• Journal: JAMA Otolaryngology - Head and Neck Surgery

• PMID: 35900743

• Type of study: Retrospective cohort study

• Hypothesis

  • Smaller ETTs will be noninferior to larger ETTs for patients intubated in the ICU and ED for the outcome of 30-day all cause in-hospital survival

• Methods

  • Retrospective cohort study

  • Single-center study

  • 814 subjects

    • > 18 years old

    • Intubated in ED/ICU

    • Mechanically-ventilated > 12 hours

  • Exclusion criteria

    • Obstructive airway masses

    • Missing data

    • Height < 160cm with smaller than 7.0 ETT

    • Height > 180cm with larger than 8.0 ETT

  • Groups - Determined by nomogram indicating appropriate size ETT for the patient's height

    • Small ETT for height

    • Appropriate ETT for height

    • Large ETT for height

  • Outcomes

    • Primary: 30-day in-hospital overall survival

    • Secondary

      • 30-day readmission

      • Tracheostomy

      • PEG tube

      • Reintubation within 14 days

      • Duration of intubation

      • Average PIP

      • Length of hospital stay

      • Composite outcome

      • Bronchoscopy

      • Ventilator-associated pneumonia

  • Statistical analysis

    • Propensity-score matched pairs

• Results

  • • No difference in primary outcome (overall in-hospital survival) between groups

    • No differences in secondary outcomes, except:

      • Small for size ETT vs. Appropriate for size ETT

        • Small for size group had an increased intubation time of 32.5 hours

      • Small for size ETT vs. Large for size ETT

        • Small for size group had in increased intubation time of 45.2 hours

        • Small for size group had an increased risk of receiving a PEG tube

• Strengths

  • • Relevant and important topic

    • Study site generalizable to other academic institutions in the US

    • Propensity score matching used

• Weaknesses

  • • Questionable primary outcome of 30-day survival

    • Would have liked to see other important secondary variables

    • Retrospective 

    • Single center

    • Lack of details on admitting diagnoses

    • PSM didn't include illness severity

    • Single institution study

    • Small # of pairs after propensity score matching

• Key Point: The use of smaller ETTs is not associated with decreased 30-day survival, but may be associated with an increased duration of intubation.

JAMA Otolaryngol Head Neck Surg. 2022 Sep 1;148(9):849-853