n centi meters = wei ght in ki l ograms/ 5 + 12 cm.
Lengt h i n centi meters = hei ght in centi meters/ 10 + 5 cm.
Rul e of 7-8-9: i nfants wei ghing 1 kg are i nt ubated to a depth of 7 cm at the
l i ps, 2-kg i nfants t o a dept h of 8 cm, and 3-kg i nf ants to a l engt h of 9 cm.
Equati ons based on the crown-rump and crown-heel l ength have been
devel oped (710).
Nasotracheal Intubation
L = (S 3) + 2, where L is t he l ength in cent i met ers, and S i s the I D of the
t ube i n mi l li meters (739).
Mul ti pl yi ng crown-heel lengt h by 0.21.
For total t ube l ength, 0.16 hei ght i n centimeters + 4.5 cm, then l eave 2 cm
of t ube outside t he nostri l of an i nf ant and 3 cm outside f or an ol der chi ld
(740).
Whi le use of speci al f ormulas may decrease t he i nci dence of bronchial i ntubat ion,
t hey are based on averages and should not be consi dered total l y rel iabl e.
Furt hermore, tube l ength marki ngs are not al ways accurate (741).
Placi ng the Cuff Just Below the Vocal Cords
Pl aci ng t he cuf f onl y a few centi meters past the vocal cords should avoi d bronchi al
i ntubat ion i n adul ts.
P. 594


Guide Marks on the Tracheal Tube
Many tubes have l ines or ri ngs to hel p posi ti on the t ube wi th respect t o the vocal
cords (Fi gs. 19.2, 19.4), and the distal porti on of some pedi at ri c tubes are col ored
(Fi g. 19.23) (147,149,153,154,742,743). Gui de (depth) marks vary in t hei r posi t i on
rel ative to t he cuff and ti p of t he tube (148,150,151,152,153,744,745).
Intentional Bronchial I ntubati on
The t ube can be advanced unti l unil at eral breath sounds and chest movement are
observed. The tube is then sl owl y wi thdrawn, not ing t he t ube l ength at nares or
gum at whi ch symmet ri cal breath sounds and chest movement return. The t ube i s
t hen wi thdrawn an addi ti onal 2 cm i n chi l dren (735). The tube shoul d be wi thdrawn
f urt her i n adul ts.
Fiberscopi c Observation through the Tube
Passi ng a f i berscope through the t ube i s equal in accuracy and f aster than a chest
x-ray f or determi ni ng tube posi t i on i n both adul ts and pedi at ri c pat i ents and i s more
accurate t han auscul tat ion (632,734,746). The ready avai labi l i ty of f i berscopes i n
most OR sui t es makes this a practical method of checki ng tube posi t ion. However,
head and neck movement duri ng the exami nat ion may cause the tube to move
(726).
Palpation of the Anterior Neck
Another method to determi ne tracheal tube l ocati on i nvol ves i nf lati ng and def l at i ng
t he cuf f whi l e palpati ng t he ant erior neck (736). The l ower border of the cuff should
be f el t just above the suprasternal notch. This method i s not tot al l y reli able (700).
Wi th uncuff ed tubes, the t i p of the tube can be fel t duri ng i nsert ion and
advancement stopped when t he t ip has j ust passed the suprasternal notch.
Monitori ng Expired Carbon Dioxi de
Moni tori ng expi red CO
2
may l ead t o the di scovery of bronchi al i nt ubat i on, but i t is
not a rel i abl e means t o detect thi s problem (698, 724,747). Ei ther an i ncrease or
decrease i n end-ti dal CO
2
may be seen.
Lighted Intubation St ylet
I nserti ng a l i ghted i ntubati on st yl et so t hat the l ight i s at the t i p of the t ube and
posi t i oni ng the t ube so that the maximum t ransi ll umi nat ed gl ow i s at t he sternal
notch and then advanci ng the tube 2 t o 3 cm can be used t o place the t ube t ip at a
sati sf actory l evel (748).
Pressure- and Fl ow-volume Loops
Peak i nspi rat ory pressure wi l l usual l y i ncrease wi t h bronchi al intubati on. Pressure-
volume and f l ow-vol ume loops (Chapt er 23) can of ten be used t o det ect bronchi al
i ntubat ion. The pressure-vol ume loop wi l l show l ow compl i ance when t he tracheal
t ube enters a mai nstem bronchus. As the tube i s wi t hdrawn, there wi l l be a marked
sudden i mprovement in compl iance as the tube l eaves t he bronchus. If peak
i nf l at i on pressure is moni tored whi l e del i veri ng a constant minute volume, bronchial
i ntubat ion wi l l cause an i mmedi ate i ncrease i n peak inf l at ion pressure (749).
Ultrasound
Ul trasonic i magi ng of the di aphragm beneath the xiphoi d process can detect
bronchial i ntubat ion (684).
Other
Decreases i n saturati on of pulse oxi metry (SpO
2
) and transcut aneous oxygen are
of ten seen wi th bronchi al i ntubat ion (618,698, 747). However, desaturat i on wi l l not
al ways be seen, even wi t h massi ve at el ectasi s. I f the pat ient i s receiving a high
oxygen concentrati on, t he oxygen saturati on may not fal l .
Acoust ic ref lectromet ry has been used to detect bronchial i ntubat ion i n the
presence of equal bi l ateral breat h sounds (730).
When a t racheal tube i s bel i eved t o be i n a bronchus, the cuff shoul d be def l ated
and the tube gentl y wi t hdrawn, the cuff re-inf l at ed, and the posi ti on rechecked. If
rei ntubat ion would be dif f i cul t because of the pat ient' s posi t i on or because t he
i ni ti al i nt ubat i on was di ff icul t, consi derat i on shoul d be given to advanci ng a
f iberscope or vent il ati on cat heter (see bel ow) i nt o the t ube before wi thdrawi ng i t. If
extubati on shoul d occur, t he t racheal tube can be qui ckl y rei nserted.
Swallowed Tracheal Tube
There are a number of case report s of a tracheal t ube being l ost in t he esophagus,
usual l y duri ng newborn resusci tati on (750,751,752,753) and i n an adul t f ol l owi ng
emergency i ntubat ion (754). The use of a connector that f i ts f i rml y into the t ube can
prevent this compl icati on. Bondi ng between the connector and the tube wi l l be
i ncreased if t he connector i s wi ped wi th al cohol bef ore bei ng i nserted into the t ube.
The t ube shoul d be long enough that i t protrudes f rom t he mouth when correct l y
pl aced and f i rml y secured. To secure the t ube, tape shoul d be at tached to the t ube
i nstead of t o the connector. If thi s compl i cati on occurs, t he tube does not need to
be removed i mmedi atel y.
Foreign Body Aspiration
During i ntubati on, a vari et y of mat erials that can cause bl ockage or check-valve
obstruct i on can be aspi rated i nto the trachea. The tracheal t ube may di sl odge
f ragments of ti ssue, i ncl uding t eeth, f rom the oral cavi t y, pharynx, or l arynx. A t ube
i nsert ed nasall y may di sl odge adenoi d or nasal t i ssue duri ng i ts passage.
P. 595


A porti on of a cuff or shaf t of the t ube i ncl udi ng the punched-out area f rom t he
Murphy eye sti l l in si tu may be l ef t i n the ai rway (755, 756, 757,758,759,760,761). A
t racheal tube can separate f rom i ts connector and sl ip below t he cords.
Ot her f oreign bodi es that have been f ound i n tracheal tubes i nclude cot tonoi ds or
pi eces of al umi num used to protect the cuf f or shaf t f rom a l aser beam, the di st al
port ion of a t racheal tube, a cap li ner f rom a t ube of anestheti c oi ntment, and parts
of sprays and l aryngoscopes (261, 628, 762,763).
Caref ul i nspect ion of equi pment bef ore use wi l l hel p t o avoid i ntroducti on of forei gn
bodies. The connector shoul d f i t f i rml y in t he tracheal tube, and the tape or
securi ng devi ce shoul d be att ached to the tube, not the connector. When a cuf f
l eaks, i t shoul d be caref ul l y exami ned f or mi ssi ng port i ons af t er i t i s removed f rom
t he pat ient.
Forei gn body aspi rati on shoul d be suspected whenever obst ruct ive signs or
symptoms appear. The pat ient' s ai rway shoul d be searched i mmedi atel y and shoul d
i ncl ude bronchoscopy i f examinati on above t he l evel of the l arynx proves f rui t l ess.
I f the f orei gn body i s above the cuff , i t mi ght be possi bl e to bl ow i t out of the
t rachea by defl ati ng the cuf f and f orci bl y compressing t he reservoi r bag i n the
breat hi ng system (764).
Leaks
A leak may make i t di ff icul t to mai ntai n adequate vent il ati on, f ai l to protect agai nst
aspi rat ion, and i ncrease the dif fi cul t y of surgery i nvol vi ng the oral cavit y (765).
During i nsert i on, the cuf f , inf l at ion tube, or t he tube i tsel f may be torn by a tooth,
t urbinate, impl ant, l aryngoscope bl ade, f orceps, or stylet (766). A probl em wi t h the
i nf l at i on system (254, 316, 765,767, 768, 769,770,771,772,773,774,775,776) or t he
syri nge used to i nf lat e the cuf f (777, 778) may make i t i mpossi bl e t o i nf l ate the cuf f .
A def ect i n the tube or eccent ri c cuf f i nf l at i on can cause a leak
(126, 312,779,780, 781, 782,783). The t racheal tube connector may be t he source of
a leak (438,618,693,784,785,786,787).
Protrusi on of the cuff above the vocal cords can resul t i n a l eak despi t e a l arge
amount of ai r bei ng i nj ected i nt o the cuff (788,789,790,791,792, 793).
The cuff can devel op a l eak whi l e the t ube i s i n place (794). Appl icati on of l ocal
anesthet ic spray has been associ ated wi t h cuf f leaks (795,796). The cuf f or other
parts of the t ube may be damaged duri ng cannul at i on of the internal j ugul ar or
subcl avi an veins, duri ng percut aneous di l atat i onal tracheost omy (Chapter 21), or by
ot her nearby procedures
(755, 797,798,799, 800, 801,802, 803, 804,805, 806,807,808,809,810,811,812,813). A
l aser beam can perf orate t he cuf f . A tube may be damaged by bi t ing
(61,66,814,815,816,817). Chewi ng gum at tached to a cuf f can cause an
unsatisf actory seal (818).
I f a l eak becomes evi dent af ter a gast ri c tube or other devi ce has been pl aced, the
possi bi li ty t hat that device has passed i nto the trachea al ongside t he t racheal tube
i nstead of i nt o the esophagus shoul d be consi dered
(176, 177,178,179, 180, 819,820).
When a l eak i s present , l aryngoscopy shoul d be perf ormed. If the cuff i s above the
vocal cords, i t shoul d be def l ated and the t ube advanced bef ore the cuf f i s
rei nf l ated. Consi derat ion shoul d be given t o usi ng a tube changer or f i berscope
duri ng this procedure, especi al l y i f i ntubat i on was di ff icul t.
I f the problem i s i n the inf l ati on system, i t may be possi bl e t o repai r the damage, or
t he l eak can be bypassed by i nserti ng a stopcock, smal l catheter, or a needl e i nto
t he l i ne bel ow t he def ect (821,822,823, 824,825,826,827). I t may be possi bl e t o seal
a cut i n the tube i tsel f by usi ng glue (828). Temporary approxi mati on of the cut
edges and ci rcumf erenti al packing may be hel pf ul (799).
I f the cuf f is l eaking, several al ternati ves are avail abl e:
Use pharyngeal packi ng to cont rol t he l eak. It may be necessary to i ncrease
t he f resh gas f l ow to compensate f or t he leak.
Fi l l the cuff wi t h a mi xture of li docai ne and sali ne (829) or use a sal i ne
i nfusi on (830).
At tach a mechanism f or mai nt ai ni ng a cont inuous gas i nf usi on i nto t he
i nf l at i on tube. Met hods descri bed i ncl ude t ubi ng connected t o an ai r-f i l l ed
pl ast i c cont ai ner t o whi ch constant external pressure i s appl ied (831,832), a
f lowmeter (833,834,835), and a syst em f or mai ntai ni ng intraocul ar pressure
(836).
Pl ace a supraglott ic devi ce such as an LMA over t he tube, and seal the
proxi mal end (837).
Replace the t racheal tube. I f this course of acti on i s sel ected, consi derat i on
shoul d be given to using a t ube exchanger.
When a damaged tube is removed, i t shoul d be carefull y exami ned to make cert ai n
t hat there are no mi ssi ng port i ons.
Intubating Device Trapped inside the Tracheal Tube
Whenever any device i s pl aced t hrough a t racheal tube, there i s a ri sk that i t coul d
become ent rapped i n the tube. Anythi ng passed down t he t racheal tube such as a
sucti on catheter, t ube exchanger, or f i berscope can pass through a Murphy eye and
become caught (Fi g. 19.34). I t may be i mpossi bl e to remove the device wi t hout al so
removi ng the tracheal tube (838). The needl e or wi re of a percutaneous
t racheostomy set (Chapt er 21) may traverse t he Murphy eye (839,840, 841).
A f l exi bl e scope or other devi ce i nsert ed into a tracheal t ube may become st uck on
removal (842). It may be possibl e to f ree i t by i nj ect i ng sal ine i nto the t racheal
t ube.
P. 596



View Figure

Figure 19.34 The tube changer has become caught in the
Murphy eye.

