Red rubber reusable ET tubes - educate me.

RE: Red rubber reusable ET tubes - educate me.

Sal the 1st — Thu, 22 Aug 2019 00:08:00 GMT

https://northamerica.covetrus.com/content/pdfs/p051027.pdf guess we are looking for something like this? - searching already

RE: Red rubber reusable ET tubes - educate me.

apache — Wed, 21 Aug 2019 23:50:41 GMT

[quote user="Alison Clare Hickman"]What do you think? Would it be worthwhile your practice using a pressure gauge with your LVHP RR ET tubes to reduce/eliminate the likelihood of tracheal trauma?[/quote]

I'm going to investigate options, I think this is a great idea. Not sure why the device needs to be disposable and expensive, going to investigate the digital manometers on ebay eyc. Will feed back, but I do have a couple of busy weeks.

RE: Red rubber reusable ET tubes - educate me.

Alison Clare Hickman — Wed, 21 Aug 2019 19:40:05 GMT

[quote user="jimbomcgrimbo"]

Castilho EC, Cerqueira Braz JR, Cataneo AJM et al. (2003) Effects of Tracheal Tube Cuff Limit Pressure (25cm H2O) and ‘Seal’ Pressure on Tracheal Mucosa of Dogs, Brazilian Journal of Anaesthesiology 53 (6): 743-755

[/quote]

apache

What do you think? Would it be worthwhile your practice using a pressure gauge with your LVHP RR ET tubes to reduce/eliminate the likelihood of tracheal trauma?

It is a hidden trauma if it is a 'minor' one. Nevetheless, it is still trauma. Maybe all your patients have thus far shown zero signs of trauma... of course they may not have had any (what we all aim for), but have any coughed post surgery? Have they had tracheal pain? (which could likely be covered/masked by POP analgesics) or had any other 'post op' issues you see, or have reported, that couldn't reasonably be attributed to other factors?

It will be great if you reply "seen no problems so far post op so feel happy I don't need to change what I do"... still though..is there the chance that someone less experienced/skilled than you placing the right tight sized ET tube &/or over enthusiastic cuff inflation would benefit from a pressure gadget for guidance?

What are your thoughts?

RE: Red rubber reusable ET tubes - educate me.

James Colver Cert. Ed, RVN — Wed, 21 Aug 2019 19:24:47 GMT

We have one ECC vet who insists upon using them, he's the most diligent vet I've ever worked with. They are provided by the practice so why not.

RE: Red rubber reusable ET tubes - educate me.

Alison Clare Hickman — Wed, 21 Aug 2019 14:30:43 GMT

James Colver Cert. Ed, RVN - yes please to that link... For me personally, I'd prefer to be pro-active in preventing any possible patient damage so am thinking about that pressure gauge thingy would be a useful tool and show best practice if using low volume high pressure tubes...

I'm all for trying to avoid (or do my very best to avoid) patient damage occurring in-practice that could have been prevented. If I have a device that gives me useful information in this respect, yes please.

Ali h

RE: Red rubber reusable ET tubes - educate me.

James Colver Cert. Ed, RVN — Wed, 21 Aug 2019 12:17:45 GMT

RE: Red rubber reusable ET tubes - educate me.

Sal the 1st — Wed, 21 Aug 2019 11:04:42 GMT

I would be interested in the link please .

RE: Red rubber reusable ET tubes - educate me.

James Colver Cert. Ed, RVN — Wed, 21 Aug 2019 10:41:05 GMT

It's a really interesting question. And I think that we have to be so careful with what we extrapolate from what's being done in humans. One of the most interesting things I read was a study showing the effects of cuff pressure. Not a nice one, as they killed the dogs and dissected them - but they found lesions on the trachea even at what we would consider as an OK cuff pressure, certainly with the subjectivity of palpating the pilot balloon or the 'leak test' method. Can find the link if anyone's interested.

RE: Red rubber reusable ET tubes - educate me.

Sal the 1st — Wed, 21 Aug 2019 02:17:52 GMT

RE: Red rubber reusable ET tubes - educate me.

