Endotracheal Tube

My practical experience with endotracheal tubes...
Always maintain all sizes of endotracheal tubes for infants, small children and adult. Few adult cuffed endotracheal tubes are a must. Nasal soft tubes size 8, 9, 10 can be lifesavers. They should be sufficiently long. They can also be used for passing a Ryle’s tube in an unconscious patient. After threading the Ryle’s tube in a well-lubricated nasal tube is passed in Oesophagus and Ryle’s tube is threaded down into the oesophagus, the nasal tube is withdrawn. If it is difficult to pass the tube nasally, pass the tube orally push the threaded Ryle’s tube and withdraw the soft tube. The oral Ryle’s tube can be railroaded into the nose with the help of catheter fixed snugly in the end of Ryle’s tube. Push the Ryle’s tube, which is stiff. Do not pull the catheter.
In case of difficult intubation a soft portex tube is passed nasally which mostly enters the larynx. Sometimes it remains anterior to the epiglottis, which can be placed posterior to the epiglottis with Magill’s forceps and threaded to enter the larynx. Sometimes the tube gets hitched against the anterior commissure and cannot advance in the larynx and trachea. It can be manoeuvred by slightly flexing the neck, which corrects the angle between the advancing tube and the trachea.
All endotracheal tubes must be washed by you with soap and water and a jet of water forced down the tube to remove all the left over secretions and finally cleaned by brush and water and dried with a towel. This will save your embarrassment when a freshly boiled tube for use shows secretions of the previous case or a foreign body like a cotton swab or even a cockroach, even a nasal turbinate has been recovered.
Nasal endotracheal tube advanced before oral extubation in case of full stomach makes life easier. Sometimes solid food and big blood clots cannot be aspirated from the oropharynx when extubated and the patient struggle for breath. Nasal tube maintains the free airway and allows sufficient time for the patient to vomit out stomach contents if he is conscious and clear the oropharynx.
All tubes should be fitted with female Noseworthy’s connections. Cobb’s connection is only useful in cases with wet lungs when intermittent suction is mandatory. The connection must be tight fitting and of correct size. Do not try to fit bigger connection as it may tear the tube (rubber).
Cuffed ET should not be used all the time. It spares your cuffed tubes. With use of air it is hardly necessary if the bellows or respirator are used. As far as possible do not inflate the cuff. Pass the proper size tube. If the air leaks by the side of tube is more, replace the tube with the next size. Use of cuff can cause oedema and damage to the mucous membrane of the trachea in long duration cases. After placement of ET inflate the cuff yourself. Over zealous Assistants always tend to over inflate the cuff. The over inflated cuff becomes a very strong stimulus and in light plane of anaesthesia it can lead to intense bronchospasm endangering life if not detected. Cases are known where inflation becomes impossible due to bronchospasm and cyanosis start appearing in spite of oxygen rich mixture used to inflate the lungs thus produced by an inflated balloon. The bronchospasm produced by over inflated balloon does not respond to usual bronchodilator treatment like injection of drugs. It only responds to:
-Deflation of cuff
-Removing the ET
-Deepening the level of anaesthesia
The simplest in the situation is deflation of cuff. The remaining methods appear to be dangerous and are not productive. For conduction of cases always have 3 sizes ready. Also do not forget to keep a nasal tube of appropriate size always ready. It is specially important in cases who are overweight, short neck or where the mouth cannot open adequately. Nasal intubation can prove a life saving procedure in all difficult intubations. In a planned case always ascertain the freedom of breathing through each nostril separately. Lubricate the nasal tube thoroughly, do not use force at any stage. You can have two obstructions while passing a tube through the nose, one at the nasopharynx where it meets the Passavant’s ridge and secondly while the tube meets the larynx at its outlet. The first difficulty should be solved by putting a finger in the nasopharynx as you advance the tube to hook it and bring it out into the pharynx, and second difficulty can always be solved by flexing the neck so that the angle of the advancing tube corresponds with the trachea. The difficulty is due to the nasal tube hitching against the anterior commissure. Do not force the nasal tube. It can cause bleeding.
Rubber tubes last about a year or more and hence one should not hesitate to boil the tube for 2 minutes before each case. Discard the tube when the tube shows signs of perish. The boiled tubes before use must be cooled and in emergency cooled under tap water. A case of an adult female is recorded who had an intubation with hot tube. This patient for Thyroidectomy needed Tracheostomy in the postoperative period. This precaution is a must in case of children and infants.
Inspect the tube before giving it for boiling for any foreign body (Cockroach) or debris. Sometimes cotton swabs used for cleaning have been detected. So look down the tube after straightening to find the presence of any obstruction. Unimaginable objects have been accidentally found inside the tube. In small tubes and Oxford tubes run the water through the tube and pass a stillette to ensure perfect patency. One must possess all types of tubes like armoured, nasal, Oxford, infant and special for specific use. If one can obtain laryngeal mask airway all 3 sizes.
Endotracheal tube connectors
One should have sets of different connections like right angle, Cobb’s, and curved as in some situations one requires various angles and various other uses for the connector. A Cobb’s connection can be used when one has to resort to suction intermittently and for giving IPPR with thumb technique and for use as Ayre’s T piece if it is not available. For routine use it is better to have a plastic female nose worthy connection fitted to each tube and a male Noseworthy connection to the catheter mount or the various unidirectional valves can directly connected to Noseworthy connection with metal connectors check the catheter mount.