Tracheal Tube Fires
Fi res i n tracheal t ubes have a hi gh l ikel ihood of causi ng seri ous harm. Fi res are
di scussed i n Chapter 32.
Tracheal Tube Obstruction
One reason f or i nsert i ng a t racheal tube is to provi de a patent ai rway (618).
Unf ortunatel y, the tube i tsel f may become the cause of obst ruct ion. Thi s i s
especi al l y a probl em wi th i nfants and chi ldren (843,844). Obst ructi on can be part i al
or compl ete. It is possi bl e to have an obst ruct ion such that i nspi rat ion i s uni mpeded
but resistance to expi rat i on is i ncreased and vi ce versa (845,846).
Causes
Biting
Unl ess protect i on in t he f orm of a bi te bl ock or oral ai rway i s provi ded, the pat ient
may bi te and obst ruct t he tube (62,64,65,847, 848, 849,850). Many of t he reported
cases i nvol ve spi ral embedded tubes that were permanent l y def ormed af ter t he bi te
was rel eased (63, 67, 68,130,848,851,852,853, 854, 855) (Fi g. 19.35). An oral ai rway
may not prevent obst ruct ion, as i t can onl y be pl aced in t he mi dl i ne (68,856,857).
Kinking
Ki nki ng i s a f requent cause of t racheal tube obst ruct ion. Spi ral embedded tubes
have been used in the OR t o overcome thi s probl em, but ki nki ng can sti ll occur at
t he pat ient end i f the connector i s not i nsert ed i nsi de the spi ral s. Kinking
someti mes occurs when the pat ient' s head posi ti on i s changed, especi al l y when t he
neck is f lexed (858,859) (Fi g. 19.36). It can al so occur when a tube i s moved f rom
one si de of the mouth to other (860). Some t ubes may ki nk i n the pharynx af ter they
have been i n pl ace for several hours. Kinki ng can be caused by other equi pment in
t he mouth (69, 861,862). Advanci ng the tube wi t h a dri l li ng movement may
i ntroduce some t orque into the tube (863).
Tubes vary in t hei r resi st ance t o ki nki ng. Smal l er t ubes ki nk more readi l y than
l arger ones. A st ructural faul t i n the tube such as t he poi nt where the inf l at ing t ube
enters the wal l of the tube (864,865,866) or the i nt racuf f area (867) can predi spose
t o kinki ng. At t i mes, t ubes are made wi t h t hi n si dewal l s. Ki nki ng someti mes occurs
at t he di stal part of the connector (868). The Endotrol tube may ki nk at the l evel of
t he gl ott i s (88). The t i p of a tube may f ol d, causi ng obstructi on (128). The
Lasertubus can ki nk at the j uncti on of the pl ast i c and out er l ayers (117).
Material in the Lumen of the Tube
A tracheal tube may be obst ructed by dri ed secreti ons, bl ood, pus, tumor, or other
t i ssue (618,869, 870,871, 872, 873,874, 875, 876,877). Lubricant that is used to help
put the connector into the tube may dry and f orm a f il m (878). A vari et y of forei gn
bodies have been found in t racheal tubes, includi ng a t ooth, f oam rubber f rom
P. 597

a mask, an i nfl ati on val ve, a cl eaning brush, an adaptor f rom an i ntravenous set , an
i ntravenous needl e, a stop f rom a st yl et, a cork, a gl ass ampoul e, pi eces of pl asti c,
part of a nasogast ri c tube, an oral medi cat ion tabl et , a smal l er t racheal t ube, part
of a paper t owel , part of a sampl i ng tube, caps f rom syringes, and dead organisms
(618, 879,880,881, 882, 883,884). Part of a styl et can be detached and remain i n the
l umen (885, 886, 887). A manufacturi ng def ect can cause obstruct i on (888).

View Figure

Figure 19.35 Spiral embedded tube permanently deformed
by patient biting down on it.


View Figure

Figure 19.36 This tube kinked in the back of the mouth.
The pen points to the site of the kink.

Spiral Embedded Tubes
Most spi ral embedded tubes do not have a Murphy eye. Anything t hat bl ocks the
bevel can cause obst ruct ion (889). I n some spi ral embedded tubes, the part of t he
t ube di stal to t he cuff has no spi rals. Thi s part may be sof t and easi l y occl uded.
Pharyngeal obst ruct ion of a spi ral embedded tube in a pati ent wi t h edema of the
t ongue has been report ed (890). Reusi ng spi ral embedded tubes predi sposes to
probl ems. Even si ngl e use tubes may have ai r bubbl es i n the wal l t hat enlarge wi th
ni trous oxi de exposure and cause obstruct ion (60).
Cuff Problems
I f the t racheal t ube cuf f herni at es or i nf l ates eccentri cal l y, i t may displ ace the bevel
f rom the center of the t rachea (Fig. 19.37). Eccent ri c cuf f expansion f rom di f fused
anesthet ic gases can cause i t to expand i n one di recti on and al l ow t he bevel to
i mpinge agai nst the t racheal wal l (Fi gs. 19.37, 19. 38) (618,891,892,893,894,895).
An i nfl ated cuf f may ball oon over t he tube ti p (618,896) (Fi g. 19.37). I nf lati ng the
cuff may cause compressi on of the tube l umen (897,898,899) (Fi g. 19.39).
Obstruct ion f rom these causes may not occur unt i l some ti me af ter i ni ti al cuf f
i nf l at i on. Def l ati ng the cuf f usual l y rel i eves t he obst ruct ion.
Cases have been reported f or whi ch a f eedi ng tube or other devi ce was connect ed
t o t he cuff i nf l ati on system (900,901). This can cause the cuff t o overi nf late and
obstruct the t ube.
External Compression or Displacement
The t rachea may be displaced by t he aorta, or t he thyroid gl and may cause t he
bevel t o li e agai nst the t racheal wal l or compress the tube. A nasogastric t ube or
sucti on catheter knot ted around t he tube or a nearby surgi cal ret ractor can cause
compressi on (902,903,904). External tracheal tube compressi on has been reported
associ ated wi th Ludwi g' s Angina, Foresti er' s di sease, or saber-sheath t rachea
(52,905,906,907,908,909,910). Bony f ragments f rom a LeFort f ract ure can cause
external compressi on of the t ube (911).
Defective Connector
I f the connector i s def ect ive or damaged duri ng i nsert i on, i t can part i al l y or
compl etel y obstruct the l umen (912, 913,914,915). To avoid probl ems wi th
rei nserti ng the connector af ter short eni ng the t racheal tube, the tube shoul d be cut
di agonal l y, maki ng a short bevel
P. 598

(916). The connector should be l ubri cat ed sl i ghtl y wi th al cohol , brought i nto the
l ongi t udi nal axi s of the tube, and t hen gentl y sl i d i nt o the tube.

View Figure

Figure 19.37 Two causes of tracheal tube obstruction. A:
The bevel is pushed against the wall of the trachea by an
eccentrically inflated cuff. B: The cuff has ballooned over
the end of the tube.


View Figure

Figure 19.38 Tracheal tube obstruction secondary to
eccentric cuff inflation. A: The cuff as removed from the
patient. B: When placed in a glass tube, the inflated cuff
pushes the bevel toward the wall of the tube.

Change in Body Position
A shi f t in body posi t ion may cause the t racheal tube t o become obst ructed
(917, 918,919). When the tube ori f i ce faces i n one di recti on and t he head is turned
t o t he other, t he ori f ice may f ace t he t racheal wal l (920).
Preventi on
Preventi ng t racheal tube obst ructi on starts wi t h t he choice of tube. Transparent
t ubes f aci l i t ate i denti f yi ng materi al or obj ects bl ocki ng t he lumen. The use of a
f enestrated (Murphy) tube may avoi d some cases of obst ruct ion. A spi ral embedded
t ube may be useful if an operat ion i nvol ves t urning t he head or other maneuvers
t hat may cause ki nki ng. Spi ral embedded t ubes shoul d not be reused. Soluti ons or
l ubricants that can f orm a f i l m barri er should be prevented f rom enteri ng the t ube
l umen (921).
The t racheal tube should be exami ned caref ul ly bef ore use and the patency of t he
l umen veri f i ed. Forei gn bodi es and other probl ems i nsi de the l umen can be
detected by i nsert i ng a stylet . The cuf f shoul d be exami ned t o make certai n that i t
i s securel y at tached and i nf l ates symmet ri cal l y. The l umen shoul d not be reduced
when t he cuff i s inf l at ed. I nsert ing a metal connector i nto t he tube may prevent
external compressi on (922). I f t he tube has a sof t f lexi bl e t ip, a stylet should be
used duri ng i nsert i on. Af ter i nserti on, the cuf f shoul d be i nf l ated as described
earl i er in t hi s chapt er. Cuf f pressure shoul d be readj usted f requent ly, especi al l y i f
ni trous oxi de is used. When an x-ray i s taken, t he posi t ion of the ori f ice and the
confi gurati on of the cuf f shoul d be exami ned. Once i nsert ed, t he tube should not be
wi thdrawn whi l e the cuf f is i nf lated, as this may cause t he cuf f t o bal loon over the
end of the t ube.

View Figure

Figure 19.39 Reduction of tube lumen by cuff. Inflation of
the cuff caused narrowing of the tube lumen.

Pl aci ng a bi te bl ock securel y bet ween the mol ar t eeth and mai ntaini ng an adequate
l evel of anesthesi a wi l l prevent bi t ing on the t ube. Various methods have been
descri bed to avoid kinking of the tube f rom t racti on on i t (923, 924, 925,926,927).
Af ter surgery, a spi ral embedded t ube shoul d be changed to a conventi onal one i f
postoperati ve i nt ubat i on is requi red (890,928).
Diagnosis and Treatment
Parti al tracheal t ube obstructi on may present as a decrease in compl i ance or
expi ratory f l ow, hi gh i nspi ratory pressures and an i ncrease i n the dif ference
bet ween peak and plat eau ai rway pressures wi t h vol ume-cont rol l ed venti l ati on,
reduced ti dal vol ume duri ng pressure-cont rol l ed venti l ati on, or wheezi ng
(929, 930,931,932). Pressure-vol ume l oops (Chapter 23) are hel pf ul i n diagnosi ng
an obstruct i on. Paradoxi cal chest movement s may be seen i n spontaneousl y
breat hi ng pati ents. The capnograph (Chapter 22) may show an i ncreased sl ope in
Phase II I and a l arger angl e (933,934,935). Rel ying on the anesthesia provi der' s
educated hand i s not rel i abl e (936). A hi gh negative i nt rathoracic pressure may
resul t i n pul monary edema (937,938,939). A problem that permi ts i nhal ati on but
prevents exhal at ion (bal l -valve obst ruct ion) may present as ci rcul atory col l apse or
barot rauma (845,940).
P. 599


Passi ng a f i berscope down t he tube may f acil i tat e di agnosi s. Al teri ng the pat ient' s
head posi t ion or def lati on of t he cuf f may rel i eve the obst ructi on. The tube can be
checked for ki nki ng ei ther by exami nati on wi th a gl oved f inger or by di rect vi si on
using a l aryngoscope. Passi ng a sucti on catheter or stylet down t he tube may be
hel pf ul .
Di gi tal pressure at the si te of the ki nk may rel ieve the obst ructi on. A ki nk i n a smal l
t ube can somet i mes be remedi ed by placing a l arger t ube over t he smal l tube
(927, 941). I f a l arge tube ki nks, i t may be possi bl e to pass a smal l er t ube through
i t. A hemost at appl i ed at 90 degrees to t he occl usi on may rel i eve obst ructi on
secondary t o bi ti ng (848,854). I f the obst ructi on i s caused by cl ot ted blood or
i nspi ssated mucus, i t may be possi bl e to remove thi s by using an embol ect omy
(Fogart y) cat heter (942,943, 944, 945). I n some cases, rotat ing the t ube over a
f iberscope or t ube exchanger may rel i eve the obst ructi on. A new device that i s
speci al ly desi gned to remove secret ions wi t hi n a tracheal t ube has been devised
(946).
Equi pment pl aced bet ween the breathing system and the tracheal tube may be t he
source of the obst ructi on. These components shoul d be consi dered i n the
di ff erenti al di agnosi s of obstructi on, especial l y if t hey are added af ter t he i ni ti al
equipment check or j ust bef ore the obstructi on was detected (947).
Aspirating Fluid from above the Cuff
Al though i t i s general l y assumed t hat a t racheal tube wi l l prevent f orei gn materi al
f rom enteri ng t he l ungs, aspi rati on can occur around the cuf f (948). I n one study of
l ong-term intubati on, secret i ons l eaki ng around the t racheal tube cuf f were t he most
i mportant ri sk f or pneumoni a in t he f i rst 8 days of i ntubat i on (949).
The i nci dence of aspi rati on is i ncreased by t he use of l ow-pressure cuff s,
spontaneous venti lati on, and f l ui d accumul ati on above the cuf f .
Use of Low-pressure Cuffs
Low cuf f pressure (bel ow 20 mm Hg) i s associ ated wi t h an increased risk of
pneumoni a i n pati ents wi th l ong-term intubati on (165,166,949,950). Many l ow-
pressure cuff s wri nkle despi te proper inf l at ion and all ow f l ui d to pass al ong t he
f olds. I nf olding can be decreased by i ncreasing t he pressure i n the cuff , using a
t hin-wal l ed cuf f , and using a t ube i n whi ch cuf f di ameter at resi dual vol ume
approxi mates t he i nternal tracheal diameter (157,164). Appl yi ng l ubricant j el l y to
t he cuf f may f il l i n t he f ol ds and prevent aspi rat i on (166,170). When ni trous oxide
admi ni st rati on i s disconti nued, there wi l l be an out fl ow of that gas f rom the cuff .
Thi s can cause the cuf f to lose vol ume and decrease the seal (205).
The ul t rat hi n pol yurethane cuf f may prevent aspi rati on bet t er t han other cuff s (951).
Spontaneous Venti lati on
During spontaneous vent i l at ion, t here wi l l be negative pressure i n t he ai rway duri ng
i nspi rati on (952). I n addi ti on, the t rachea t ends to di late duri ng spontaneous
i nspi rati on. Wi th t hi n-wal l ed cuff s, the negat ive ai rway pressure wi l l be transmi t ted
t o t he cuff . Wi th an uncuff ed t ube, the negat ive pressure wi l l be appl ied around the
t ube. If t he negati ve pressure exceeds the l eak pressure around t he tube, bl ood or
secreti ons may be drawn i nt o the t rachea (953). I ntermi ttent posi tive pressure,
PEEP, and pressure-supported vent i l ati on wi l l l ower t he i nci dence of aspi rat i on but
not tot al l y prevent i t (166,952).
Flui d Accumulation above the Cuff
Sucti oni ng to maintai n a cl ear oropharynx wi l l decrease the pressure exert ed by
f lui d above the cuf f . I t has been suggested t hat the cuff be placed j ust below t he
vocal cords to reduce the vol ume of f l ui d t hat cannot be removed by sucti oni ng.
However, if the cuf f i s j ust below t he cords, head movement may cause the t ube t o
move upward, causi ng the cuf f to exert pressure on the cords and i ncreasi ng t he
ri sk of inadvertent extubati on. Furt hermore, a cuf f pl aced j ust bel ow the cords may
compress nerve endi ngs agai nst the t hyroi d carti l age, resul t i ng in vocal cord
paral ysis. If the pat i ent i s in a head-up posi t i on, the hydrostat ic pressure exerted
by t he f l ui d wi l l be hi gher t han if the pati ent i s supi ne.
Bl ood f rom the pharynx can drain bel ow t he vocal cords and accumulate above the
cuff . If suf f i ci ent t i me elapses f or t hi s bl ood to cl ot , i t can f orm a sheath between
t he tube and the t racheal wal l . Duri ng extubat ion, this sheath may fall i nto the
t rachea, causing compl et e or parti al obst ructi on.
A tracheal tube that i ncorporates a dedicated suct i on l umen and channel can be
used to cl ear secret ions above the cuff . Studi es show t hat usi ng this tube may
reduce t he i nci dence of venti l ator-associ ated pneumoni a duri ng l ong-term
i ntubat ion (132,133,134,135,136,137,138).
Aspi rat ion can occur on extubati on. Pharyngeal sucti on may not remove al l of the
f lui d above the tube, and i t can f i nd i ts way i nto t he lungs when t he tube i s
removed. Recommendati ons t o avoi d this i ncl ude wi t hdrawi ng the i nf lated cuff unti l
i t i mpinges on the lower surf ace of t he vocal cords, pl aci ng t he pati ent i n a head
down and lateral posi ti on before cuf f def l ati on, and def l at ing the cuf f duri ng
appli cati on of posi ti ve ai rway pressure to bl ow mat eri al col lected above the cuff
i nto t he pharynx, where i t can be removed by sucti oni ng (484).
Misplacement of Other Equipment into the Trachea
A tracheal tube keeps t he gl ott i s open, maki ng i t easi er t o pass other equipment
i nto t he tracheobronchi al t ree
P. 600