Sal the 1st — Tue, 20 Aug 2019 23:48:02 GMT

again a genuine question from me and I'm not quite sure how to word it - is it possible that in humans endo tubes are being used which are smaller relative to the size of the trachea with a larger cuff to effect a seal, and good oxygenation over a prolonged period is achieved not through the patient's increased respiratory effort against a smaller tube but with the aid of mechanical ventilation and muscle relaxants - whereas in veterinary practice the tendency is towards a larger tube and therefore a larger internal diameter offering less resistance to spontaneous breaths and because of its size needing a smaller cuff?

The reason I ask this is that whilst I was hunting through some of the ex NHS stock I have I came across some endo tubes that give you the actual cuff diameter when inflated - a 6.5mm internal diameter oral/nasal with an external diameter of 8.8mm and a cuff diameter of 22mm. The cuff diameter would suggest that something quite a bit bigger than a tube of 8.8mm external diameter would fit down there and offer less respiratory resistance?

Hope that made sense?

RE: Red rubber reusable ET tubes - educate me.

James Colver Cert. Ed, RVN — Tue, 20 Aug 2019 21:57:00 GMT

I'm not trying to change anyone's mind on this occasion. Just voicing an opinion. I have no doubt that the reference list will not include anything that will change Apache's mind. I just wrote up the case because it was interesting, and likely to be under-recognised. People are free to use whichever tubes they see fit. I won't use the red rubber ones, our hospital has binned them all - that's good enough for me :)

RE: Red rubber reusable ET tubes - educate me.

apache — Tue, 20 Aug 2019 21:55:41 GMT

James Colver Cert. Ed, RVN, interesting. Not something I had heard of. I'm not sure the literature in people supports LVHP tubes as a causative factor - it occurs even when uncuffed tubes are used:

"Various types of ETTs were used for intubation, including cuffed rubber tubes, cuffed silicone tubes, and uncuffed silicone tubes. Cuffed ETTs were used in 37.7%, whereas cuffed high volume, low pressure, and uncuffed endotracheal tubes were used in 22.6 and 20.8% of the study population, respectively. An uncuffed ETT was used in all pediatric subjects. Intubation was traumatic in 9 subjects. The median (IQR) size of the ETT was 7.5 (6–9.3) mm. The information regarding ETT cuff pressure was available for 12 subjects, and the pressure was maintained at <25 cm H₂O in 11 of these subjects. In 3 other subjects, the ETT cuff was not inflated. The median (IQR) duration of intubation was 36 (14–96) h. Ten subjects had an ETT dwelling time of ≤5 h. There was no difference in the duration of intubation in the pediatric and the adult age group (see"

https://www.ncbi.nlm.nih.gov/pubmed/27247431

[quote user="Chris Geddes"]Anyway it doesn't make any difference to me what you do, and you clearly have a closed mind in any case.[/quote]

No, I'm very open minded. Happy to bin all the red rubber ones as soon as I can source different ones when someone proves to me that they are better, and the added waste is worth it. I'm not going to change because it's fashionable and that's what referral centres or human hospitals do.

I'm very interested in relevant literature, a very old paper looking at humans ventilated and intubated for over 24 hours after heart surgery has no relevance to me whatsoever.

We work in an evidence based way, but are mindful not to jump on the unsubstantiated gold standard bandwagon!

RE: Red rubber reusable ET tubes - educate me.

James Colver Cert. Ed, RVN — Tue, 20 Aug 2019 21:49:09 GMT

Lastly, I would say that in my experience working in different practices, red rubber tubes have fallen out of favour. They used to be the norm years ago - perhaps there was no alternative, but most places I have worked in recent years have changed to PVC or silicone tubes with low pressure cuffs. And in the absence of evidence, it's never a bad idea to look at what the majority of your counterparts are doing, especially those that specialise in that particular subject. It would be interesting to hear the thoughts of a veterinary anaesthetist on this, perhaps I'll send some correspondence out.

RE: Red rubber reusable ET tubes - educate me.

Alison Clare Hickman — Tue, 20 Aug 2019 21:46:31 GMT

Cheers James Colver Cert. Ed, RVN

apache

More info. Plus let'slook out for Jimbomcgrimbo's article, take notes/advice/references?!??!?

