An 87-kg male patient, orally intubated with a size 7.5 mm inner diameter (ID) endotracheal tube, is being mechanically ventilated in the pressure-controlled continuous mandatory ventila-tion (PC-CMV) mode

During patient rounds, both the low-pressure and low-volume alarms are sounding persistently on the ventilator. Upon observation of the patient, the respiratory therapist hears murmuring from the patient, with audible sounds during inspiration. The respiratory therapist notes the position of the endotracheal tube is 21 cm at the gum line, measures the cuff pressure, and adds 3 mL of air to the cuff. To make an appropriate seal, it requires 44 cm H2O. The respiratory therapist should do which of the following?
a. Change to a larger size endotracheal tube.
b. Add air to the cuff and clamp the pilot tube.
c. Check the position of the endotracheal tube.
d. Reposition the endotracheal tube in the mouth.

ANS: A
The endotracheal tube (ET tube) used with this patient is too small. This is evident from the fact that it is requiring 44 cm H2O to seal the airway and also because a size 7.5 mm ET tube should be used for a small adult female. This patient should have at least a size 8 mm ET tube. The placement of the tube is appropriate for the size, being 21 cm at the gum line, so repositioning is not necessary. Since the respiratory therapist has already added, measured, and noted that the airway can be sealed, but with a higher than normal pressure, we know that there is no problem with the pilot balloon.