(176, 177,178,179, 180, 819,820, 954). Mi spl aced i t ems have i ncl uded gast ric tubes,
esophageal stethoscopes, t emperature probes, and el ect rocardi ogram (ECG) l eads.
Scan Artifacts
Worki ng in t he MRI envi ronment is discussed in Chapter 30. Art if acts may be seen
on a computed tomography (CT) scan when radiopaque markers are present on a
t racheal tube. Tubes wi thout t hese markers are avai labl e and should be used for
t his appl icati on (955, 956). The metal l i c spri ng i n the i nf l ati on device of a plast ic
t ube can cause an art i f act on an MRI scan (957,958,959). Reposi ti oni ng i t away
f rom the pat ient wi l l usual l y sol ve the problem. Wi re-rei nf orced tracheal tubes wi l l
cause i mage di stort i on when used in an MRI uni t . Nyl on-rei nforced t ubes are
recommended f or this appl icati on (960).
Unintended Extubation
Acci dent al (spontaneous) di sl ocati on of a t racheal tube f rom t he trachea is at best
a nui sance and at worst a l i fe-t hreat eni ng emergency. I t occurs more commonl y i n
smal l er pati ents and i n pat ients wi th burns (459,843).
Neck extensi on or l at eral head rotat ion head can cause cephalad tube movement
(154, 421,711,713, 716, 717). Thi s movement i s i ncreased wi t h nasal i nt ubat ion
(961). The prone posi ti on (962) or upper ai rway swel l i ng can cause t he tube to
move cephalad (789).
Removing a gast ri c tube ent wi ned around the tracheal tube can cause extubat ion
(963).
Acci dent al extubati on can occur when the cuf f i s posi t ioned bet ween or just bel ow
t he cords. If the cuf f i s distended as a resul t of overi nfl ati on or ni trous oxide
di ff usion, i t may herni ate upward. Thi s may resul t i n a l eak. A common response i s
t o i nj ect more ai r i nto t he cuff . If the cuff i s at or just above the vocal cords, thi s
may cause t he tube t o move f arther out of the t rachea.
Removing an adhesive surgi cal drape t hat is posi ti oned over the tracheal t ube may
resul t i n uni ntended removal of the tube (964, 965). Thi s can be avoi ded by placing
something over t he part of t he adhesive st ri p that i s to come i nt o cont act wi t h the
ai rway devi ce (966).
Ant i disconnect devi ces may i ncrease the ri sk of i nadvertent extubati on. I t may be
pref erabl e f or t he connect i on bet ween the tube and the breathing syst em to gi ve
way under strai n t han t o permi t t he tube to be pul l ed out.
To prevent i nadvertent extubat i on, t he t ube shoul d be posi ti oned wi t h the t i p i n the
mi ddl e thi rd of the t rachea wi t h t he neck i n a neutral posi ti on. A cuff t hat requi res
f requent i nf l ati on shoul d suggest t hat i t may be si t uated between the vocal cords.
The t ube shoul d be wel l secured. I f the securi ng tape becomes wet , i t should be
repl aced. Pul l i ng on t he tube should be avoi ded. Care shoul d be taken t o avoi d
extubati on whenever the pat ient is posi ti oned. Usi ng an RAE t ube may decrease
t he i nci dence of acci dent al extubati on.
I f unpl anned extubati on occurs i n the lat eral posi ti on, usi ng a supragl ot ti c device
(Chapter 17) may resul t i n more reli abl e ai rway cont rol compared wi t h t racheal
i ntubat ion i n the lat eral posi ti on (967).
Infection
A hi gh inci dence of si nusi tis and oti t is duri ng and f ol lowi ng nasot racheal intubat ion
has been reported (337,338,339,340,341,342, 343, 968,969). Duri ng l ong-t erm
i ntubat ion, t he rat es of nosocomi al si nusi ti s and pneumoni a do not dif fer
si gni f icant l y between oral and nasal i nt ubati on (970).
Difficult Extubation
A di ff icul t ext ubati on is a rare but dangerous probl em (971). A common cause is
f ai l ure of t he cuf f to def l ate. This may be due to obstruct i on of the i nf l at ion t ube. If
t he obst ruct ion i s di stal to t he pi l ot bal l oon, the bal l oon wi l l of fer no cl ue that the
cuff has not def l at ed (972). Heat f rom a l aser or a dri l l may mel t t he inf l ati ng tube,
causi ng i t to occlude (973). The pati ent may bi te the i nf lati ng tube, causi ng i t to
become occluded. Some users pul l t he pi lot bal loon and i nf l at i on val ve f rom the
i nf l at i on tube t o def l ate t he cuf f . Thi s can cause the i nf l ati on tube t o seal
(514, 515,516). The connect or may occl ude t he i nf l at ion t ube i f i t f i ts bel ow t he
poi nt where the t ube l eaves the t racheal tube wal l (253). A retaining bandage may
ki nk the pi lot tube. The i nf lati ng tube may become entangl ed wi th a nasogastri c
t ube or t urbinate (974). Wi th a sponge cuf f , def l ati on wi l l be di f f icul t if t he i nf l at i on
t ube i s cut or detached (192,193). A f ol d or f l ange in t he cuf f may i mpede
extubati on (975,976,977). Edema of the l arynx may make extubati on dif f i cul t (281).
I f the t racheal or i nf lati on tube is t ransf ixed to adjacent t i ssues, extubat ion wi l l be
di ff i cul t (839, 978,979,980, 981). This probl em is commonl y associ ated wi t h surgi cal
procedures near the tube. A suture may catch a port i on of the t ube wal l or be ti ed
around i t. Forci bl y removing the tube may cause ti ssue disrupti on and l ead to fatal
consequences.
When i t i s i mpossi bl e to def l ate the cuf f , a cut i n the i nf lati on tube may rel i eve t he
pressure i n the cuff (516). I t may be possi bl e to i nsert a syri nge and needl e into t he
stump of t he pi lot tube and def l ate the cuf f . If t he cuff sti l l remains i nf l ated, the
t ube shoul d be pul l ed out unt i l the cuf f is close to the undersurf ace of t he vocal
cords. A needl e can then be i nsert ed through the cri cot hyroi d membrane,
puncturi ng the cuf f (982). Al ternatel y, the t ube can be wi t hdrawn so that t he cuf f i s
seen bel ow the cords and punctured f rom above wi th a sharp obj ect (983, 984).
Removal may be aided by rel axing the vocal
P. 601

cords and/or tube rotat ion (971,983). If the t ube i s surgical l y f ixed to adjacent
t i ssues, surgi cal re-explorat ion may be requi red.
Emergence Phenomena
Undesi rable phenomena duri ng emergence and extubat i on include coughi ng,
bucki ng, rest l essness, increases i n arteri al bl ood pressure, tachycardi a, and
i ncreases in i nt raocul ar pressure. The i nci dence of most of t hese problems can be
decreased by f i ll ing the t racheal tube cuf f wi th a l i docai ne sol ut ion
(985, 986,987,988, 989). Li docai ne wi l l dif fuse through the t racheal tube cuf f (990).
The addi ti on of sodi um bicarbonat e increases t he di ff usion rat e (991,992). Sprayi ng
t he trachea wi t h l i docai ne bef ore i nt ubat i on wi l l decrease t he inci dence of coughi ng
on emergence af ter cases of l ess than 2 hours' durati on (993).
Postoperative Sore Throat
Sore throat is a common postoperat ive compl ai nt
(228, 231,238,994, 995, 996,997, 998, 999). I t i s more common i n f emal es, f ol lowi ng
operati ons i nvolvi ng the head and neck, wi t h use of larger tubes, and when t he
pati ent i s i n the prone posi t i on. Cuff desi gn may be a contri buti ng f actor (1000).
Li mi t i ng intracuf f pressure may decrease t he i nci dence (1000,1001,1002). The
i nci dence of sore throat i s hi gh wi t h t he sponge cuff (114).
St udi es associ at ing the i nci dence of sore throat wi th t he ef f ect of t opi cal l i docai ne,
steroi ds, and lubri cants on t he cuf f of f er conf l icti ng resul ts
(994, 1003,1004,1005,1006). Some studies have f ound t hat i nf lati ng the cuf f wi t h a
l i docai ne or sal ine sol uti on wi l l decrease t he i nci dence and severi t y of sore throat
(986, 987,992,1007,1008,1009,1010, 1011). Sodi um bicarbonate may enhance the
l i docai ne ef fect (1008). Preoperati ve i nhal ati on of a steroid or gargl i ng wi th sodium
azulene sul f onate may hel p (1012, 1013).
Hoarseness
Hoarseness i s commonl y seen af ter i ntubati on. Its inci dence may be decreased by
using t ubes wi t h l ow-pressure cuff s, small er t ubes, and l ubri cati on wi t h l i docai ne
j el l y (1014,1015). Hoarseness i ncreases wi t h di f f icul t and l ong i ntubat ion but not
wi th i ncreased intracuf f pressure (231,998). Hoarseness that i s persistent or t hat
devel ops l ater i n the postoperati ve peri od shoul d be i nvesti gated.
Neurologic Injuries
Tri geminal , li ngual , buccal , and hypogl ossal nerve pal si es have been reported
f ol l owi ng short -term i ntubat i on (965,1016,1017,1018,1019, 1020). Mental nerve
neuropraxi a has been report ed af ter use of an oral RAE t ube (1021).
Upper Airway Edema
Edema may occur anywhere al ong t he path of t he t ube, i ncluding the tongue,
l i ngual f ol l icles, uvula, epi gl ott i s, aryepi gl ott i c f ol ds, vent ri cul ar f ol ds, vocal cords,
and the retroaryt enoi d and subgl ot ti c spaces
(971, 1022,1023,1024,1025, 1026,1027,1028, 1029,1030,1031,1032). The mouth f l oor
can swel l due t o sialadeni t is f rom a submandi bul ar duct obst ructed by a t racheal
t ube (1032).
Laryngeal edema (posti ntubat i on croup or inf l ammat i on, acute edemat ous stenosi s,
st ri dor, and subglot t ic edema) encroaches on the ai rway l umen, especial l y in t he
young chi l d, i n whom a mi l d degree of edema may produce a si gni f icant reducti on
i n the i nternal cross-sect ional area. Because the cri coid cart i l age compl etel y
surrounds t he subgl ot ti c regi on, no external expansi on of the swol l en ti ssues may
occur at thi s l ocat i on.
Laryngeal edema has a peak inci dence between 1 and 4 years of age. I t i s most
commonl y seen af ter surgery invol vi ng the head and neck and wi t h i ncreased
durat ion of i ntubat ion. It is more common i n adul t f emal es than in adul t mal es
(1033). The presence or absence of a l eak or the hi story of a recent respi rat ory
i nfect ion does not correl ate wi t h the i ncidence of croup (301). I nf l ammati on,
mechani cal trauma, a t ube t hat i s too large, moti on, and al lergi c reacti ons to t he
t ube i tself or materi al s used i n lubri cati on or st eri l i zati on have been postul ated as
mechani sms of l aryngeal edema.
Edema may manif est i tsel f any ti me during t he fi rst 48 hours af t er extubati on.
Usual l y, the f i rst signs are evident 1 to 2 hours post operat i vel y. I n i ts mi l dest f orm,
t here i s hoarseness or croupy cough. In the most severe cases, respi ratory
obstruct i on wi l l occur. Decompensati on can be rapid.
Preventi ng l aryngeal edema begi ns wi th avoiding i rri tant st imul i . If there i s an
upper respi ratory i nfect ion, the use of a f ace mask or l aryngeal mask shoul d be
st rongl y considered. Tubes, sprays, and lubri cants that are used on the tubes
shoul d be steri le. Intubat ion shoul d be at raumati c, and adequat e anestheti c depth
and/or good muscl e rel axati on shoul d be maint ai ned t o prevent tube movement.
Head movement should be kept t o a mi ni mum.
Vocal Cord Dysfunction
Vocal cord paral ysis and paresi s have been report ed af ter tracheal i ntubati on
despi te the i ntubati on bei ng atraumat i c and the si t e of t he surgery remote f rom the
head and neck (550,1034, 1035,1036,1037). Most cases resolve spontaneously,
usual l y wi thi n days or weeks, but i t may be l ong term (1038). Posi t ioni ng the tube
wi th t he cuf f j ust bel ow t he cords and high cuf f pressure may i ncrease t he
i nci dence of thi s problem. Because a tube moves cephal ad wi th head or neck
extensi on, the cuf f may
P. 602