More input better decisions (well, that's my aim!). Erm, I don't mean that, that isn't yours btw!!! Peace love just want info... Cheesy grinnage

RE: Red rubber reusable ET tubes - educate me.

Alison Clare Hickman — Tue, 20 Aug 2019 21:44:21 GMT

Cheers Jimbomcgrimbo

RE: Red rubber reusable ET tubes - educate me.

James Colver Cert. Ed, RVN — Tue, 20 Aug 2019 21:42:09 GMT

Just read the thread. As always, there is not enough evidence on the subject to be able to say that one particular tube type should not be used. I myself do not favour red rubber tubes, or any low volume, high pressure tube. There IS plenty of evidence telling us that without a pressure gauge, we are almost certainly over-cuffing, sometimes dangerously so (much of the time we won't see the damage to the trachea, it will heal and the animal will be fine. Sometimes the trachea may rupture, form an OFTP or sustain some other ischaemic injury) and it seems perfectly reasonable to assume that risk of these pressure-related injuries can be mitigated in part by using a low pressure cuff. Or a pressure gauge - but these cost £20 and have a life-span of 100 uses - Many practice owners aren't going to stomach the cost of this, or will see it as unnecessary ("never had a problem blah blah blah") so low pressure tubes seem to me to be the logical, and safest choice.

RE: Red rubber reusable ET tubes - educate me.

James Colver Cert. Ed, RVN — Tue, 20 Aug 2019 21:29:05 GMT

Hi Alison, wrote a case study about a dog who developed an obstructive fibrinous tracheal pseudomembrane after being intubated with a RR tube, including a bit of literature review as well on the subject of ET tubes. OFTP seems to be a rare phenomenon, associated with LVHP tubes. Will be in Vet Times within the next few weeks xx

RE: Red rubber reusable ET tubes - educate me.

Chris Geddes — Tue, 20 Aug 2019 10:46:01 GMT

[quote user="apache"]Try harder.[/quote]

Er, I don't need to try harder.

You said that you wanted to be educated, you said you were interested in evidence and opinion, and I provided some to try to help you.

I never knew that research had an expiry date, that's an interesting one.

Anyway it doesn't make any difference to me what you do, and you clearly have a closed mind in any case. I shan't comment again.

RE: Red rubber reusable ET tubes - educate me.

molladog — Tue, 20 Aug 2019 08:21:43 GMT

Totally agree with all you say Apache.

RE: Red rubber reusable ET tubes - educate me.

Sal the 1st — Mon, 19 Aug 2019 21:58:02 GMT

A question for Chris Geddes. Hasn't the size of cuff on the Portex Blue Lines increased in size since that paper came out? I think it has - If I dig out an old Portex type (same vintage as the paper) and compare to what is available now there is a very obvious difference. My main issue with the PBL types now is that the cuff is absolutely huge and when its deflated for intubation it has wrinkles and folds in it and when these are stuck into a trachea even if they are very soft those wrinkles and folds are going to cause irritation. Would the irritation and possible damage from that cuff be any different to the smoother cuff on a red rubber type? (honest question - I don't know the answer)

We get a number of freebie plastic tubes via a contact at local hospital where the outer pack has been opened but then not used - in adult humans the most common sizes are 7.0, 7.5 and 8.0 which are quite a bit smaller than some of the tubes we use in dogs so whilst a smaller diameter tube with a huge cuff might work in humans would the same necessarily apply in a large dog?

RE: Red rubber reusable ET tubes - educate me.

apache — Mon, 19 Aug 2019 21:30:33 GMT

[quote user="Chris Geddes"]I think simply because cuff is low volume high pressure and so increased risk of tracheal rupture. I'm not sure there is evidence to confirm this in animals (there is in humans - see below) but it does make sense, high pressure = more likely to rupture! That's enough for me that I wouldn't use them if I were to go back into practice.[/quote]

Try harder. A 37 year old paper in humans intubated for 24 hours for heart surgery tells us NOTHING about the risk of tracheal rupture in our veterinary patients.

[quote user="Chris Geddes"]There is also the issue that you can't check they are clear as they are not transparent,[/quote]

I have a capnograph to check that. A clear tube or LMA can become blocked once in situ.

