Cutting the ET tube a few centimeters (the part protruding out of mouth) reduces the dead space. And this may decrease the time for oxygen to reach the lungs.and this will improve patient outcomes. What are your thoughts?
I totally agree with Shawn . Cutting a tube has just a little benefit. The airway resistance is based on the Hagen-Poiseullie-Equation . The key parameter is inner diameter of the tube and flow. It is inversely proportional to the power of 4th of the diameter. So for example an 8mm endotracheal tube has an resistance of 4mbar/l/s and a 6mm tube a resistance of 12mbar/l/s at a flow of 30l/min. The length of the tube is not as important. Another point is the status of respirator-therapy. If patient is just intubated or on a stable respiratory therpay why sholud you change anything ? In weaning status we have to beneficial data for cutting the tube. If you really want to decrease the tube resistance for spontaneous breathing trials(e.g. weaning) change the tube to a bigger I.D. or do a tracheosotmy or simply extubate the patient if there are not contraindication (neurological status, adequate cough, ....)
I agree with the comments regarding airway resistance as the diameter is more important thatn the length of the tube, but lets forget resistance and think more about dead space. How long is too long for an Et Tube? Any thougts? In veterinary medicine, we asked our students to measure the length of the Et tube going from the tip of the shoulder to the end of the nose. It is often advised to cut the tube if it is too long to decresae dead space and possible rebreathing effect. But really, what is too long? Of course, it will depend of the breathing system, rebreathing vs. non-rebreathing and the FGF (non rebreathing system).
I agree with above comments. The dead space ventilation should be viewed as the proportion of the tidal volume delivered with each breath. Pediatricians are more concerned with this problem in neonatal ventilation. In Newborn babies even the small dead space ventilation may be proportionately more in relation to the tidal volume delivered especially in certain volume controlled ventilator modes. on the other hand the the ET length should not be too small also to avoid undue tube displacements. Cutting of ET tube may not be very beneficial in older children and adults.
It could be the better idea to cut the ETT a few length to reduced dead space gases exchange (If it is extra long ) only after when it is placed and fixed well enough that you are sure it wouldn't be disconnected during surgery .
Cutting the tube seems to be a common practice in the UK, but personally I can't see so much benefit of it (see above). According to dead space-your whole circle has much more effect.
1. Agreed that this will decrease dead space.
2. Can be helpful in weaning period but not much when patient is on ventilatory support.
3. May be beneficial in ARDS as low tidal volumes are preferred in this condition as decreased dead space will further help to keep tidal volumes on lower side (adjusted).
4. Though this may decrease the time for oxygen to reach the lungs but this probably will not improve patient outcome.
Hi everyone. One aspect you haven't mentioned is access to the tracheobronchial tree for secretion clearance. With an uncut tube, most closed suction systems (and many open ones) will fail to get sufficiently far to clear the mainstem bronchi adequately in patients with copious secretions. Also. depending on the method of tube fixation, long tubes can encourage the ETT to sit on the roof of the mouth and bend along it, which promotes dis-lodgement.
Personally I dont cut ETT's - dangerous practice once patient intubated and means that the ETT cannot be kept in a dependant position increases "rain-out" from the ETT thereby increasing the risk of a VAP. Dead space may be imprtant in the smalest of patients and I agree optimise flow by siting an appropriately sized ETT.
Also by having a dependant ETT you minimise the risk of nares trauma.
Hope this helps
Mark
I am of the personal opinion that the advantage of cutting the Et tube is far less than the disadvantage. I usually cut the Et tube only when I want to put the patient on T piece during weaning process. If the patient is on ventilatory support, length of Et tube rarely matters to me as I hardly see ARDS patients. The biggest advantage of not cutting the tube I felt is that it becomes easier for the paramedics to take care of the patient.
Trust this answers your query.
Madhavan Menon
I do not agree with Andrew Fergusen´s opinion that you should cut the tube to achieve a adequate access to the bronchial system e.g. with closed suction systems. Using these systems is completly unselective. You are not able to intubate a selective bronchus and you never should forget the risk of bronchial bleedings esp. at the carina region caused by the suction cath. If the patient is not able to cough the secrete up to the trachea bronchioscopic controlled suction and lavage you should be the right choice
As a pediarician, we routinely cutted the ETT tube a few cm. But the point is how much cm should we cut it so that it wasn't too long, might be cause kinking , nor too short, might be damaged nares.
There is no study to prove the benefit of cutting short the endotracheal tube at least in pediatric population. I recall a Japanese professor told me that he never cut the ETT short. He believed a premature infant can breathe through a uncut ETT (means a higher beathing effort) with CPAP then it means the baby is ready to be extubated. Some of us will cut the tube to 11 cm for neonates as mentioned in old NRP textbook. One thing for sure is that if the tube is cut too short then there will be a lot of so called "self-extubation". This is because the tube is prone to slide out more frequent during nursing of airway care with a short tibe without enough wiggle room. One thing to add. You do not cut the ETT after the tube is secured since it means the scissors will be very close to the face of the patient which is a big "no-no" for safety reason (Never trust you skill or luck. I have seen bad thing happened.).