become posi ti oned i n the subgl ot ti c region and shoul d be readj usted when the
pati ent remai ns i n thi s posi ti on f or a l ong t ime (154).
Ulcerations
Ul cerat ions (erosi ons) of t he l arynx and t rachea are common, even when a t ube has
been in pl ace f or onl y a short t i me. The i nci dence and severi t y i ncrease wi th t he
durat ion of i ntubat ion. Ul cers vary f rom superf i ci al l esions invol vi ng onl y the
mucosa to deep l esi ons i n which the underl yi ng cart i l age i s exposed. The end resul t
wi l l depend on the l ocati on and severi ty as wel l as other f actors, such as i nf ect i on,
t hat af f ect the heal i ng process. I f the ul cer i s superf ici al , regenerati on to normal
epi t hel i um occurs rel ati vel y qui ckl y. When the damage i s deeper, t he regenerat i on
f ol l ows t he same pattern as for t he superfi ci al damage but is more protracted. If the
ul cer is very deep, scar t issue may f orm.
Cases of uvul ar necrosis f ol lowi ng i ntubati on have been reported (1039,1040).
Vocal Cord Granuloma
The i nci dence of vocal cord granul oma fol l owi ng i ntubati on (i ntubati on or
postanest hesi a granuloma) i s report ed to be between 1 i n 800 and 1 i n 20,000
(1041,1042). Most occur i n adul ts, and they are more common i n women. A number
of possi bl e et iologies have been proposed, i ncl udi ng t rauma, i nfecti on, too l arge a
t racheal tube, excessive cuf f pressure, durati on of i ntubati on, and the t ube
posi t i on.
Symptoms i ncl ude persistent hoarseness, i ntermi ttent voi ce loss, pai n or di scomf ort
i n the throat, a f eel i ng of f ul lness or t ensi on i n the throat , chronic cough,
hemoptysi s, and pai n extendi ng to t he ear. Some cases are symptoml ess.
Occasi onal l y, respi ratory obst ructi on i s seen. Sympt oms may st art af ter extubat ion
or may not devel op f or as l ong as several months.
Persi st ent hoarseness af ter int ubati on warrants l aryngeal exami nat ion. If the
exami nati on reveals ul cerat i on over the vocal processes, strict voi ce rest t o al l ow
heali ng to t ake place may prevent the devel opment of a granuloma.
Latex Allergy
Whi le most tracheal t ubes are made f rom PVC, some l aser t ubes are made f rom
l atex-cont ai ni ng rubber. A careful hi st ory shoul d be taken and proper precauti ons
undertaken if t hese tubes are used. Latex al l ergy i s di scussed i n Chapter 15.
Gastric Tube Knotted around the Tracheal Tube
A gast ric tube may f orm a knot around the tracheal t ube (902,963,1043,1044,1045).
Tandem movement of both the nasogastric tube and the t racheal tube should
suggest this probl em. Opti ons f or deal i ng wi th t hi s i nclude cut ti ng the knot under
di rect vi si on, l eavi ng the knot ted t ube i n pl ace unt i l tracheal extubat i on is
perf ormed, and rei ntubat ion.
Macroglossia
Macrogl ossi a can be a serious probl em resul t i ng in ai rway obst ruct ion af ter
extubati on. Pat ients i n the prone posi ti on, especi al ly f or prol onged peri ods of ti me,
usual l y have edema i n the dependent facial st ructures (1046,1047). Macrogl ossi a
has also been reported i n pat ients i n the si tt i ng posi ti on (1048). Hemorrhage i nt o
t he tongue can occur i n an anti coagul ated pat ient (1049). Li ngual i schemia can al so
occur (1050).
Tracheal Stenosis
Tracheal stenosi s f ol l owi ng bri ef i ntubati on has been reported (1051,1052).
However, this probl em is more common wi t h l ong-t erm i ntubati on.
Cuff Inflated with Medication
Cases have been reported where a syri nge or i nt ravenous l i ne was connected to
t he cuf f i nf l at ion syst em. Medicati on or f l ui d was then i nj ected (1053).
Airway Management Adjuncts
Stylets
A st yl et (i nt roducer, i ntubat i ng or mal l eabl e st yl et) i s designed t o f i t insi de a
t racheal tube and change the shape of the tracheal t ube to f aci l i t ate i ntubati on. A
st yl et i s al so usef ul to check the pat ency of a tracheal tube. A styl et should al ways
be i mmedi atel y avai l able when i ntubati on i s perf ormed. Many anesthesi a provi ders
rout inel y use a styl et , whi l e others reserve i ts use for dif f icul t int ubati ons.
Description
A variety of stylets are avai l abl e. Some have speci al nonst ick surf aces. There
shoul d be a means to l i mi t t he depth t hat t he st yl et i s inserted i nt o the t racheal
t ube (Fig. 19.40). If a securi ng devi ce i s not present , the stylet should be bent
acutel y at the machi ne end (Fig. 19.41). The machine end of the st yl et may have a
means to prevent the tube f rom rotati ng on t he st yl et. A styl et
P. 603

shoul d have enough mal l eabi l i t y so that i ts shape can be changed easi l y and wi l l
yi el d if pressed against sof t t i ssues, yet enough ri gi di ty t o mai ntain i ts shape duri ng
i ntubat ion. I t should be resi stant to chi pping and breaki ng. I t shoul d have a smooth
surf ace devoi d of sharp edges. Some stylets al l ow the user t o change t hei r shape
i n si tu (1054,1055) (Fi g. 19.42). These may be especi al ly usef ul i n t he pati ent wi t h
a cervi cal spi ne injury. The st yl et may have a l i ght at the end to assi st i n
vi suali zati on duri ng and af ter placement.

View Figure

Figure 19.40 Malleable stylets with adjustable stops. The
stop fits into the tracheal tube and prevents the stylet from
protruding beyond the distal tip of the tube. (Courtesy of
Rusch, Inc.)

Techniques of Use
Unl ess the st yl et has a non-st ick coat ing, a thin f i l m of lubri cant shoul d be spread
over i ts l engt h bef ore i nsert i on (1056, 1057). The stylet should be i nsert ed i nto the
t ube unti l the distal end reaches the bevel and shoul d be f i xed so that i t cannot
advance. Occasi onal l y, the pat i ent 's ai rway may requi re extendi ng the styl et t i p
beyond t he tracheal t ube bevel , but thi s i s best avoi ded (1057). Removi ng the
connector f rom t he tube bef ore i nsert i ng the styl et may make i t easi er t o wi t hdraw
t he st yl et and decrease t he l i kel i hood of damage t o the stylet, especial l y if the t ube
has a smal l diameter. I f t he connector i s left i n pl ace, the f l anges, if present ,
shoul d be located at the 2 and 8 o' cl ock posi ti ons when viewi ng the tracheal t ube
al ong the central axis (1057).
The t ube and stylet should t hen be bent to t he desi red shape. For routi ne
i ntubat ions, a st raight or sl i ghtl y curved conf i gurat ion is usual l y best . When deali ng
wi th an anteri or l arynx, a J or hockey st i ck conf igurati on, wi t h t he pati ent end of
t he tube bent anteri orl y at an angl e of 70 to 80, i s most commonl y used. Bending
t he midpoi nt of t he t ube to the ri ght or l ef t may resul t in a bet t er vi ew of t he larynx
(1058). Removi ng the styl et i n si tu can be di ff icul t and may resul t i n acci dent
extubati on (1059,1060, 1061). I f excessive force i s needed, t he st yl et i s ki nked or
t oo sharpl y bent and shoul d be ref ormed or di scarded.

View Figure

Figure 19.41 Malleable stylets. The proximal end must be
bent to prevent it from protruding past the patient end of the
tracheal tube.

P. 604



View Figure

Figure 19.42 Schroeder stylet. By pushing on the proximal
part, the angle of the tube is increased.

The t racheal tube is held so t hat t he thumb rests on the connector. The l arynx i s
exposed and the t racheal t ube inserted. In most cases, uni mpeded passage is
achieved by i nt roduci ng the uni t through the ri ght si de of the mouth whi l e pointi ng
t he tracheal t ube t ip t oward the l arynx and simul taneousl y supi nati ng the hand 30
t o 40 f rom the vert i cal (1057). Adj ustments to the angl e of entry are easi l y made
by moving the connector and/or supi nat ing or pronati ng the hand. The t humb i s
used to advance t he t racheal tube. When the di st al part of the tube i s bel ieved t o
have passed the vocal cords, the st yl et i s caref ul l y wi thdrawn f rom the tube.
Counterpressure on the tube i n the opposi te di rect ion f rom the pul l on t he st yl et
may be necessary t o prevent the t racheal tube f rom bei ng removed. As the styl et is
wi thdrawn, t he ti p of t he tube t ypicall y moves anteri orl y (1056). I f t hi s ant eri or
movement i s ti med wi th passage under the epi glot t is, i t may hel p t o di rect the tube
t hrough an ant eriorl y posi ti oned gl ot ti s.
A sl i ghtl y di ff erent t echni que invol ves i nserti ng the st yl et i nto the t ube, angl i ng the
di stal port ion ant eri orl y, and t hen removi ng the styl et f rom the tube (1062). The
st yl et i s pl aced i n a readi l y accessible l ocat i on. The tube i s advanced to t he vi ci ni t y
of t he l arynx and the st yl et reinserted. Thi s wi l l reduce the pressure on ti ssues as
t he tracheal t ube i s inserted.
Bl i nd styleted t racheal intubati on may be perf ormed (1063).
Problems
The use of a st yl et may be associated wi th t rauma to the ai rway or esophagus
(574, 1064,1065). The risk is i ncreased if the t ip of the st yl et prot rudes f rom the
pati ent end of the tube. I f the tube i s advanced int o the ai rway wi th an acute angl e
on the st yl et, t he t ube t ip may be f orced into t he anteri or larynx. The st yl et shoul d
be retract ed as t he tube is advanced beyond t he gl ott i s.
Part of the st yl et may be sheared of f
(885, 886,887,1066,1067,1068,1069, 1070,1071,1072,1073, 1074,1075,1076). The
st yl et may damage t he tracheal tube. The i nf l at ion tube can become ent angl ed i n
t he st yl et (1077). The t racheal tube may not advance over the styl et af t er i nt ubat i on
(1059,1060,1061).
Bougies
Description
The classi c bougi e (int ubati ng or i nt ubat i on cat heter or i nt roducer, gui de,
i ntroducer or st ylet; Eschmann tracheal i nt roducer) i s shown i n Fi gure 19.43. I t is
f abricated f rom a brai ded pol yester base wi t h a resi n coati ng. I t s col or i s gol den
brown, and i t is reusable. It is holl ow except at i ts ends, but the ends may be cut
away so that i t can be passed over a smal l er gui de or used t o moni t or CO
2

(1078,1079,1080,1081). Pl aci ng twi st ed wi res i n the hol low l umen al lows the bougi e
t o be shaped (1082). Some bougies have l ength marki ngs.

View Figure

Figure 19.43 Bougie.

P. 605



View Figure

Figure 19.44 Tip of bougie.

