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

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 Issues with uncuffed tubes Too small a tube - difficult ventilation 1,2 1 Fine, Borland. Pediatric Anesthesia, 2004 2 Stocks JG. BMJ, 1966 3.0mm 3.5mm4.0mm Pressure on cricoidAirway leak Fig: Gerber AC, SPANZA, 2007. Too large a tube - higher risk of subglottic stenosis 1,2

3. 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, 2006. Holzki J. Paediatric Anaesthesia, 1997. Weiss and Gerber. Pediatric Anesthesia, 2006. 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

4. 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

5. 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.

6. 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, 2004. Introducing a microthin polyurethane cuff Clinically verified, anatomically correct vocal cord depth mark

7. 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.

8. 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 25-30 cm H 2 O; considered lower in pediatrics Fig: Dullenkopf et al. Pediatric Anesthesia, 2004. 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.

9. 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.

10. 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.

11. 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

12. 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.

13. 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; 49:232-237 15715626 Cuffed tracheal tubes in children – things have changed, Editorial Weiss, et al.Pediatric Anesthesia 2006; 16:1005-1007 16972827 Tracheal Sealing Characteristics of Pediatric Cuffed Tracheal Tubes Dullenkopf, et al.Pediatric Anesthesia 2004; 14:825-830 15385010 Appropriate Placement of Intubation Depth Marks in a New Cuffed Paediatric Tracheal Tube Weiss, et al.British Journal of Anaesthesia 2005; 94:80-7 15486002 Intubation Depth Markings Allow an Improved Positioning of Endotracheal Tubes in Children Weiss, et al.Can J Anesth 2005; 52:721-726 16103385 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: 695-700 16984952

14. 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 2007. * 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$0.15 Anesthesia Gas Savings (example: Sevoflorane) 1 Duration of anesthesiamin57.7**66.5** Fresh gas flowLt/min2.450.95 Sevo costs per patient$/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

15. 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