I think for long term ventilation in the ICU it is better to cut the ETT because of the possibility of kinking and unrecognized endobronchial intubation. In the OR I do not think that is necessary because the patient is continuously monitored by professionals and for limited period period.
Do not forget some type of endotracheal tube can not be cut say like the special ETT for HFJV. And, it will be difficult to secure the shortened ETT if Neo-Bar is used.
I am agree with Mark Davidson, in OR or PACU ICU, do not cut OTT, is a malpractice.
Yes its appropriate to cut the tube after intubation as it does decrease the resistance. In critically ill patient even a slight increase in resistance and greatly affect the work of breathing
Always check the Chest X ray before any decision to cut the ETT. If the tube is identified to be 2 CM above the Carina and you are satisfied with the position, record the CM marking at the patients teeth prior to any intervention. Scissors in close proximity to the balloon pilot tube can pose risk as a small cut in the pilot tube can lead to a poor seal and potential aspiration or inadvertent extubation. Cutting the ETT to overcome dead space in unto itself should not be considered as this can be overcome with a small increase in PEEP. Cutting though for safety with a concern that a protruding ETT is at risk of being accidently removed as a patient is becoming conscious, particularly in the long term ICU patient, is worth considering.
I am pediatric anesthesiologist .I prefer to cut ETT in small neonates & infants,because it prevent kinking,tube displacement,it makes easy suction ,.I keep about 3-4 cm out of mouth.I am so satisfied with cutting the ETT.it is my usual practice in operating room.
Cutting the tip of ETT provides several benefits
1. Reduce the dead volume, hence improve ventilation and oxygenation
2. It prevents kinking and improve stability of ETT so that it will not drag on the cuff and tracheal wall
3. It will reduce resistance and eliminate unnecessary increased peak airway pressure not-related to patients airways
4. It will reduce the possibility of lodging sticky secretions and sputum and ETT obstruction (usually on the inner end of ETT) by easier endotracheal toilet and suctioning
HOWEVER, a minimum of 5 cm from the tip of the teeth should be spared for easier manipulation and after making sure that the ETT is in place (lower end 2 cm above the carina) and not slipped out. it should be noted that manipulations of ETT especially for ETT suctioning may cause the ETT to slip out of its place
Cutting the ETT is my daily practice in the NICU. It's very important for the NB, esp those premature infant. It could reduce the dead space, resistance and decrease WOB .
There is no evidence that cutting the tube improves physiological outcomes, but it is likely to for some parameters. However with regards your question, I would bet this would not translate into improved patient outcomes. I would reiterate the advantages of cutting before intubation rather than using scissors near small noses
We only use in small tubes in patients with sever COPD or asthma and increased resistances in airway. It decreases dead space an you can see modest improvements in blood gases. In pediatrics is more important because represent a higher percentage of dead space
It certainly is logical to decrease L in order to decrease resistance, but it can be dangerous to cut the tube AFTER intubation. You will be interrupting ventilation and somtimes it is difficult to replace the adaptor without dislodging the ETT. If I anticipate the need, I cut the tube prior to intubating the patient and "seal" the adaptor-tube interface by wiping the surfaces with alcohol before reattaching.
It seems logical to cut the ETT to decrease the resistance but we do not have evidence it will provide any benefit. Some Japanese center will not cut ETT short since it can help determine which premature infants are ready to be extubated if they can maintain good ventilation with uncut ETT. Also, we do not cut ETT if it is for HFJV.
Yes, we do it all the time.One should be careful not to overdo and allow it slip into the mouth......
Too lengthy tube apart from all mentioned above can kink with body warmth and obstruct the airway either partial or complete harming the patient!!
If your skills are good enough to manage the situation, all is possible. Have a sharp scissors and make sure you dont harm the patient with sharps and also make sure you have enough help. At the most you may have to oxygenate the patient for a second time or reintubate the patient with a different ETT. Safety is anaesthesia and anaesthesia is safe practice.
I essentially agree with all respondents... though I am confused as to whether we are discussing shortening the length of the circuit (dead space) or is it a resistance issue (length/internal diameter of ETT) which I am interpreting as different entities?
Shortening the tubing from ventilator to ETT will address the former (as stated no RCT validating this practice) and is more practical then cutting the ETT, while shortening the ETT may address the latter (e.g resistance and work of breathing) in combination with appropriate pressure support depending on clinical scenario.
I don't cut the ETT, and haven't heard it discussed or seen anyone do it for quite some time now. My reasons, firstly, unless you cut prior to insertion you are increasing the risk of adverse events. Secondly, I agree with Jason, there are many far more effective ways to decrease dead space. Thirdly, one final caveat; never, ever cut the ETT in a burns patient.