The dist al end may be angled 30 degrees t o 45 degrees (1083,1084) (Fi g. 19. 44).
Thi s makes i t easi er t o pass the device t hrough the l aryngeal inlet and prevents the
bougi e f rom advanci ng too f ar (1085). A bougi e wi t h a strai ght t ip may be usef ul f or
t racheal tube exchange (510, 1086), but i s less advantageous than an AEC
(1087,1088).
A bougie can be constructed f rom ot her materi als (1089,1090, 1091,1092). The
pl ast i c cannul a f rom a Laryngeal Tracheal Anesthesi a (LTA) ki t may be used as a
bougi e (1093,1094, 1095, 1096). Si ngl e-use bougi es are avai l abl e but may not work
as wel l as reusabl e ones and/or may have greater potent ial f or trauma
(1097,1098,1099,1100, 1101,1102,1103,1104, 1105,1106,1107,1108). A hol l ow
bougi e al l ows veri f i cati on of correct posi t ion by i nsert i ng a f i ne fi beropt i c
endoscope through i t or by using capnography (1092) or the esophageal detector
device (1109).
A bougie wi th an angl ed ti p is especial l y usef ul when the operator recognizes some
anatomi cal l andmarks but cannot di rect t he t i p of the t racheal tube i nto the
l aryngeal i nlet or when movement of t he head and/or neck is undesi rabl e
(536, 1110,1111,1112,1113, 1114,1115,1116, 1117,1118,1119,1120,1121,1122,1123,
1124, 1125,1126,1127,1128, 1129,1130,1131,1132). I n t hese si tuati ons, i t is of ten
possi bl e t o i ntubate t he t rachea wi th t he thinner and more maneuverabl e bougie
and then gui de the t racheal tube i nt o the t rachea over i t.
Techniques of Use as an Aid to I ntubati on
I t i s i mportant to have bougi es of vari ous di ameters avai l abl e.
Bef ore use, a bougi e shoul d be caref ul l y inspected f or f ractures and tested f or
ri gi di ty (1076,1133). I t should be wel l l ubri cat ed. I t can be pl aced f i rst i n the
t racheal tube wi t h the t ip prot ruding, or i t can be pl aced i nto t he gl ot ti s and t he
t racheal tube t hen advanced over i t.
A bougie can be placed i n the t rachea by i nt ernal palpati on of posterior pharyngeal
and glot t ic st ructures or wi th the aid of a ri gi d l aryngoscope or bronchoscope, a
f lexible endoscope, or a supragl ot tic ai rway devi ce
(1121,1134,1135,1136, 1137,1138,1139). It i s bet ter to pre-posi t ion t he bougie i n
t he l aryngeal mask so that i t exi ts through the mi ddl e, rat her t han pass i t bl i ndl y
(1140).
Because the ti p i s angl ed, the t ip shoul d be i ntroduced poi nti ng anteri orl y. If t he t ip
becomes st uck at the ant eri or commissure, i t shoul d be rot ated 180 and then
advanced (367). If the ai rway curvature i s ext reme, t he ti p can be di rected even
more ant eri orl y by l i f t ing i t wi t h f orceps (536). The f ai l ure rate f rom using t he
st rai ght bougi e may be decreased by usi ng a laryngeal (dental ) mi rror (1141,1142).
The bougi e should be advanced gentl y. The f i rst si gn that t he ti p is t raversi ng the
l arynx may be a f ai nt upward pressure fel t by the person who is appl yi ng cri coid
pressure (1125). As t he bougi e advances over the tracheal rings, i t wi l l of ten
produce a cli cking sensati on. The bougie may rotate as i t enters a mai n bronchus
and come to a stop when i t reaches a smal l er bronchus (1111,1118,1121,1143). I n
t he l i ght l y anestheti zed, nonparal yzed pati ent , a cough suggests tracheal rat her
t han esophageal placement (1144). If t he bougi e is holl ow, t he proxi mal end may be
at tached t o a capnograph to conf i rm i nt rat racheal pl acement (1144,1145). However,
CO
2
may not be det ected i f the openi ngs are bl ocked by secreti ons or the t ip i s
passed too far. Pharyngeal pl acement of the t ip coul d yield f al se-posi tive resul ts. I f
cl i cks are not eli ci ted, the bougi e shoul d be gent l y advanced t o a maxi mum
di stance of 45 cm (1146).
During nasal intubat ion, the bougi e i s advanced through the nost ri l and int o the
l arynx. I t i s then observed by usi ng a laryngoscope (367). The bougi e is di rected
t oward t he vocal cords under di rect vi si on. When t he t ip i s i nsi de the l aryngeal
i nl et, t he bougi e is rotated so that the t ip poi nts posteri orl y. It wi l l usual ly t hen
advance i nt o the t rachea. In the pat i ent wi th a l i mi ted mouth openi ng, i t may be
possi bl e t o bl i ndl y pass the bougie through a nostri l and i nto t he trachea (412).
Once t he bougi e i s bel i eved to be in the trachea, the t racheal tube wi t h i t s l umen
l ubricated wi t h a water-sol ubl e gel i s gentl y advanced (rail roaded) over the bougi e
by using a rotary mot i on. A tracheal tube that is designed t o mi ni mi ze the gap
bet ween t he l eadi ng edge of the tube and the i ntubati on catheter may faci l i tat e
i nsert i on (13, 89). I ntubat ion may be f acil i tated by l eavi ng t he laryngoscope i n the
mouth, a j aw thrust, or rot at ing t he t racheal tube countercl ockwise 90 degrees
(357, 535,536,1125,1131,1147,1148, 1149). A bronchoscopi c adapter (Fi g. 19.32)
can be used to check f or i nt ratracheal pl acement of the t racheal tube wi thout
removi ng the bougi e (1150). The bougi e is then wi t hdrawn. I f the bougi e i s
i nadvert ent l y placed i n the esophagus, i t may be used as a guide f or i nsert i ng t he
LMA ProSeal (1151).
A second techni que i s t o prei nsert t he bougi e i nto the t racheal tube so that i ts ti p
prot rudes approxi mat el y 5 cm beyond t hat of t he tube (1125). Thi s may save a f ew
seconds but may make steeri ng t he ti p to the lef t or ri ght more di ff i cul t.
P. 606


Other Uses
A useful techni que f or exchanging a t racheal tube is to insert a bougi e al ongsi de
t he exi sting tube (1152). The exi st ing tube i s then removed, and a new tube is
i nsert ed over t he bougi e.
A bougie can be used t o improve t he ut i l i ty of t he UpsherScope (Chapter 18) by
di recti ng the tracheal t ube t i p anteri orl y (1153).
A bougie can be used t o di rect the ProSeal LMA into t he esophagus (1154) or to
change a ProSeal LMA (1155).
Evaluation
As an ai d to the di f f icul t intubat ion, the bougi e may be superi or to a st yl et
(1110,1114,1146,1156, 1157,1158). I t may be the f i rst i t em t hat shoul d be t ri ed
when l aryngoscope-assist ed t racheal intubati on i s not successf ul (1159).
A bougie may be especial l y usef ul i n the pat i ent wi th a severel y compromised upper
ai rway, anteri or l arynx, or l i mi t ed mouth openi ng (1160). If glott ic exposure i s
i mpossible, the bougi e may be i nserted bl i ndl y toward t he presumed l aryngeal i nl et
and advanced unt i l resi stance i s encountered. The t racheal t ube is t hen t hreaded
over the bougi e.
Usi ng a bougi e may resul t i n trauma to the ai rway (1125,1161,1162, 1163,1164).
The f orce exert ed by the t i p i s i ncreased when the bougi e i s hel d near t he ti p
(1097). The t i p of the bougi e may become det ached, and t he outer l ayer may
become f ract ured (1133, 1165). The bougie can be a source of contaminati on
(1166,1167).
Airway Exchange Catheters
Description
An AEC (gui ding catheter, di rector, st yl et catheter, catheter gui de, elasti c st yl et ,
t racheal tube repl acement obt urator, t ube changer or exchanger, vent i lat i on or
exchange bougi e, j et-st yle catheter, j et stylet , i ntubati on cat heter, i ntubati ng
i ntroducer) (Fi gs. 19.45, 19.46) can be used f or a number of purposes
(486, 505,1168). Numerous ones i n di f feri ng si zes are on the market. Some have an
angul ar di stal ti p si mi lar to a bougie. Some have a sti ff eni ng cannula. An AEC i s
more fl exi bl e and l onger than a bougi e.

View Figure

Figure 19.45 A: Airway exchange catheter. Note the marks
showing the distance from the tip and the holes near the tip.
B: The proximal connections allow administration of
oxygen, jet ventilation, connection to a CO
2
analyzer, or
suctioning. (Courtesy of Cook Critical Care, a division of
Cook, Inc.)

P. 607



View Figure

Figure 19.46 Tube changer in place. (Picture courtesy of
Kendall Healthcare Products, Inc.)

When used as a tube changer, the cathet er must be long enough so that the tube
can be compl etel y removed wi t hout the cat het er bei ng pul l ed f rom the t rachea. Its
l ength must be greater than doubl e that of t he tube bei ng exchanged. It shoul d be
st i ff enough that i t wi l l not kink as the tube i s removed or rei nsert ed. Depth
marki ngs t hat are large, ci rcumf erenti al , and bold are hel pf ul as t hey al l ow an
esti mati on of how f ar the catheter has been i nserted i nt o the ai rway. A catheter
wi th mul ti pl e di stal si de hol es may decrease t he pressure del i vered at the di stal
end, mini mi ze catheter whi ppi ng, and cent er t he cathet er wi t hi n the trachea duri ng
j et venti l ati on (1169).
Vari ous devices have served as AECs, incl udi ng sucti on cat heters, bougi es,
urethral cat heters, embolectomy cathet ers, gastri c tubes, pl asti c sheaths, guide
wi res, and f lexi ble-t ipped st yl ets
(1137,1170,1171,1172, 1173,1174,1175,1176, 1177,1178,1179,1180).
Hol l ow devi ces al l ow oxygen admi ni st rat i on by i nsuf fl ati on or j et venti l ati on and
CO
2
measurement . Adaptors f or these purposes are of ten f urnished wi th t he AEC.
Jet vent i lati on through an AEC can provi de sati sf actory gas exchange i n most
cases (1181). The l ength and smal l ID make manual vent i l at ion wi t h a resusci tati on
bag i mpract ical .
Uses
The choi ce of an appropriat el y si zed t ube changer can be vi tal . The best chance of
a tracheal tube passi ng easi l y over a catheter i nto the t rachea occurs when t he
catheter has a rel ati vel y large OD and the tube has a rel ati vel y smal l ID
(1182,1183). The AEC may be l abel ed wi th t he recommended di ameter tube to be
used wi t h i t . Ai rway exchangers sui t abl e for pedi at ri c tracheal t ubes are avai l able.
A si l i cone spray or wat er-solubl e l ubri cant should be appl i ed t o the outside of the
AEC.
The marki ng on t he cat heter shoul d be matched wi th t he centi met er markings on
t he tracheal t ube t o avoi d advanci ng t he AEC too deepl y. The user must al ways be
cogni zant of t he dept h that t he cat het er i s inserted, because deep inserti on
i ncreases the risk of perf orati on and barot rauma wi t h j et venti lati on. The AEC
shoul d never be i nserted agai nst a resi stance.
I f the AEC i s passed through the sel f -seal i ng di aphragm on a bronchoscopy adaptor
(Fi g. 19.32), venti l ati on can t ake place around the cathet er. Thi s al l ows t he use of
capnography to confi rm i nt rat racheal l ocati on of the tube wi t hout removing the
catheter (1184).
A laryngoscope shoul d be used when passing a t racheal tube over an AEC t o
f aci li t ate passage past the supragl ott i c ti ssues (1182, 1183). Twi sti ng t he tube may
ai d i ts advancement . If resistance is encountered, the t ube shoul d be turned 90
degrees countercl ockwi se.
A jet venti l ator should be i mmedi atel y avai labl e i n case the new t ube does not
f ol l ow t he AEC i nt o the t rachea, and t he jet venti lator should be preset at 25
pounds per square i nch (psi ) (1183). A short i nspi ratory t i me and l ong expi ratory
t i me shoul d be used i ni ti al l y.
Tracheal Tube or Supraglottic Device Exchange
An AEC is especi al l y usef ul for exchangi ng a tracheal tube i n a pat ient who was
di ff i cul t to i nt ubate. It may also decrease the ri sk of ai rway di f f i cul t ies i n pat i ents
wi th an uncompromi sed l aryngeal vi ew duri ng di rect laryngoscopy (1185). Duri ng
t ube exchange, vent i l at ion can be mai ntained by inserti ng the tube changer vi a a
f iberopti c adaptor (Fi g. 19.32). Oxygen i nsuf f l at ion i s achi eved by connecti ng the
exchange cathet er t o an oxygen fl owmet er.
Replacing an Existing Tube
The l ubri cated tube changer i s inserted i nto the t racheal tube and advanced unt i l i t
has reached t he end of the t ube as i ndi cated by depth marki ngs. Al t ernatel y, the
t ube changer may be pl aced al ongsi de the tube (1186,1187). Whi le the tube
P. 608

