Cuffed or Uncuffed Endotracheal Tubes in Pediatric Anesthesia

The Debate Should Finally End

By Dr. Magdy Fathy FRCA

Objective• the issue of cuffed vs. uncuffed ET tubes in

children is not a cut and dried issue.

• We need to be aware of the ongoing discussion

• Some paediatric anesthetists still do not accept the cuffed ET tube as the preferred airway option for children.

• Editorials,Pro/Con Debates

• What does the research say

• Textbook recommendations

Introduction

Only uncuffed tubes should be used in children below the age of 8-10 years.

This is the traditional teaching in pediatric anesthesia and intensive

care.

The argument to use only uncuffed tracheal tubes in this group of

children is based on the finding that the narrowest part of the airway

is the cricoid.

Introducing an uncuffed tracheal tube that just fits and seals within

the cricoid makes a cuff unnecessary

Since long time, many authors have promulgated, without evidence,

that uncuffed tubes are required until the pediatric larynx goes

through a transformation from cone-shaped to cylindrical at 8 yr of

age.

The History

Landmark Description of the Pediatric Airway

The infant larynx is more cephalad

The epiglottis is longer, stiff, U shaped

The cricoid ring is the narrowest portion of the airway

The pediatric laryngeal and cricoid relationship has been described

as “funnel-shaped” with the apex of the funnel at the level of the

cricoid.

This funnel-shaped airway description, based on a limited number of

postmortem airway measurements,

much of our basic understanding of the physiology and anatomy of the paediatric airway has changed

Basic understanding has changed

Developmental changes of laryngeal dimensions in unparalyzed, sedated children. Anesthesiology 2003; 98:41–5

The narrowest portions of the

larynx are the glottic opening (vocal

cord level) and the immediate sub-

vocal cord level,

There is no change in the

relationships of these dimensions

relative to cricoid dimensions

throughout childhood.

ANESTHESIA & ANALGESIA

Pediatric Laryngeal Dimensions: An Age-Based Analysis

Vol. 108, No. 5, May 2009

Pediatric Laryngeal Dimensions: An

Age-Based Analysis

In anesthetized paralyzed children, the glottis was

narrower than the cricoid in children from infancy to

adolescence.

The pediatric larynx is more cylindrical than funnel-

shaped and an age-based transition from a pediatric

funnel-shaped to the cylindrical adult larynx was not

observed

Studies conducted using different measurement

techniques measured airway dimensions using two

different techniques (magnetic resonance imaging and

videobronchoscopy) and found that the glottis is

narrower than the cricoid

Figure 1. Measuring laryngeal dimensions.

Dalal P G et al. Anesth Analg 2009;108:1475-1479

©2009 by Lippincott Williams & Wilkins

Paediatric airway management: What is new?Ramesh S, Jayanthi R, ArchanaSR.Indian J Anaesth. 2012 Sep; 56(5):448-53.

The History

Initially there was no cuff and red rubber tubes caused mucosal

irritation

The first cuffs were high pressure

High-compliance low pressure cuffs were developed in the 1970’s

2nd generation cuffed tubes with softer polyurethane are now

available

In 2004 a new cuffed pediatric tracheal tube became available with

improved design and excellent sealing properties

This tracheal tube was successfully tested in pediatric patients from

birth up to adolescence in several clinical settings

Examination of the literature

What does the research say ?

List of Editorials,Pro/Con Debates , and Case

studies

Leong L et al. The design of pediatric tracheal tubes. Paediatric

Anaesthesia. 2009

Holzki J et al. Iatrogenic damage to the pediatric airway

Mechanisms and scar development. Paediatric Anaesthesia. 2009

Weber T, Salvi N et al. Pro-Con Debate Cuffed vs non-cuffed

endotracheal tubes for pediatric anesthesia. Paediatric Anaesthesia.

