Endotracheal Tube Size in Critically Ill Patients

Abstract

To determine if smaller endotracheal tubes are noninferior to larger endotracheal tubes with respect to critical illness outcomes. DESIGN, SETTING, AND PARTICIPANTSThis propensity score-matched retrospective cohort study included all adult patients who underwent endotracheal intubation in the emergency department or intensive care unit and received mechanical ventilation for at least 12 hours from June 2020 to November 2020 at a single tertiary referral academic medical center. EXPOSURES Endotracheal intubation.MAIN OUTCOMES AND MEASURES Propensity score-matched analyses were performed with respect to the primary end point of 30-day all-cause in-hospital survival as well as the secondary end points of duration of invasive mechanical ventilation, length of hospital stay, mean peak inspiratory pressure, 30-day readmission, need for reintubation, and need for tracheostomy or gastrostomy tube placement.RESULTS Overall, 523 participants (64%) were men and 291 (36%) were women. Of these, 814 patients were categorized into 3 endotracheal tube groups: small for height (n = 182), appropriate for height (n = 408), and large for height (n = 224). There was not a significant difference in 30-day all-cause in-hospital survival between groups ([HR, 1.1; 95% CI, 0.7-1.7] for small vs appropriate; [HR, 1.1; 95% CI, 0.7-1.6] for large vs appropriate). Patients with small-for-height endotracheal tubes had longer intubation durations (mean difference, 32.5 hrs [95% CI, 6.4-58.6 hrs]) compared with patients with appropriate-for-height tubes.CONCLUSIONS AND RELEVANCE Despite differences in intubation duration, the results of this cohort study suggest that smaller endotracheal tube sizes are not associated with impaired survival or recovery from critical illness. They support future prospective exploration of the association of smaller endotracheal tube sizes with recovery from critical illness.

Reassessing Endotracheal Tube Size in Critically Ill Patients

“…The study findings that patients with small-for-height ETTs did not experience higher rates of mortality, reintubation, tracheostomy, ventilator-associated pneumonia, or prolonged hospital stay provide a rationale for investigating the effect of tube size on associated quality-of-life outcomes. The present study did not incorporate patient-reported measures or quality-of-life outcomes.…”

“…Little is known as to whether larger ETTs improve recovery. Esianor and colleagues found no difference in 30-day all-cause in-hospital survival between patients with small, appropriate, or large-for-height endotracheal tubes. If larger tubes do not improve survival, is survivorship a better focus?…”

“…To the Editor We read with great interest the article by Esianor and colleagues on endotracheal tube (ETT) size in critically ill patients . Laryngotracheal injuries after invasive mechanical ventilation range from reversible pressure injuries to permanent damage, scarring, fistulas, and transmural lesions .…”

“…Investigating the association between ETT size and clinical outcomes is difficult, partly because randomizing patients to small or large ETT sizes is inappropriate and unethical. The propensity-matching nearest neighbor approach used in this study adjusted for potential confounders; but it cannot correct for unknown influences—including the judgment of clinicians whose intimate patient knowledge or inclinations can modify decisions in ways not accounted for by calculated scores. Uncaptured data on disease severity, airway abnormalities, organ failure, prior use of high-flow oxygen, or other unmodeled factors could systematically differ between groups.…”

Reasessing Endotracheal Tube Size in Critically Ill Patients—Reply

“…In Reply We greatly appreciate the response of Dr Brenner and colleagues to our recent study . We are in complete agreement about the potential harms of large endotracheal tubes (ETT), which are commonly used in routine clinical care.…”