changer is held steady, the exi sti ng tube i s wi thdrawn. A new tracheal tube i s then
t hreaded over t he tube changer and advanced unti l i t is at the proper depth.
Tracheal pl acement shoul d be conf i rmed by usi ng CO
2
moni tori ng, the EDD, or a
f lexible endoscope. The tube changer i s then wi t hdrawn. Thi s techni que has been
used to exchange a t racheal t ube pl aced submental l y (1188), a nasotracheal tube
(1086), a doubl e-l umen f or a conventi onal si ngl e-l umen tube (1189,1190), a Uni vent
t ube for a si ngl e-l umen t ube (1191), and to repl ace a tracheostomy tube (1192).
Changing a Tracheal Tube from Oral to Nasal
To change an oral tube to a nasal tube, t he tube changer may be passed through
t he oral tube and a tracheal t ube passed t hrough t he nose into the pharynx. The
oral tube i s removed, l eavi ng the tube changer in t he trachea. The nasal tube is
i nsert ed int o the t rachea next to the changer.
An al ternate met hod i s to advance the t ube changer through the nose, then pl ace i t
al ongsi de the existi ng t racheal tube. The exi sti ng tube i s then removed and a
t racheal tube advanced over the exchanger i nto t he trachea.
I n anot her t echni que, t he exchange cathet er i s advanced i nto one of the nares and
t hen brought out through t he mouth (1193). The catheter is then advanced into the
oral t racheal tube. The orot racheal t ube i s then sl owl y wi thdrawn, cutt ing i t
l ongi t udi nal l y unti l i t i s removed f rom the exchange catheter. A tracheal tube i s
t hen advanced over t he exchange catheter.
Another techni que has been descri bed (1168, 1194). A sucti on catheter or other
device is i nsert ed through the nares, and the other end i s retri eved t hrough the
mouth. The AEC i s i nserted into the oral tube, and t he oral t ube i s removed. The
catheter is at tached to the nasal part, and the nasal end is pul l ed out unti l the
upper end of the cat heter appears. This t hen serves as a gui de for a t racheal tube,
whi ch i s advanced through the nose i nto the t rachea.
Changing a Tracheal Tube from Nasal to Oral
Wi th one t echnique, a t ube changer is pl aced oral l y al ongside the t racheal tube (by
using di rect l aryngoscopy or a f l exibl e endoscope) (1195,1196). Al ternatel y, a
f iberscope l oaded wi t h a t racheal t ube can be placed al ongside t he t racheal tube
(478, 1197). A tube changer is passed t hrough the nasal tube, which is t hen
wi thdrawn i nt o the pharynx. A t racheal tube i s advanced over the f i rst tube changer
(or the f i berscope) unti l i t is i n the t rachea. The nasal tube and tube exchanger are
t hen removed. If i t i s not possi bl e to advance the oral tube, t he nasal tube can be
passed back i nto the trachea over the tube changer.
Wi th another techni que, a tube changer i s passed through the nasal tube, t hen t he
nasal t ube i s compl etel y wi t hdrawn (1168, 1198,1199). The t ube exchanger i s
l ocated i n the pharynx and pul l ed out through the mouth. A t racheal tube is t hen
advanced over the t ube changer into the trachea.
Intubation
The AEC can be used si mi larl y to a bougie to faci l i tate i ntubat i on wi t h a si ngle-
l umen or doubl e-l umen tube (1200,1201,1202,1203,1204,1205,1206).
A gui de wi re may be i nsert ed into the t rachea and the t ube changer then inserted
over the gui de wi re (1207,1208). Some cathet ers can be pl aced over a f i berscope
(1209). A supraglot t ic ai rway device can be used to pl ace the cathet er, al though t he
success rate is not hi gh wi th bl ind insert i on (1210,1211,1212). I t i s bett er t o place
t he AEC by usi ng a f l exi bl e endoscope (1206, 1213,1214) or preload i t so that i t
passes t hrough the mi dl i ne sl i t in t he supraglot t ic devi ce (1140).
Extubation
Despi te est abl i shed ext ubat ion cri teri a, i t i s di ff icul t to rel i abl y predi ct subsequent
respi ratory di st ress (485,505,797,1215, 1216,1217,1218,1219). An extubati on tri al
shoul d be consi dered, especi al l y f or a pati ent who mi ght be di ff icul t to rei ntubat e.
The ai rway exchange cat heter i s i nsert ed i nt o t he t racheal tube, whi ch i s then
removed. The catheter f orms a bri dge t hat wi l l al l ow rei ntubat i on, admi ni st rati on of
suppl emental oxygen, venti l at ion, or measurement of end-t i dal CO
2
f rom the
t rachea. If t he pati ent i s abl e to venti l ate adequatel y, the catheter i s removed. The
use of an AEC might produce cost savi ngs by demonstrati ng that pat i ents wi l l
t olerat e extubati on earl ier.
AECs have been l ef t i n place for l ong peri ods of ti me and are wel l tolerated by most
pati ents (1187,1216,1217, 1220,1221). Lubri cat i ng the distal end of the changer
wi th l i docai ne j el l y may hel p the pat ient t ol erate i t bet ter (1222). The pat i ent can
vocal ize whi l e the cat heter remai ns in t he trachea (1217). Mani pul ati on of the tube
changer may be used to st i mul ate the cough ref lex (1220). Oxygen administrati on
t hrough the exchange catheter may obviat e the need f or facemask or nasal cannul a
f ol l owi ng extubat ion. It is possi bl e to enri ch the oxygen cont ent of the gas del i vered
t hrough the catheter by using a f acemask.
Other Uses
An AEC may be used to provi de venti l ati on duri ng microl aryngeal surgery (1168). I t
can provide a usef ul guide to the t rachea duri ng f l exible endoscopy.
Whi le a t racheostomy i s bei ng perf ormed, i t may be useful to re-establ i sh an ai rway
i f a probl em occurs and may guide t he surgeon to the tracheal l umen
(807, 1223,1224,1225,1226).
Another use f or t he AEC i s duri ng ret rograde intubat ion (Chapter 21). The
exchange cathet er i s passed over a gui de inserted t ransl aryngeal ly and passed
retrograde t o the oropharynx or nasopharynx (1078,1227,1228).
Ot her uses for the AEC i ncl ude disti ngui shing esophageal f rom tracheal i nt ubat i on
(605), venti l ati ng
P. 609

t he pat ient duri ng management of intraoperat i ve tracheal i nj ury (1229), faci l i tat i ng
passage of a tracheal t ube over a f i berscope (1230), f aci l i tati ng subment al
i ntubat ion (1231), and venti l ati on of part of t he l ung during thoracotomy (1232).
Complicati ons
Ai rway perf orat ion has been report ed as a compl i cat i on of an AEC
(505, 1215,1233,1234,1235). The ri sk of perf orati on i s rel ated to t he depth of
i nsert i on. The exchange cat heter shoul d never be i nserted agai nst a resi st ance.
The use of j et venti l ati on t hrough t he AEC may resul t in barot rauma
(1169,1181,1216,1236, 1237,1238). The use of standard vent il at ion t hrough a 15-
mm connector i s l ess dangerous, so j et vent i l at ion should be used onl y if standard
venti l ati on f ai ls t o provide adequate gas exchange. The risk of barot rauma wi t h jet
venti l ati on may be decreased by loweri ng the gas pressure, usi ng a short
i nspi ratory t i me, provi ding a l ong expi rat ory ti me, and sel ecti ng a properl y si zed
exchange cathet er (1215,1233, 1239). I t i s import ant t o keep the di st al t i p of the
ai rway exchanger above the cari na. If i ncompl ete chest def l at i on occurs, jet
venti l ati on shoul d be di sconti nued (1240).
There are a number of other compl icati ons associated wi th t he AEC. The catheter
may not sl ip of f t he fl exi bl e endoscope if the f i t i s too ti ght (1241). The tracheal
t ube may f ail to pass over the AEC. Part of t he catheter may break off and be
aspi rated (1133, 1242,1243). The exchange catheter may be inadvert ent l y removed
(1217). The repl acement t racheal t ube may not end up i n t he t rachea (1244). The
channel in t he exchange cathet er t ube changer may become occl uded by
secreti ons, incorrectl y i mpl ying esophageal pl acement (1245). The cat het er may
di sl odge a mucous pl ug, causing ai r way obstruct i on (1246). The catheter may exi t
t hrough a si de hol e in t he tracheal tube (817). Gastric perf orati on secondary t o
oxygen i nsuff lated through a catheter i n t he esophagus has been report ed (1247).
The catheter may shear (1248).
Lighted Intubation Stylets
A l i ght ed i ntubat ion stylet (l i ght wand, [f l exi bl e] l i ghted st yl et , Trachl i ght
TM
,
i l l umi nat ing or l i ghted i ntubat i ng or i ntubat ion stylet) uses transi l l uminat i on of the
sof t t i ssues i n t he anteri or neck to gui de the t ip of the t racheal tube into the
t rachea or t o determi ne t he posi t ion of the tracheal t ube or other ai rway devi ce
(1249,1250,1251,1252, 1253,1254,1255,1256, 1257,1258,1259,1260,1261). Duri ng
di rect l aryngoscopy, t he li ghted st yl et can be used t o i mprove the vi ew i n t he
hypopharynx.
The l i ght ed st ylet i s especiall y useful in si tuat ions where a f i berscope i s
unavai l abl e or endoscopy is dif f i cul t t o perform (e. g. , when an ai rway i s obscured
by bl ood or secret ions or when a pati ent' s head cannot be f l exed or extended).
Description
Several di ff erent l i ghted styl ets are avail abl e commerci al l y. Each has a reusabl e
handl e contai ni ng the power source and a mal leabl e wand wi t h a l i ght at the end.
The wand sect i on may be det achabl e f rom the handl e and may be di sposabl e.
Depth marki ngs shoul d be present . Li ghted st yl ets dif f er f rom st yl et l aryngoscopes
i n that they do not have a means t o see t hrough the styl et. There i s onl y a l i ght
t ransmissi on bundle. Stylet l aryngoscopes are di scussed i n Chapter 18.
Some have a means to secure the li ghted styl et to the t racheal tube. I t may have a
t i p t hat can be mani pul at ed during i nsert i on. On some devi ces, i t is possi bl e t o vary
t he l engt h of the wand secti on to accommodat e t racheal t ubes of various lengths.
Some have a ret ractabl e i nner st yl et that all ows t he di stal porti on to be made
semi ri gi d.
Some of the devi ces use f i beroptic l ight. The l i ght bl inks af ter bei ng cont i nuousl y
ON for 30 seconds (1260). Pediatric l i ght ed st yl ets that can accommodat e tubes as
smal l as 2.5 mm are avai lable (1257,1260).
Techniques of Use
A l i ght ed i ntubat ion stylet that i s l ubri cat ed wi th a si l i cone spray or a wat er-based
l ubricant i s passed through a tracheal t ube so t hat t he l i ght i s j ust short of the end
of t he t ube (1262). I f the bul b prot rudes past t he tube, t rauma may resul t . Adul t -
si zed tubes must be t ri mmed when used wi t h short er st yl ets. The stylet should be
f i rml y at tached to the t ube.
The styl et i s bent to t he desi red shape. For oral i ntubat ion, a 75- t o 120-degree
bend just proxi mal t o the cuff i s recommended (1255, 1260,1263). Care shoul d be
t aken not to bend the stylet at t he poi nt at whi ch the bulb meets t he shaf t (1254). I t
may be usef ul to measure the mandi bul ar-hyoid di stance (1251). Another study
f ound good success wi t h a bent l engt h of 6. 5 cm (1264). If the pati ent has
prot ruding upper t eet h, another bend to coinci de wi t h the teeth should be made
(1265). I f desi red, a catheter may be threaded under t he housing and used to
admi ni ster t opi cal anesthesi a (1266).
Sof teni ng the t racheal tube (by i mmersi on in warm sal ine soluti on or by placi ng i t
i nsi de the hose f rom a forced-ai r warmi ng device) and reversi ng l oadi ng the tube
(upsi de down f rom t he usual posi ti on) may f aci l i t ate passing the t ube i nto the
t rachea (531).
A rel at i vel y extended posi t ion wi l l make i t easier to observe the neck. In obese or
pediatric pati ents or i n pati ents wi t h extremel y short necks, pl aci ng a pi ll ow under
t he shoulders and neck may be usef ul . It hel ps if an assi stant ret racts t he breast or
chest wal l t i ssues
P. 610

and i ndents the tissues around the t rachea. These maneuvers enhance
t ransi l l umi nat ion i n the anteri or neck. The room l i ghts shoul d be di mmed or t he
anterior neck shaded i n obese pati ents or i n t hose wi t h thi ck necks (1267,1268).
The operator may stand at the head or to t he si de of the pat i ent 's head. Loweri ng
t he bed may ai d i n observi ng the neck. The mouth is opened, and the tongue and
mandible are pul l ed f or ward. A bi te bl ock may be needed to prevent the pati ent
f rom bi ti ng the tube-stylet. The t ube shoul d be i nserted f rom t he si de, then brought
i nto t he mi dl i ne of t he oropharynx. I t i s then rot at ed toward t he ti p of the chi n and
rocked (1267). The li ghted styl et may be insert ed t hrough the i ntubati ng port of a
mask (1269).
As the tube and st yl et are advanced, the l i ght t rans-il l umi nates the t i ssues and can
be seen through the anteri or neck. A properl y advanci ng l i ghted st yl et produces a
wel l -def i ned bri ght gl ow i n t he midl i ne. A f ai nt gl ow above the l aryngeal promi nence
i ndi cates t hat t he ti p i s i n the val lecul a. A wi despread glow t o ei t her side of the
mi dl i ne si gnals entry into a pyri form f ossa. A very di ff use, fuzzy, or absent l i ght
means that the esophagus has been entered. Thi s can be corrected by retract i ng
and l i f t i ng the styl et t o bri ng t he ti p more anteri or (1251).
Appl ying cri coi d pressure may i ncrease t he i ntensi ty of the i l lumi nat i on but may
prol ong the int ubati on at tempt and i ncrease the f ai lure rate (1270). I f resi stance i s
f el t , t he l i ghted st yl et -t ube shoul d be rocked backward and t he ti p redi rected by
using t he gl ow f rom t he l ight as a gui de.
A loss of resi stance and/ or cl i ck may be fel t when the l i ght wand i s advanced under
t he epi gl ott i s and through the cords (1261,1267). When the l arynx is sharpl y t rans-
i l l umi nated, the t racheal tube shoul d be advanced into t he trachea. The l ocki ng
device is then rel eased and the l ightwand wi thdrawn f rom t he tracheal tube.
A modi f i cat i on to thi s techni que has been described (1271). Rat her t han retract i ng
t he st yl et on the Trachl ight, the thumb i s used to push the handle vertical l y down
whi l e t he f inger holdi ng t he st yl et mai ntains i t s posi t ion. Thi s retracts the stylet
di stal ly whi l e convert i ng some of the vert ical height of t he st yl et i nto hori zontal
di stance.
Another techni que f or oral i nt ubati on has been descri bed. Thi s techni que uti l izes
t he Bul lard Laryngoscope (Chapter 18) to visual l y assist intubat ion wi t h t he l ighted
i ntubat ion stylet. The Bul l ard st yl et i s removed. The cords are i denti f i ed, and the
Bul l ard scope i s moved t o the l ef t. A t racheal tube over a l ighted stylet is used to
i ntubate the l arynx. Thi s is gui ded int o posi ti on under di rect vi si on f rom the Bul l ard
scope (1272).
I f venti lati on i s needed duri ng i ntubat i on, t he tracheal tube over the l i ghted st yl et
can be i nsert ed t hrough the diaphragm of a venti lati ng mask (1273) or t hrough a
supraglott ic ai rway device (1274,1275,1276, 1277,1278,1279,1280,1281,1282).
The pati ent wi t h a clenched jaw can be i nt ubated by ret racti ng the cheek and
i nsert i ng the li ghtwand f rom the si de l ateral to t he teeth.
Nasal i ntubati on can be perf ormed by usi ng a l i ght ed i ntubat ion stylet
(372, 402,1252,1255,1256, 1257,1258,1283,1284, 1285, 1286,1287). The shape of t he
st yl et shoul d be prepared against the pat i ent prof i l e. The l i ghted st yl et wi th t racheal
t ube i s i nsert ed through the nost ri l and gentl y advanced. When the l i ght i s seen i n
t he oropharynx, the handle i s rotat ed and the ti p di rected toward the thyroi d
promi nence, using the gl ow of the li ght as a gui de. Fl exi ng the pat i ent 's neck,
applying pressure to t he larynx, or i nf l ati ng t he tracheal t ube cuf f may help to al ign
t he tracheal t ube t ip wi th t he gl ot ti s. The Endot rol tube (di scussed earl i er) may be
useful for nasal i ntubat ion wi t h a l i ghted st yl et.
The l i ght ed intubati on st yl et can be used t o ai d di rect laryngoscopy (1288). Pl aci ng
t he l i ghted st yl et i n the t racheal tube wi l l i mprove t he vi ew i n the hypopharynx, and
t ransi l l umi nat ion can assist i n guiding t he tracheal tube i nto the t rachea. In another
t echni que, t he l i ghted i ntubat i on st ylet is placed through the Murphy eye of t he
t racheal tube and advanced beyond the end of the tube (1289). Once the t i p of the
l i ghted stylet is i n the t rachea, the t racheal t ube is threaded over i t . Rotati ng the
t racheal tube may aid i n advanci ng i t.
Useful Situations
St udi es suggest that the l i ght ed i ntubat ion styl et can pl ay a maj or role i n tracheal
i ntubat ion, especi al l y i n pat i ents whose l arynx cannot be visual i zed wi th
conventi onal di rect laryngoscopy
(1256,1260,1290,1291, 1292,1293,1294,1295, 1296,1297,1298,1299,1300,1301,1302
, 1303). These i ncl ude pati ents wi th a li mi ted mouth openi ng, mi cro-gnathi a,
promi nent upper i ncisors, restri cted cervi cal spi ne movement or spi nal
i mmobi l i zat i on, glossoptosis or glossomegal y, or restricted access to the ai rway
(hal o t ract ion, st ereotaxi c f rame). It may be especi al l y usef ul i n si tuat i ons i n which
a fl exibl e endoscope is unavai l abl e (e.g. , ambulances or emergency depart ments)
or endoscopy i s di ff icul t to perf orm (e.g., when the ai rway i s obscured by blood or
secreti ons or when a pat i ent' s head cannot be f l exed or extended) (1303, 1304). I t
may al so be advantageous wi th extensi ve dental work or poor t eeth (1256). The
l i ghted i ntubati on st yl et i s usef ul when the anesthesia provider has l imi ted use of
t he l ef t arm (1305). It has been i ncl uded on the ASA Pract i ce Gui del ines for
Management of t he Dif f icul t Ai rway on t he nonemergency pathway (506).
Ot her si tuat i ons where the l i ghted int ubati on st yl et may be usef ul i ncl ude pati ents
i n head f rames and where head extensi on is not possi bl e. In thi s si tuati on, t he
success rate was not as hi gh and t ook l onger than di rect l aryngoscopy (1306).
P. 611