2009

Duracher C et al. Evaluation of cuffed tracheal tube size predicted

using the Khine formula in children. Paediatric Anaesthesia. 2008

Flynn PE et al. The use of cuffed tracheal tubes for paediatric

tracheal intubation, a survey of specialist practice in the United

Kingdom. European Journal of Anaesthesiology. 2008

List of Editorials,Pro/Con Debates , and Case

studies

Silva MJ et al. Ischemic subglottic damage following a short-time

intubation. European Journal of Emergency Medicine. 2008

Aker J. An emerging clinical paradigm: the cuffed pediatric

endotracheal tube. AANA Journal. 2008

Moehrlen U et al. Scanning electron-microscopic evaluation of cuff

shoulders in pediatric tracheal tubes. Paediatric Anaesthesia. 2008

Weiss M et al. Cuffed tracheal tubes in children: past, present and

future. Expert Review of Medical Devices. 2007

Weiss M. et al. Comparison of cuffed and uncuffed preformed oral

pediatric tracheal tubes. Paediatric Anaesthesia. 2006

Weiss M et al. Cuffed tracheal tubes in children –things have

changed. Paediatric Anaesthesia. 2006

Ashtekar CS et al. Do cuffed endotracheal tubes increase the risk of

airway mucosal injury and post-extubation stridor in children?

Archives of Disease in Childhood. 2005

List of Editorials,Pro/Con Debates , and Case

studies

Weiss M et al. Appropriate placement of intubation depth marks in a new

cuffed paediatric tracheal tube. British Journal of Anaesthesia. 2005

Bernet V et al. Outer diameter and shape of paediatric tracheal tube cuffs at

higher inflation pressures. Anaesthesia. 2005

Dullenkopf A et al. Fit and seal characteristics of a new paediatric tracheal

tube with high volume-low pressure polyurethane cuff. Acta

Anaesthesiologica Scandinavia. 2005

Fine G et al. The future of the cuffed endotracheal tube. Paediatric

Anaesthesia. 2004

Bell C. Endotracheal tube cuff pressure is unpredictable in children. Survey

of Anesthesiology. 2004

Devys JM et al. Cuff compliance of pediatric and adult cuffed tracheal tubes:

an experimental study. Paediatric Anaesthesia. 2004

Dillier CM et al. Laryngeal damage due to an unexpectedly large and

inappropriately designed cuffed pediatric tracheal tube in a 13-month-old

child. Canadian Journal of Anaesthesia. 2004

What’s the Research

Deakers TW, et al. Cuffed endotracheal tubes in

pediatric intensive care. The Journal of Pediatrics. 1994

Khine HH, et al. Comparison of cuffed and uncuffed

endotracheal tubes in young children during general

anesthesia. Anesthesiology 1997

Newth CJL, et al. The use of cuffed versus uncuffed

endotracheal tubes in pediatric intensive care. The

Journal of Pediatrics. 2004

Salgo B, et al. Evaluation of a new recommendation for

improved cuffed tracheal tube size selection in infants

and small children. Acta Anesthesiologica Scandinavica

2006

The American Heart Association (AHA) and the

International Liaison Committee on Resuscitation

The American Heart Association (AHA) and the International Liaison

Committee on Resuscitation (ILCOR) stated in their 2005 guidelines

for pediatric resuscitation , stat that,

The use of cuffed tracheal tubes in infants and children is now an

accepted alternative to uncuffed tracheal tubes and that they have to

be preferred over uncuffed tracheal tubes under certain conditions.

The reason for this change was that evidence has accumulated that

cuffed tubes can be used safely in children

SPA-APA Meeting San Francisco 2007

Cuffed tracheal tubes in smaller children are increasingly

used because of the high chance to insert a correctly

sized tracheal tube at the first intubation attempt

In several anesthesia institutions cuffed tracheal tubes

are successfully routinely used from size internal

diameter 4.0 mm and cuffed tracheal tubes are to prefer

in patients at risk for pulmonary aspiration,

With low lung compliance (including laparoscopic and

thoracoscopic procedures, and surgery on cardio-

pulmonary bypass) and in whom precise ventilation

and/or CO2 control is important

Weiss M, et al and the European Paediatric Endotracheal

Intubation Study Group. British Journal of Anaesthesia

Weiss M, et al and the European Paediatric Endotracheal

Intubation Study Group. British Journal of Anaesthesia

Prospective randomized controlled multi-centre trial of cuffed

or uncuffed endotracheal tubes in small children

The aim of this study was to compare post-extubation morbidity and

TT exchange rates when using cuffed vs uncuffed tubes in small

children

Patients aged from birth to 5 yr requiring general anaesthesia with

TT intubation were included in 24 European paediatric anaesthesia

centres.

