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78th Annual PostGraduate Assembly in Anesthesiology (PGA78) 2024
December 6 - 9, 2024 | New York City
4082
Sizing Preferences in Endotracheal Tube Selection and Knowledge of Glottic Stenosis Risk Factors: A Comparative Study Among Anesthesiologists, Intensivists, and Emergency Physicians
Poster Presenter
Part of Topic
Size Matters: Endotracheal Tube Sizing Preferences and Familiarity of Glottic Stenosis Among Intubating Physicians
Jason S. Chwa1; Elizabeth A. Shuman MD2; Karla O’Dell MD2
1Keck School of Medicine, University of Southern California, Los Angeles, CA
2Department of Otolaryngology – Head and Neck Surgery, University of Southern California, Los Angeles, CA
INTRODUCTION
•Acute laryngeal injury (ALgI) has been shown to occur in ~57% of patients intubated with an endotracheal tube (ETT) for ≥12 hours and is associated with posterior glottic stenosis (PGS).1
•There is compelling evidence that height is the primary determinant of tracheal morphology,2-3 but no widely accepted guidelines for adult ETT sizing exist.
•“Smaller-for-height” ETTs have been shown to have little impact on ventilator pressure during anesthesia and are also associated with better laryngeal functional outcomes in critical-care settings.4
•“Large-for-height” ETTs lead to greater risk of ALgI.1
STUDY AIM
•Understand how factors driving ETT size selection differ across non-otolaryngology specialties who intubate patients frequently: Anesthesiologists, Intensivists, and Emergency Medicine physicians.
•Characterize familiarity of posterior glottic stenosis among these physicians.
METHODS
•Anonymous, online 14-question Qualtrics survey distributed to all faculty Anesthesiologists, Intensivists, and EM physicians at a single tertiary care institution from January 2024 – June 2024.
•Non-faculty physician providers (e.g., residents, CRNAs) were not invited to participate.
•Participants completed questions pertaining to their training, ETT sizing preferences, factors considered in decision-making, and familiarity regarding risk factors of posterior glottic stenosis.
RESULTS
•Standard ETT size was reported by 94 (91.3%) respondents to be 7.5 mm or larger in males and by 92 (89.3%) respondents to be 7.0 mm or larger in females.
•There was a significant difference among specialties in preferred ETT size for females (P<0.001). Anesthesiologists tended to prefer smaller ETT sizes in females compared to both Intensivists (P=0.001) and EM physicians (P=0.003).
•All respondents preferred a significantly larger ETT for males compared to females (P<0.001).
Top Selection Factors Across All Specialties
1.Need for bronchoscopy
2.Potential for complications
3.Concerns about mucus plugging
Top PGS Risk Factors by Respondents
•Length of intubation (68.0%)
•Cuff pressure (62.1%)
•ETT size (60.2%),
•Multiple intubations/re-intubation (59.2%)
•Ischemia (31.1%)
DISCUSSION
•Recent literature supports attempts to intubate with smaller ETTs unless there is a compelling reason to do otherwise.4 ~20-30% of patients may be intubated with an inappropriately large ETT (≥1.0mm larger than recommended based on patient height).2
•~83% of patients that develop iatrogenic ALgI-related laryngotracheal stenosis are female.2 Providers preferred larger ETT size for males compared to females, which may be attributed to use of potentially unreliably sex-based heuristics.
•Standard bronchoscopes are ~5.7mm, so ETTs ≥7.5mm may be preferred to provide access while maintaining safe airway pressures.
• Only ~4% of mechanically ventilated ICU patients required bronchoscopy in the US annually,5 and use of narrower bronchoscopes can circumvent ventilatory complications with smaller ETTs.3
•Cuff pressure was erroneously identified as a PGS risk factor by a significant proportion of respondents. Providers may falsely equate PGS to tracheal stenosis.
•Our findings should motivate future quality improvement initiatives aimed at reducing ALgI incidence.
REFERENCES
1.Shinn JR, Kimura KS, Campbell BR, et al. Incidence and Outcomes of Acute Laryngeal Injury After Prolonged Mechanical Ventilation. Crit Care Med. 2019;47(12):1699-1706.
2.Coordes A, Rademacher G, Knopke S, et al. Selection and placement of oral ventilation tubes based on tracheal morphometry. Laryngoscope. 2011;121(6):1225-1230.
3.De La Chapa JS, Webb K, Stadlin C, et al. Evolving Endotracheal Tube Preferences and Practices: Intensivist Knowledge Gaps and Sex Disparities. Laryngoscope. 2023;133(11):3080-3086.
4.Schiff BA. The Relationship between Body Mass, Tracheal Diameter, Endotracheal Tube Size, and Tracheal Stenosis. Int Anesthesiol Clin. 2017;55(1):42-51.
5.Wayne MT, Seelye S, Molling D, et al. Variation in U.S. Hospital Practices for Bronchoscopy in the Intensive Care Unit. Ann Am Thorac Soc. 2022;19(6):1061-1065.
CONTACT
Jason Chwa / jchwa@usc.edu / 626-262-2366