[quote user="Chris Geddes"]and because they are thicker you also have increased airway resistance.[/quote]

Possible, but less chance of kink. Easier intubation - I can find you HEAPS of papers looking at failed intubation in people, the need for stylets, bougies etc - all unnecessary faff with the traditional tubes.

[quote user="Chris Geddes"] If I were to have an anaesthetic [edit] I'd want a single use PVC/silicone ETT. [/quote]

Me too, but I'm not a dog. I have some disposable plastic tubes and when I operated on my dog I'd pick a red rubber one every time.

[quote user="Chris Geddes"]Are you sure your red rubber ones are designed to be used vastly more times than that? Are they not designed to be used 10x?[/quote]

They are designed to be re-used. I've never read anything specifying a specific lifetime, but I could be mistaken. I'll look next time I get a new one - could be a while.

If my rack of 15 tubes each saves 10 tubes that's 150 tubes saved. Honestly some of them may be reused 50-100 times. The ones that get thrown out tend to be the less often used sizes - I wonder if some rubber protection exists.

RE: Red rubber reusable ET tubes - educate me.

Chris Geddes — Mon, 19 Aug 2019 18:05:03 GMT

By the way, when you say

Designed for re-use. I'm not re-using an item designed to be thrown away, whatever your disinfection protocol.

And:

Red rubber are 5X the cost and can be used vastly more times than that

Are you sure your red rubber ones are designed to be used vastly more times than that? Are they not designed to be used 10x?

RE: Red rubber reusable ET tubes - educate me.

Chris Geddes — Mon, 19 Aug 2019 17:56:11 GMT

You could say I'm biased in that I work for Docsinnovent, who make v-gels, but I'm not biased in that it makes no difference to me what type of ETT people use!

Before I joined Docsinnovent I had no particular expertise in anaesthesia. Since I've joined, I've spoken to a lot of anaesthetists and attended a lot of anaesthesia lectures. BOTTOM OF THE EVIDENCE PYRAMID I know - but expert opinion = every one I've spoken to says to avoid red rubber tubes like the plague. I think simply because cuff is low volume high pressure and so increased risk of tracheal rupture. I'm not sure there is evidence to confirm this in animals (there is in humans - see below) but it does make sense, high pressure = more likely to rupture! That's enough for me that I wouldn't use them if I were to go back into practice.

https://thorax.bmj.com/content/thoraxjnl/37/7/500.full.pdf?fbclid=IwAR20pfKRXWp0_NM7NQGoQX9lUb1kIA1uQc60x6tynQ58hPfrecI-rFe7Sw4

There is also the issue that you can't check they are clear as they are not transparent, and because they are thicker you also have increased airway resistance.

In terms of waste, my personal view is that plastic is wonderful stuff that we misuse ridiculously, and so need to use responsibly. If I were to have an anaesthetic and have an ETT (I'd prefer a supraglottic airway device of course!) - I'd want a single use PVC/silicone ETT. I think that is justifiable use of plastic. Probably the same amount as in a plastic bottle, with a major benefit for me. For me, some use of plastic is justifiable - minimise not eliminate. The other thing to remember is that a used ETT should go in clinical waste and therefore be incinerated, so it's not littering the environment at least.

RE: Red rubber reusable ET tubes - educate me.

Alison Clare Hickman — Sun, 18 Aug 2019 21:02:53 GMT

James Colver Cert. Ed, RVN

You said you have researched this subject? Am very interested in your input, pleeeeeeease?!?! TIA

RE: Red rubber reusable ET tubes - educate me.

Sal the 1st — Sun, 18 Aug 2019 19:45:42 GMT

just opinion - we use some red rubber , the cuffs are a lot better and less damaging.Trying to get low profile/low volume cuffs on the disposables is murder as they are essentially a human product with a veterinary stamp on them. Many places - ourselves included will re use disposable tubes -not keen as those voluminous cuffs when let down can trap a lot of muck if they aren't re inflated to clean them. I might be old fashioned but red rubber over disposables any day and if they aren't left too long in the Milton they have a very long life. We also (shock , horror) store our tubes on an open rack, they are quickly accessible when needed without having to root through a drawer - have we noticed any problems as a result of storing on a rack? - that would be a NO