Yes, we do it especially in extreme and very preterm (EVLBW) neonates with severe RDS, because ETT represent a high percentage of dead space in EVLBW neonates. It decreases not only dead space and also resistances in airway (small size EETs are always used in EVLBW neonates) and it afterwards improve blood gases.
Though theoretically speaking, cutting the tube might decrease the dead space but changing the settings is a safer and more convenient way in general patients... as for small babies and COAD patients, it will be wiser to cut it before intubation to avoid unfoerseen complications it may cause
Dead space has never been a concern and the need to cut the ETT to reduce the dead space. It is to prevent kinking mainly and true should be careful while you cut the tube to size in a burns patient.
I do not recommend cutting the tube in ICU setting. In my experience, dead space and resistance issues can be taken care without cutting the tube. We are accustomed to see a particular length of ETT of particular size, On round in ICU /OR, just one walk around and most of us can tell which tube is more in or out and they will be most of the time right. In Operation theatre kinking can be an issue if you are not able to visualize the tube/ face, so always keep tube under vision. Another issue- why manufactures make particular length for a size? Only in neonates in ICU- may be, I am not sure. If most of the neonatalogist do it, they should do proper study and give recommendations to the manufacturers.
We do not cut the tube after intubation. We feel that this is a good idea to cut the unnecessary segment to not only reduce air flow resistance but make oxygen reach the lung more quickly.
We will try this later
For adult patients internal diameter of tracheal tube varies between 0.5-1 cm. If we cut the tube 1 cm piece, dead space will be reduced only 0.78-3.14 mL. This volume is not important to reduce dead space and to improve gas exchange. Moreover shortening of the tube is not helpful to reach oxygen into the lung more quickly. And tube lenght is not important to airflow but diameter is important.
The truth is nobody knows the right answer. If shorten the tube has a benefit why manufactuers make the tube so long? Dead space 0.78-3.14 ml maybe nothing to adults but will be almost 1.5 ml/kg for a 500 gramer (1/3 of the tidal volume). We can use any kind of rationale to support our own opinion but nobody is able to prove it without a RCT.
0.78-3.14ml dead space for adults. For preterm neonates if we cut the tube 1 cm piece, dead space willl be reduce jsut 0.3-0.6 mL. This volume is not important to reduce dead space volume even a 500 gr pretem. Moreover compliance of new anesthesia circuits and endotracheal tubes are very love. Additionaly we can observe dead space increase withETco2 and we can eliminate two ways: CO2 absorbants or high flow anesthesia. Risk of extubation with shorten tube is more important in a 500 gr neonate.
Cutting or not cutting an ETT is an age old question. After many years in anaesthetics, I have come to the following conclusion.
1) With modern ventilators and breathing systems, resistance and dead space is a 'non-issue'in ventilated patients and as stressed by others, cutting a tube insitu can cause problems.
2) There should be a policy of cutting or not cutting in a department, especially when the same patient may be looked after by more than one person.
3) In the event when the ETT is going to be out of sight, draped over or covered, it may be wiser to cut it to size to minimise chances of kinking.
4) vigilance, communication, agreement, and then adherence to agreed policy.
Best of luck.
cutting of ET is usually not required in our practice exept in IUGR neonates who require higher number of ET but full length is not required and as to prevent kinking we can cut it.
never felt too good about cutting the tube....it somehow felt like the patient isn't getting much out of it but the chance of accidental extubation and need for more careful care about the tube increased. this cutting idea is one of those dogma that are passed on the generations. my older colleagues did it so many of my colleagues do it as well. if I am the one to choose- don't cut is my choice in adults
Cutting of ET tube is not required except in small neonates. The concern of dead space is not at all relevant in adults.
Any manipulation of medical devices should be avoided if possible. That´s my personal opinion. Shorter ETs in special situations should be used if neccesary although dead space should not be an extra challenge if we have ventilation dispositives available (such as ECMO...?).
There is no significant impact on reducing dead space by cutting ET for 1-3 cm after intubation. It may be done to avoid kinking (if its not an armored one) due to critical positioning of the patient (e.g., prone). But what about the use of catheter mount? Doesn't it increase the dead space significantly?
In my opinion, with appropriate ventulation, for instance using PEEP, appripriatete rate and the modern uptodate machines, dead space during ventilation is of little consequence. Or none! Ans to try and cut the tube further and 'mess' with it with the possibility of misplacing it is not worth it. Another important point is that uf the tube protrudes too far from the lips, kinking can happen. Brware of that, appropriate alarm stup and paying attention to alarms ans take action, fast..
When reduction of deadspace and ressistance to airflow is considered cutting ETT tube has very little signiifcance.
Off course, the impact is negligible in adults population but in neonates or preterm equipment headspace has significant share from MV.