Tracheal Tube Selection for Laryngoscopy and Intubation
For airway management requiring laryngoscopy and intubation, use a tracheal tube size of 7.0-8.0 mm internal diameter (ID) in women or 8.0-9.0 mm ID in men, and preferentially select tubes with subglottic suction ports when available. 1
Recommended Tube Specifications
Size Selection
- Women: 7.0-8.0 mm internal diameter 1
- Men: 8.0-9.0 mm internal diameter 1
- These sizes align with standard local practice and provide adequate ventilation while minimizing trauma 1
Tube Features
- Prioritize tubes with subglottic suction ports to reduce ventilator-associated complications 1
- Standard cuffed endotracheal tubes are appropriate for most clinical scenarios 1
Tube Placement Technique
Depth and Position
- Pass the cuff 1-2 cm below the vocal cords to avoid inadvertent endobronchial intubation 1
- Maintain continuous visualization on the videolaryngoscope screen during tube passage to ensure proper placement 1
- Difficult laryngoscopy is specifically associated with inadvertent endobronchial intubation, making careful depth assessment critical 1
Post-Intubation Verification
- Obtain a chest X-ray to confirm appropriate tracheal tube insertion depth, though this does not confirm tracheal (versus esophageal) placement 1
- Capnography remains the gold standard for confirming tracheal placement 1
Adjuncts for Tube Insertion
Stylets and Bougies
- With videolaryngoscopes using Macintosh blades: A bougie may be used and can be pre-loaded within the tracheal tube 1
- With hyperangulated videolaryngoscope blades: A stylet is required for successful tube passage 1
- Exercise caution when removing bougies or stylets to avoid spraying secretions on the intubating team 1
Standard Direct Laryngoscopy Setup
- If videolaryngoscopy is unavailable, use a standard Macintosh blade with a bougie (either pre-loaded or immediately available) 1
Special Considerations for Tube Exchange
High-Risk Exchange Situations
- When a tracheal tube requires urgent replacement (displaced, blocked, kinked, cuff failure, or undersized tube), always use videolaryngoscopy over direct laryngoscopy as it provides superior glottic view, higher success rates, and fewer complications 1
- Maintain airway continuity throughout the exchange procedure using airway exchange catheters (AECs) specifically designed for this purpose 1
Critical Safety Warning for AECs
- Do not administer oxygen via an AEC during tracheal tube exchange, even though some AECs are hollow and permit oxygen flow 1
- Low-flow oxygen administration via an AEC risks barotrauma if the catheter tip is placed or migrates beyond the carina 1
- If an AEC is left in place after extubation, administer oxygen by other means 1
Common Pitfalls to Avoid
Tube Size Errors
- Avoid selecting tubes that are too small, as this may necessitate a high-risk tube exchange procedure later 1
- Difficult or fiberoptic airway management sometimes results in placement of inappropriately small tubes that require subsequent exchange 1
Placement Complications
- Traumatic intubation can cause air leak or pneumothorax, particularly in difficult laryngoscopy scenarios 1
- Monitor for bleeding, swelling, and surgical emphysema if the airway has been traumatized 1
- Pharyngeal or oesophageal injury from difficult airway management may lead to deep infection and life-threatening sepsis 1
Post-Intubation Monitoring
- Watch for "red flags" including absence or change of capnograph waveform, chest wall movement changes, increasing airway pressure, reducing tidal volume, inability to pass a suction catheter, obvious air leak, or vocalization with an inflated cuff 1
- These signs should prompt immediate attention to the airway and breathing circuit, particularly after patient movement or procedures 1