Endotracheal tubes (ETTs) for mechanical ventilation are ubiquitous, with size typically selected to match the expected airway diameter and ventilation requirements of the patient. There is evidence to suggest that the use of larger ETT’s are associated with increased airway injury ranging from post operative sore throat (POST) to laryngotracheal stenosis (LTS). Unfortunately current clinical practice regarding ETT selection in adults are not universally standardized, but some physicians use sex, height and BMI as a factor. This has resulted in considerable variability used by different providers and institutions for intubations. In this session, we will present the impact of using inappropriately sized ETT’s in terms of potential complications and outcomes. We will also present on how to address these sequelae and most importantly implement system wide change on how to avoid the use of inappropriately sized ETT’s.