Kimberly-Clark* M ICROCUFF * Endotracheal Tubes Finally, a cuffed ET tube designed for the pediatric anatomy M ICROCUFF * Pediatric Endotracheal Tubes

M ICROCUFF * Endotracheal Tubes CONTENTS Traditional Practice Uncuffed Tube Shortcomings Solution: M ICROCUFF* Cuffed Tube Benefits Clinical Evidence Summary Ordering Information Best Practice Cuffed Tube Concerns References Overview Issues with uncuffed tubes Too small a tube - difficult ventilation 1,2 1 Fine, Borland. Pediatric Anesthesia, Stocks JG. BMJ, mm 3.5mm4.0mm Pressure on cricoidAirway leak Fig: Gerber AC, SPANZA, Too large a tube - higher risk of subglottic stenosis 1,2

M ICROCUFF * Endotracheal Tubes CONTENTS Traditional Practice Uncuffed Tube Shortcomings Solution: M ICROCUFF* Cuffed Tube Benefits Clinical Evidence Summary Ordering Information Best Practice Cuffed Tube Concerns References Overview Sealing Differences With Uncuffed Tubes Suominen P et al. Paediatric Anaesthesia, Holzki J. Paediatric Anaesthesia, Weiss and Gerber. Pediatric Anesthesia, Carina Crocoid Glottis  Inaccurate monitoring  Higher risk of aspiration  Difficult ventilation  Higher gas flow rate Undersized TubesOversized Tubes  2.8 times more likely to develop adverse events  Primary cause (92%) for laryngeal trauma in a 65 patient study Air Leak

M ICROCUFF * Endotracheal Tubes CONTENTS Traditional Practice Uncuffed Tube Shortcomings Solution: M ICROCUFF* Cuffed Tube Benefits Clinical Evidence Summary Ordering Information Best Practice Cuffed Tube Concerns References Overview Ideal Placement & Features of Cuffed Pediatric Tubes  Short, cylindrical cuff placed near the tracheal tube tip  Cuff placement in the trachea, not in the pressure-sensitive larynx  Anatomically-based depth mark results in correct placement  Tip should rest mid-trachea to avoid endobronchial tip migration  Low cuff pressure to reduce risk of airway trauma Carina Crocoid Glottis Mid-Trachea Proper cuff position

M ICROCUFF * Endotracheal Tubes CONTENTS Traditional Practice Uncuffed Tube Shortcomings Solution: M ICROCUFF* Cuffed Tube Benefits Clinical Evidence Summary Ordering Information Best Practice Cuffed Tube Concerns References Overview Many cuffed ET tubes have an inappropriate design for pediatric use  Too high cuff position, too long cuffs  Absent or unreliable depth marks  No reliable size selection recommendations Cuff position should avoid pressure- sensitive vocal cords and cricoid ring Weiss M, et al. British Journal of Anaesthesia, 2004.

M ICROCUFF * Endotracheal Tubes CONTENTS Traditional Practice Uncuffed Tube Shortcomings Solution: M ICROCUFF* Cuffed Tube Benefits Clinical Evidence Summary Ordering Information Best Practice Cuffed Tube Concerns References Overview The Solution: K IMBERLY -C LARK * M ICROCUFF * ET Tube Finally, a cuffed ET tube specifically designed for the pediatric anatomy Finally, a cuffed ET tube specifically designed for the pediatric anatomy Superior seal at ultra-low pressures Confidence in a sealed airway Short, distally- placed cuff Ensures correct placement, avoiding repeated intubations Dullenkopf A et al. Pediatric Anesthesia, Introducing a microthin polyurethane cuff Clinically verified, anatomically correct vocal cord depth mark

M ICROCUFF * Endotracheal Tubes CONTENTS Traditional Practice Uncuffed Tube Shortcomings Solution: M ICROCUFF* Cuffed Tube Benefits Clinical Evidence Summary Ordering Information Best Practice Cuffed Tube Concerns References Overview M ICROCUFF * is designed for ideal anatomical cuff placement in the pediatric airway  Short, cylindrical cuff near tracheal tube tip  Correct intubation depth mark  Reduces risk of endobronchial intubation “Depth marks of the new M ICROCUFF * paediatric tracheal tube allow adequate placing of the tracheal tube with a cuff-free subglottic zone and without the risk for endobronchial intubation in children from birth to adolescence.” Weiss, et al. British Journal of Anaesthesia, 2005.

M ICROCUFF * Endotracheal Tubes CONTENTS Traditional Practice Uncuffed Tube Shortcomings Solution: M ICROCUFF* Cuffed Tube Benefits Clinical Evidence Summary Ordering Information Best Practice Cuffed Tube Concerns References Overview “This preliminary investigation suggests that the new M ICROCUFF* pediatric tube with ultra-thin high volume-low pressure cuff membrane allows effective tracheal sealing at very low cuff pressures.” Advanced microthin polyurethane cuff seals the airway at ultra-low pressure Median cuff pressure. n=4x20 patients. Patient ages 2-4 yrs. Tube ID 4.0mm. Capillary perfusion pressure in adults is cm H 2 O; considered lower in pediatrics Fig: Dullenkopf et al. Pediatric Anesthesia, Median cuff pressure to seal the trachea in children aged 2-4 (n=4x20 patients, tube ID 4.0mm). Dullenkopf A et al. Pediatric Anesthesia, 2004.