The l i ght ed intubati on st yl et may be especial l y useful in emergency sett i ngs (1254).
I t i s possi bl e to use t he devi ce f rom the f ront or si de of the pati ent , so t he
t echni que can be used in cramped quarters such as hal l ways and hel i copters
(1291,1257). It i s especi al l y sui t ed to low-l i ght set t ings.
The l i ght ed st ylet can be used to check that the t racheal tube has ent ered the
t rachea and not the esophagus (1280,1307,1308) as wel l as to check f or proper
depth of the t racheal tube (748,1309). I t has been used to ident if y the t rachea
duri ng tracheostomy (1310).
A l i ght ed st yl et can be used to ai d ret rograde int ubati on (1311,1312) and t o pl ace a
doubl e-l umen bronchi al tube (1313,1314). It may be usef ul i n the pati ent wi t h a
cl enched j aw i n whom nasal i ntubati on is cont rai ndicated (1315), the pati ent wi t h
cervi cal instabi l i ty (1316,1317), and t racheostomy (1318).
A l i ght ed st yl et may be used to ai d i ntubat i on through a l aryngeal mask
(1279,1280,1282,1319, 1320,1321,1322,1323, 1324,1325,1326,1327,1328,1329,1330
, 1331,1332). It can be used i n pediatri c pati ents (1291, 1294,1297,1333,1334). I t
can be used wi th t he pat ient i n the l at eral posi t ion (1335).
Contraindications
Contrai ndi cat ions to use of the l i ghted i ntubat ion stylet i nclude pati ents wi t h
t umors, i nfect ion, trauma, or f orei gn bodi es i n the upper ai rway; anythi ng t hat
i nterf eres wi t h transmission of the l i ght f rom t he neck (anteri or neck scarri ng,
f lexion cont racti ons, a beard, excessive adi pose ti ssue, mi dl ine neck tumors or
swel l i ngs, coveri ng of the bul b wi t h bl ood and/or secret ions); and potenti al cervical
spine i nst abil i t y.
Thi s i s not an emergency ai rway techni que. The procedure can take a signi fi cant
amount of t i me and may need to be performed i n the dark (1336). For can' t
i ntubatecan' t venti l ate si tuati ons, a supragl ot ti c ai rway devi ce (Chapter 17) may
be more appropri ate.
I t i s more di ff icul t to use t he l ighted i ntubati on styl et i n chi ldren and i nf ants t han in
adul ts and shoul d not be undertaken i n smal l pat ients wi t hout experi ence i n ol der
ones (1302).
Advantages
The l i ght ed intubati on st yl et i s si mpl e, i nexpensi ve, l i ghtwei ght, reusabl e, rel i abl e,
compact , easi l y cl eaned, port abl e, and reasonabl y durabl e. I ntubat ion can be
accompl i shed rapi dl y af t er f aci l i t y wi t h the techni que has been at tained
(1259,1260,1331,1337, 1338). I t can be performed wi th cricoi d pressure and i n
uncooperati ve pat i ents (1303). The presence of bl ood or secreti ons i s not a st rong
i mpedi ment to success. I t can be used when access t o the head and ai rway are
l i mi ted. Head and neck manipul ati on can be kept to a mini mum. A wi de mouth
openi ng is not requi red.
I ntubat ion by usi ng the l i ght ed st yl et i s associ ated wi t h a l ow i nci dence of mucosal
i nj ury, dysphagi a, sore throat , and dent al t rauma compared wi th di rect
l aryngoscopy (1259,1261, 1339,1340), but one study f ound a greater incidence of
hoarseness wi t h the l ight ed stylet (1341).
The ci rcul at ory responses and ef f ects on i ntraocul ar pressures are si mi l ar to di rect
l aryngoscopy (1339,1341, 1342,1343,1344,1345,1346, 1347,1348,1349). In awake
pati ents, the magni tude of stress i s less than wi t h a laryngoscope (1350).
The i nt ubat i on techni que wi t h t he l ighted styl et is easi l y l earned, al t hough there i s
a learning curve (1340).
Compared wi t h bli nd nasal i nt ubat i on, nasal i ntubati on wi th a l i ghted styl et has
been shown t o requi re less ti me and f ewer att empts (1252). In pati ents wi t h cervi cal
spine disorders, intubati on wi th a l ighted styl et is f aster and associ ated wi t h a
hi gher success rate t han i ntubati on through an i ntubati ng l aryngeal mask (1298). It
causes l ess cervical spine movement than int ubati on wi th a Maci nt osh
l aryngoscope and is f aster t han using a Bull ard l aryngoscope or f iberscope (1317).
Disadvantages
Thi s i s a bli nd approach and prof ici ency i n use requi res practi ce. The ti me to
i ntubat ion and number of at t empts are greater t han wi th t he pat ients i nt ubated wi th
a ri gi d laryngoscope (1250,1251,1256,1341,1351).
Complications
The bulb or l ens may become detached (1250,1254,1290,1352, 1353). The device
may f racture near the handl e (1354).
There i s the potenti al f or t rauma i n the upper ai rway associated wi th i ts use. Cases
of aryt enoid di sl ocati on and epi glott is malposi ti on have been reported
(1355,1356,1357). A case has been report ed where the epi gl ott is was parti al l y
pushed i nt o the l aryngeal i nlet (1355).
I t i s not uncommon to cause some bleedi ng wi t h thi s technique. I f this techni que
f ai l s, the presence of blood makes f i beropt ic techni ques more dif f i cul t .
Wi th repeated use and st eri l i zati on, the styl et may become i rregular and di ff i cul t to
retract (1358). A small amount of l ubricant may hel p t he probl em. The el ectri cal
contact between the st yl et and the handl e may fail , causi ng intermi tt ent l i ght .
Whi le t here is concern that the bul b coul d cause a burn i n the t rachea, this has not
been report ed. The absence of inj ury may be a resul t of conti nuous movement of
t he l i ght bul b (1359).
P. 612



View Figure

Figure 19.47 Magill's forceps. (Picture courtesy of Sun
Med.)

Forceps
Forceps can be used to di rect a t racheal tube i nto the l arynx or a gast ri c tube or
ot her devi ce i nto t he esophagus. I t may al so be used to i nsert or remove
pharyngeal packi ng and to remove f orei gn bodi es f rom the upper ai r way or
esophagus (1360, 1361). Forceps shoul d be i mmediatel y avai l able whenever an
i ntubat ion i s perf ormed.
Description
A popular type is Magi l l ' s f orceps (Fig. 19.47). These are desi gned so t hat when
t he graspi ng ends are i n the axis of the t racheal tube, the handl e i s to the ri ght .
When t he larynx is exposed, most of the forceps is out of t he l i ne of si ght .
Modi f icati ons of Magi ll ' s forceps and use of ot her devi ces have been described
(1362,1363,1364,1365, 1366,1367,1368).
Problems
The t racheal tube cuf f may become damaged, especiall y when f orceps are used
wi th hi gh-volume, l ow-pressure cuf fs. The tube shoul d not be grasped at the cuf f .
Another way t o avoi d cuf f damage is to smoot h the ri dges on t he forceps (1362).
The f orceps may cause damage to t he ai rway mucosa. Another probl em i s that one
arm of the f orceps may become l odged in a Murphy eye (28). A f orceps may break
(1369,1370).
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P. 629


Questions
For the f ol lowing quest ion, sel ect the correct answer
1. The best way to detect an esophageal intubation is
A. Seei ng the t ube pass through the vocal cords
B. Observi ng chest wal l movement duri ng i nspi rati on and exhal ati on
C. Heari ng breat h sounds duri ng cont rol l ed venti l ati on
D. Moni t oring CO
2
i n exhal ed gases
E. Seei ng a drop i n oxygen sat urati on as measured by pulse oxi meter
Vi ew AnswerFor the fol l owing quest i ons, answer
i f A, B, and C are correct
i f A and C are correct
i f B and D are correct
i s D i s correct
i f A, B, C, and D are correct .
2. Factors that hel p to determine the resistance to breathi ng that resul t from
the use of a tracheal tube include
A. Tube length
B. I D of the t ube
C. Tube conf i gurat ion
D. Gas viscosi t y
Vi ew Answer3. Which statements about dead space are accurate?
A. Pedi atric t ubes and connectors can i ncrease dead space above normal
B. The use of a shorter t racheal tube wi l l decrease dead space
C. Mechani cal venti lati on can overcome the eff ects of i ncreased dead space
D. The dead space of t he t ube pl us connector i s greater t han natural dead space in
adul ts
Vi ew Answer4. Materials commonly used in tracheal tubes today include
A. PVC
B. Rubber
C. Si l icone
D. Pol yethyl ene
Vi ew Answer5. Concerni ng the Murphy eye,
A. I t may reduce t rauma duri ng nasal intubati on
B. A f i beropti c scope may become trapped i n i t
C. I t may mask a ri ght mai nstem bronchi al i nt ubati on
D. Secreti ons may tend to accumulate there
Vi ew Answer6. Advantages of a spiral embedded tracheal tube i ncl ude
A. Ease of i nsert ion over a f iberscope
B. Resi stance t o ki nki ng
C. Fl exibl e enough to be pl aced i n t racheost omi es
D. Unl i kel y to be the cause of obst ructi on
Vi ew Answer7. Wi th respect to tracheal tube size,
A. Pedi atric t ubes are si zed by the OD
B. Tubes l arger t han si ze 6.0 must have the OD marked on t hem
C. The French scale i s requi red to be marked on the t ube
D. Si ze i s of ten di spl ayed on the pil ot bal l oon
Vi ew Answer8. Wi th tracheal tubes,
A. Cuff pressure should be kept bet ween 25 and 34 cm H
2
O
B. Measuri ng t he i nt racuff pressure in hi gh-pressure cuff s gi ves an i ndi cat i on of the
pressure appl ied to the t racheal wal l
C. Ni trous oxi de can cause the cuf f pressure t o i ncrease
D. I nt racuff pressure in l ow-pressure cuf f s does not vary during cont rol l ed
venti l ati on
Vi ew Answer9. Advantages of the foam cuff tube i nclude
A. Measuri ng i nt racuf f pressure i s not necessary
B. Even large cuf f s do not present excessi ve pressure t o the t racheal wal l
C. Di ff usion of anestheti c agents wi l l not aff ect cuf f pressure
D. A seal suf f icient to prevent aspi rati on wi l l be achi eved regardl ess of the rel at ive
si ze of t he tube and t rachea
Vi ew Answer10. Features of the Lanz pressure-regulati ng val ve include
A. I t gives an i ndi cati on of cuff inf l ati on
B. I t has an external reservoi r f or cuf f ai r
C. I t l i mi ts the pressure i n t he cuf f
D. I nt racuff pressure is mai ntai ned at 26 to 33 torr
Vi ew Answer11. Products approved for use as a laser-resistant wrap for
tracheal tubes i ncl ude
A. Copper f oi l
B. Al umi num tape
C. Al umi num foi l
D. Sponge and adhesive-backed corrugated sil ver foi l
Vi ew Answer12. Disadvantages of wrappi ng tracheal tubes include
A. The OD of the tube i s increased
B. A rough surf ace may be created
C. A ref l ected beam coul d damage other ti ssues
D. The ai rway coul d become obstructed
Vi ew Answer13. Problems associated with a tracheal tube cuff that i s too
l arge i nclude
A. Pressure on the t racheal wal l wi l l be i ncreased
B. Trauma to the vocal cords is more l i kel y
C. I nt racuff pressure wi l l be i ncreased
D. Aspi rati on is more l i kel y to occur
Vi ew Answer14. In determini ng proper i nfl ation of a l ow-pressure, hi gh-
vol ume cuff,
A. The vol ume of ai r j ust needed t o aboli sh ai r l eak may not be enough to prevent
aspi rat ion
B. The feel of the infl ati on bal loon i s a good i ndi cati on of t he cuff pressure
C. Measurement of cuf f pressure i s needed to determi ne proper i nf lati on
D. Cuff pressure needs to be checked duri ng the inspi ratory phase of venti lati on
Vi ew Answer15. Possibl e compl icati ons of nasotracheal i ntubation
i ncl ude
A. Removal of segments of t urbinates
B. Esophageal perf orat ion
C. Perf orati on of the nasal septum
D. Perf orati on i nto the retropharyngeal space
Vi ew Answer16. Ways to mi nimize trauma when a nasal i ntubati on is
performed include
A. Avoi di ng lubri cants
B. Warmi ng t he t racheal tube
C. Vasodi l ati ng the nasal mucosa
D. Using small er t ubes than t hose that woul d be used f or oral i ntubati on
Vi ew AnswerP. 630