The use of cuffed TTs in small children provides a reliably sealed

airway at cuff pressures of <or=20 cm H(2)O, reduces the need for

TT exchanges, and does not increase the risk for post-extubation

stridor compared with uncuffed TTs

Textbook recommendations

Textbook recommendations

5th2000

Uncuffed < 10 years

6th2005

Uncuffed < 6 years

7th2009

Cuffed OK even in

infants

Textbook recommendations

3rd2001

Uncuffed < 8 years

4th2009

Traditional

teaching…Uncuffed <

8 years

Recent data …

Textbook recommendations

6th1996

Uncuffed < 8 years

7th2006

Uncuffed tubes may

be OK

Textbook recommendations

3rd1996

Uncuffed < 8 years

4th2008

No mention in text

Charts indicate cuffed

OK down to 2 years

Textbook recommendations

5th2002

Uncuffed < 6 –8 yrs

6th2006

Uncuffed < 6 –8 yrs

7th2010

Recent evidence …

safe for all ages

Excellent Insight

As far back as the

3rdEdition in 1994 the

use of cuffed tubes is

considered.

Chapter by Dennis

Fisher, MD

Gregory’s Pediatric Anesthesia 3rdEdition 1994

“Until recently I routinely used uncuffed ETTs for all

patients less than 6 years of age. However, in many

instances I found myself replacing tubes that leaked at

low pressure. . . I now frequently insert a cuffed

endotracheal tube , and measure the leak with the cuff

deflated. If the leak pressure is appropriate I leave the

tube in place and check periodically that the cuff has not

inflated during administration of nitrous oxide.” Dennis

Fisher MD

Cuffed Endotracheal Tubes inPediatric Anesthesia

The Debate

Uncuffed tube drawbacks

There are drawbacks to having a ventilation leak around the tube.

an inaccurate capnographic tracing,

inaccurate spirometric tidal volume measurement,

inaccurate end-tidal anesthetic level measurement, waste and

increased cost of inhaled anesthetics,

increased pollution of the operating room environment,

increased airway fire risk,

possible need to change the endotracheal tube to a different size

(often only recognized after the surgical procedure has begun),

lack of ability to regulate the tracheal seal with change in respiratory

system compliance, and an increased risk of microaspiration

Advantages with CTT

Less pollution with anesthetic gas

Decreased gas use

Decreased risk of aspiration

Able to precisely control ventilation

Able to guarantee PEEP

Monitoring of respiratory function

Able to adjust for change in compliance

all types of endotracheal tubes have the potential to cause damage,

and there are likely many other factors (previous intubations, patient

movement, coexisting morbidity, etc.) that play a significant role in the generation of airway edema and scarring.

This endotracheal tube should contain a high-volume, low-pressure

cuff, with a standard ratio of internal to external diameter

To date, simple cuff pressure release valve, cuff manometers and

cuff pressure regulators are available for clinical use

ETT in Neonates

Studies of freshly extubated neonatal larynges demonstrate damage

to all areas of the glottic and subglottic regions.

The rigid cricoid ring and the vocal folds are particularly susceptible

to damage from mucosal shear because of the lack of any

substantial submucosal layer in these areas.

This is most likely what happens when an uncuffed endotracheal

tube is used, which has a large enough external diameter to provide

adequate ventilation without an excessive leak, especially with

movement of the infants’ head and neck.

But evidence of the clinical efficacy of cuffed endotracheal tubes in

the neonatal setting is absent; thus, neonatologists have not been

as eager as pediatric anesthesiologists to transition to cuffed

endotracheal tubes in their practice

Where do we stand now?

The use of cuffed ETTs in young children

increases the responsibility of the whole team

Meticulous care with size, tube position,

stabilization, sedation

Cuff pressure should be monitored

In the OR

Cuffed tubes will reduce the number of reintubations and

contamination from anesthetic gases

Incidence of post-extubation stridor should not be

greater with appropriate sized tubes

In several anesthesia institutions cuffed tracheal tubes

are successfully routinely used from size internal

diameter 4.0 mm and cuffed tracheal tubes are to prefer

in patients at risk for pulmonary aspiration

May still consider uncuffed tubes in infants

Where I Stand

Based on current scientific data cuffed tubes can be safely used in

infants and young children provided that a correctly sized tracheal

tube,

All children requiring tracheal intubation should benefit from a

standard type of endotracheal tube that is associated with the best

evidenced-based outcomes

Continuous cuff pressure control and adequately designed tracheal

tubes should be used

Except for unique clinical circumstances (e.g., purposeful bronchial

intubation for neonatal thoracic surgery and lung isolation), there is no longer a feasible role for the use of the uncuffed tube in pediatricanesthesia, or in chronically ventilated children beyond the neonatal period.