M ICROCUFF * Endotracheal Tubes CONTENTS Traditional Practice Uncuffed Tube Shortcomings Solution: M ICROCUFF* Cuffed Tube Benefits Clinical Evidence Summary Ordering Information Best Practice Cuffed Tube Concerns References Overview M ICROCUFF * Endotracheal Tubes provide confidence in a sealed airway  Seals with a cuff, not a rigid tube shaft in the cricoid  Low rate of tube exchange  Positive pressure ventilation with sealed airway  Ensures reliable end-tidal CO 2 monitoring  Reduced risk of aspiration of blood and secretions  Low gas flow rates Dullenkopf, et al. Acta Anaesthesiologica Scandinavica, 2005.

M ICROCUFF * Endotracheal Tubes CONTENTS Traditional Practice Uncuffed Tube Shortcomings Solution: M ICROCUFF* Cuffed Tube Benefits Clinical Evidence Summary Ordering Information Best Practice Cuffed Tube Concerns References Overview M ICROCUFF * ET tubes allow for safe tracheal intubation and sealing in children  500 patient study  Only 1.6% had to be reintubated due to incorrect tube size  Only 0.4% experienced post extubation croup requiring short term therapy “The thin-walled polyurethane cuff membrane provides tracheal sealing at lower cuff pressure than reported, probably contributing to the low incidence of postextubation croup.” 15 Dullenkopf, et al. Acta Anaesthesiologica Scandinavica, 2005.

M ICROCUFF * Endotracheal Tubes CONTENTS Traditional Practice Uncuffed Tube Shortcomings Solution: M ICROCUFF* Cuffed Tube Benefits Clinical Evidence Summary Ordering Information Best Practice Cuffed Tube Concerns References Overview Evidence-Based Positive Clinical Outcomes Prospective Randomized Multi-Center Study  24 centers across Europe: n = 2,249 patients  Avg patient age of 1.9 years (3.0mm-4.5mm tubes used)  Tube exchange: 2.1% MICROCUFF, 29.9% uncuffed tubes  Post-extubation stridor: 4.38% MICROCUFF, 4.69% uncuffed tubes  Cuff pressure to seal the trachea: 10.6 cm H 2 O Source: ad Swiss Med Wkly 2008:138 (41-42), October 18, 2008

M ICROCUFF * Endotracheal Tubes CONTENTS Traditional Practice Uncuffed Tube Shortcomings Solution: M ICROCUFF* Cuffed Tube Benefits Clinical Evidence Summary Ordering Information Best Practice Cuffed Tube Concerns References Overview " M ICROCUFF* allowed safe positioning of the tube cuff and tube tip in almost all children investigated when placed with the tracheal tube bend at the lower incisors or alveolar ridge.” M ICROCUFF * RAE tubes are clinically verified  n = 166 patients  97% depth mark was positioned at or below vocal cords  100% tube tip remained above carina  100% correct tube size selection Weiss, M, et al. British Journal of Anaesthesia, 2006.

M ICROCUFF * Endotracheal Tubes CONTENTS Traditional Practice Uncuffed Tube Shortcomings Solution: M ICROCUFF* Cuffed Tube Benefits Clinical Evidence Summary Ordering Information Best Practice Cuffed Tube Concerns References Overview MICROCUFF Pediatric – Top Clinical Articles Article TitleAuthorPublicationPUBMED Reference Number MICROCUFF PEDIATRIC ET TUBE Fit and Seal Characteristics of a New Paediatric Tracheal Tube with High-Volume Low-Pressure Polyurethane Cuff Dullenkopf, et al.Acta Anaesthesiol Scand 2005; 49: Cuffed tracheal tubes in children – things have changed, Editorial Weiss, et al.Pediatric Anesthesia 2006; 16: Tracheal Sealing Characteristics of Pediatric Cuffed Tracheal Tubes Dullenkopf, et al.Pediatric Anesthesia 2004; 14: Appropriate Placement of Intubation Depth Marks in a New Cuffed Paediatric Tracheal Tube Weiss, et al.British Journal of Anaesthesia 2005; 94: Intubation Depth Markings Allow an Improved Positioning of Endotracheal Tubes in Children Weiss, et al.Can J Anesth 2005; 52: Clinical evaluation of cuff and tube tip position in a newly designed paediatric preformed oral cuffed tracheal tube Weiss, et al.Br J Anaesth 2006; 97:

M ICROCUFF * Endotracheal Tubes CONTENTS Traditional Practice Uncuffed Tube Shortcomings Solution: M ICROCUFF* Cuffed Tube Benefits Clinical Evidence Summary Ordering Information Best Practice Cuffed Tube Concerns References Overview MICROCUFF ET tubes offer cost benefits “… the increased costs for a cuffed paediatric tracheal tube are more than outweighed alone by savings in Sevorane consumption.” 1 1 Schmitz et al. Euroanesthesia (ESA) Congress, Munich * Translated from Euros to Dollars using Apr 2009 exchange rate 1Eu=1.3 Dollar ** Not statistically different Cost ItemMeasurementUncuffedMICROCUFF Tube Exchange Rate30%2% Tube replacementAdded $/patient$0.75$0.15 Anesthesia Gas Savings (example: Sevoflorane) 1 Duration of anesthesiamin57.7**66.5** Fresh gas flowLt/min Sevo costs per patient$/patient$19.24*$6.59* Total Costs$19.99$6.74 Cost Savings With MICROCUFF$13.25  Study by Schmitz compared MICROCUFF * tubes to Sheridan uncuffed tubes

M ICROCUFF * Endotracheal Tubes CONTENTS Traditional Practice Uncuffed Tube Shortcomings Solution: M ICROCUFF* Cuffed Tube Benefits Clinical Evidence Summary Ordering Information Best Practice Cuffed Tube Concerns References Overview Sizes Available Recommended Size Selection Chart