17. If there i s a leak around the tracheal tube that recurs despi te added ai r,
A. The tube may be sli di ng i n and out of a bronchus
B. The cuf f may be above the cords
C. Gas may be dif f usi ng out of the cuf f
D. There may be a l eak i n the cuff
Vi ew Answer18. Factors that tend to promote i nadvertent bronchial
i ntubati on include
A. Trendel enburg posi ti on
B. Neck f l exion
C. Laparoscopy
D. Use of RAE tubes for chi l dren
Vi ew Answer19. Rel iable methods for determi ning the presence of an
i nadvertent bronchial i ntubation i ncl ude
A. Auscul t at ion of the l ungs
B. Pulse oxi metry
C. End-t i dal CO
2
moni toring
D. Fi berscopi c vi sual i zat i on through the tube
Vi ew Answer20. Ways to handle a cuff l eak i ncl ude
A. Reint ubati on
B. Packi ng the pharynx
C. At tachi ng a mechani sm f or cont inuous ai r i nf usi on to the cuf f i nf lat i on system
D. Fi l l the cuf f wi t h l i docane and sal ine
Vi ew Answer21. Ways of preventi ng tracheal tube obstructi on include
A. Checki ng t he cuf f f or even i nf l ati on
B. Not wi t hdrawi ng the tube wi t h the cuff i nf l ated
C. Using an oral ai rway or bi t e bl ock
D. Putt ing t racti on on the t racheal tube
Vi ew Answer22. Factors i ncreasing the incidence of aspirati on of gastric
contents include
A. Head-up posi t ion
B. Control led vent il ati on
C. Accumul at i on of fl ui d above the cuff
D. Hi gh-pressure cuff s
Vi ew Answer23. Factors that i ncrease the li kel i hood of accidental
extubati on include
A. Removi ng an adhesi ve pl asti c drape
B. Usi ng anti di sconnect devices
C. Removi ng a nasogast ri c t ube bef ore ext ubati on
D. Pl aci ng the tube at t he cari na
Vi ew Answer24. Possibl e causes of di fficult extubati on i ncl ude
A. Obstruct i on of t he inf l at ing mechanism
B. Pul l i ng the pi l ot ball oon and inf l ati on devi ce f rom t he i nf lat i ng mechani sm
C. Surgi cal transfi xi on
D. Swel l i ng in t he ai rway
Vi ew Answer25. Postoperative sore throat
A. Is more common i n mal es t han f emal es
B. Is increased i f the pat ient i s in t he prone posi t ion
C. I s rel ated to both durat i on of anesthesia and age of t he pat ient
D. I s associ ated wi t h use of l arger t ubes
Vi ew Answer26. Concerni ng hoarseness foll owing i ntubation,
A. The i ncidence i s decreased wi th t he use of l ow-pressure cuff s
B. Lubricati on of t he t ube wi th l i docai ne j el l y does not decrease t he inci dence
C. Smal l er t ubes are associ ated wi t h a decreased inci -dence
D. The i ncidence i s not i ncreased i f the i nt ubati on was traumati c
Vi ew Answer27. Laryngeal edema
A. May be caused by pre-existi ng i nfl ammati on, bacteri al contami nat ion, or
chemical s
B. May be caused by i nadequat e muscl e rel axati on or t oo l arge a t ube
C. May be caused by an al lergi c react ion to the tube or l ubri cants
D. Can occur anyt i me duri ng t he f i rst 48 hours af ter ext u-bat ion
Vi ew Answer28. Granulomas of the vocal cords
A. Are found most commonl y i n mal es
B. May not become symptomati c for several months
C. Are most common in chi l dren
D. May be sympt omless
Vi ew Answer29. Disadvantages of preformed RAE tubes include
A. The tube may not be cut
B. I ncreased resistance
C. Hei ght and wei ght are not useful to determine the proper si ze tube
D. Age i n years i s not usef ul t o determi ne the proper si ze tube
Vi ew Answer30. Advantages of the mi crolaryngeal tracheal surgery tube
i ncl ude
A. Smal l diameter provi ding bet ter visibil i t y f or the surgeon
B. Lower resi stance t o both inhal ati on and exhal ati on
C. Can be used f or pat i ents wi t h a narrowed ai rway
D. Can be used wi th l asers
Vi ew Answer31. Which tube(s) have a high-pressure cuff?
A. Nort on tracheal tube
B. Sheri dan Laser t racheal tube
C. Lasertubus
D. I nt ubat i ng l aryngeal mask tracheal tube
Vi ew Answer32. Disadvantage(s) of usi ng a tracheal tube with a l ow-
pressure cuff include
A. Aspi rat i on of f lui d f rom the upper ai rway i nto t he trachea
B. I t may be torn easi l y
C. A great er i nci dence of sore t hroat compared wi t h the hi gh-pressure cuff
D. More di f f icul ty duri ng inserti on
Vi ew Answer33. Situation(s) that wil l cause tracheal tube cuff pressure to
vary include
A. Heated humi dif i cat ion
B. Oxygen di f fusion i nto the cuf f
C. Changes i n head posi ti on away f rom the neutral posi ti on
D. I ncreases in al t i tude
Vi ew Answer34. What are some ways to l imi t changes i n the intracuff
pressure in the low-pressure cuffs?
A. Moni tori ng cuff pressure
B. Fi l l i ng t he cuf f wi th a mixture of oxygen and ni trous oxide
C. Fi l l i ng the cuf f wi th wat er or sal ine
D. Leavi ng a syri nge at tached to t he i nf lat i on tube
Vi ew Answer35. Advantages of cuffed tracheal tubes include
A. Less operat i ng room poll uti on wi t h anestheti c gases
B. Decreased aspi rati on ri sk
C. I mproved moni tori ng of respi ratory gases
D. Greater margi n of saf et y
Vi ew Answer36. Drawbacks of using cuffed tubes in chil dren i ncl ude
A. Possi bl e obst ructi on by t he cuff
B. Hi gher gas f l ows must be used
C. Sucti oning through the tube is more di ff icul t
D. Lower i nf lat i on pressure must be used
Vi ew AnswerP. 631


37. Advantages of oral intubati on include
A. Can be perf ormed qui ckl y
B. Mi ni mal cervi cal spi ne mot ion
C. Can use a t racheal t ube wi th a l arger di ameter
D. Wel l tol erated i n the consci ous pat ient
Vi ew Answer38. Indicati ons for nasotracheal intubati on include
A. Temporomandibul ar joi nt movement l i mi tat i on
B. I nt raoral pat hol ogy
C. Cervi cal spi ne i njury
D. Fractured maxi l l a
Vi ew Answer39. Advantages of nasotracheal i ntubati on include
A. A l arger t ube can be used
B. Tube wi l l not be occluded by bi t ing
C. Lower i nci dence of bact eremi a
D. Less cervi cal spi ne movement t han oral i nt ubat i on
Vi ew Answer40. Relati ve contraindicati ons to nasotracheal i ntubation
i ncl ude
A. Coagul opathi es
B. Previ ous repai r of the cri bi f orm plate
C. Abscesses
D. Trans-sphenoidal surgery
Vi ew Answer41. Which technique(s) wil l facil i tate passing a tracheal tube
through the vocal cords over a flexi ble endoscope, bougie, or exchange
catheter?
A. Warmi ng t he t racheal tube
B. Rotati ng the tube counterclockwi se 180 degrees
C. Appl ying a j aw thrust
D. Using a smal l er endoscope, bougi e, or exchange cat heter
Vi ew Answer42. Way(s) to avoid trauma associated with tracheal
i ntubati on include
A. Thermosof teni ng the tube
B. Use onl y gent le pressure
C. Do not let a devi ce i n the t racheal tube protrude f rom the ti p
D. Appl ying a vasoconst rictor t o the nose
Vi ew Answer43. Whil e observi ng chest wal l moti on as a test of tracheal
i ntubati on, which condi ti ons may si mulate tracheal i ntubati on during an
esophageal i ntubati on?
A. Pati ents wi t h a low l ung vol ume
B. Obese pati ents
C. Low chest wal l compl i ance
D. Abdomi nal respi rati on
Vi ew Answer44. Which auscul tatory techni que(s) gi ve the most rel iabl e
i ndi cation that the tracheal tube is in the trachea?
A. Auscul t at ion of the upper abdomen and lungs
B. Gurgl i ng sounds wi t h venti lati on
C. Ai rway auscul tat i on
D. Auscul tati on of high mi d-axi l lary area
Vi ew Answer45. Situations where end-tidal CO
2
detecti on may not
i ndi cate that the trachea has been intubated include
A. Cardi ac arrest
B. Exhal ed gases in the stomach
C. Pulmonary embol ism
D. Bronchospasm
Vi ew Answer46. Situations where the esophageal detector device wi ll be
more accurate in detecti ng tracheal i ntubation than CO
2
moni toring i nclude
A. Severe bronchospasm
B. Cardi ac arrest
C. Pulmonary embol ism
D. One-way t racheal tube obstruct ion
Vi ew Answer47. Situations where CO
2
monitori ng may cause a fal se-
positive readi ng about tracheal tube pl acement include
A. Exhal ed gases forced int o the stomach duri ng previous mask vent i l at ion
B. I nt ravenous l actated Ri nger' s sol ut i on
C. Antacids t hat have reacted wi th gast ri c aci d to f orm CO
2

D. Bronchospasm
Vi ew Answer48. Compl icati ons that can occur wi th the l i ghted stylet
i ncl ude
A. Burns f rom the hot l i ght bulb
B. Aryt enoi d di sl ocati on
C. Takes more ti me and more attempts than bl i nd nasal i ntubat i on
D. Epigl ot ti s mal posi t ion
Vi ew Answer49. Ways to avoid tracheal tube obstruction i ncl ude
A. Usi ng t ransparent tracheal t ubes
B. Def l at ing the cuf f before wi thdrawi ng t he tube
C. Cut ti ng t he machi ne end of t he tube at a bevel before the connector is i nsert ed
D. Pl aci ng a bi te block bet ween t he inci sor t eeth
Vi ew Answer50. Indicati ons that a parti al tracheal tube obstruction is
present may include which of the fol l owing?
A. Wheezi ng
B. An al terati on i n t he pressure-volume l oop
C. Paradoxi cal chest movements duri ng spont aneous breat hi ng
D. A decreased sl ope i n Phase II I and a smal l er angl e on t he capnogram
Vi ew Answer51. A partial tracheal tube obstructi on can be diagnosed by
which of the fol lowi ng maneuvers?
A. Def l at ing the tracheal tube cuf f
B. Di gi tal examinati on
C. Fi berscopi c exami nat i on
D. I nsert i ng a styl et or sucti on catheter
Vi ew Answer52. Ways to relieve a parti al ly obstructed tracheal tube
i ncl ude
A. Usi ng a hemostat or clamp to rel i eve the ki nk
B. Passi ng a smal l er tube through the t racheal tube
C. Using an embol ect omy catheter
D. Pl aci ng a l arger t racheal tube over the ki nked t racheal t ube
Vi ew Answer53. Which of these techniques may avoid pul monary
aspirati on when the tracheal tube is removed?
A. Wi thdrawi ng the tube wi t h the cuf f infl ated unt il the cuff is j ust above t he vocal
cords
B. Pl acing the pat i ent i n the head down l at eral posi ti on
C. Wi thdrawi ng the tracheal t ube duri ng sucti oning
D. Wi thdrawi ng the tube under posi t ive pressure in t he trachea
Vi ew AnswerP. 632


54. Situations that can contri bute to macrogl ossia include
A. Si t ti ng posi t i on
B. Anti coagul at i on
C. Prone posi ti on
D. Hemorrhage i n the pharynx
Vi ew Answer55. Indicati on(s) that a bougie has entered the trachea
i ncl ude
A. Rotati on, i f the bougie enters a mai nst em bronchus
B. A cl i cki ng sensat ion as i t passes over tracheal ri ngs
C. Resistance as i t enters smal l er bronchi
D. A decrease i n f orce needed to advance the bougi e
Vi ew Answer56. Situations where the li ghted intubati on stylet is
parti cularly useful include
A. Li mi ted mouth openi ng
B. Mi crognathi a
C. When a f lexi ble endoscope i s not avai l abl e
D. When the anesthesi a provi der has l i mi ted use of the lef t arm
Vi ew Answer57. Contrai ndi cations to the li ghted styl et technique of
i ntubati on include
A. Forei gn bodi es in t he upper ai rway
B. Pl acing doubl e-lumen or bronchi al tubes
C. I nf ection
D. Cervi cal instabi l i ty
Vi ew Answer