Airway (part 2)3 June, 2010 by: colinparker
Thanks for joining us… In this episode we explore the evolution of the endotracheal tube, in particular, whether we should be using cuffed ETTs in preference to the traditional pediatric standard of uncuffed tubes.
On our quest for knowledge, we spoke to some of our colleagues with brains and experience, and looked to the medical literature for guidance. We found some opinions and some research to share with you.
We would welcome your comments. Do you use cuffed ETTs for children in your Emergency Department? Let us know, whether the news is good, bad, or even ugly.
We’ve included a few references here for the papers we had a look at, in case you’d like to have a browse and make up your own mind. Below the references is a summary of what my Paediatric Intensivist colleague thinks.
Cuffed vs Uncuffed Endotracheal Tubes: a few papers:
- Khine 1997: Comparison of Cuffed and Uncuffed Endotracheal Tubes in Young Children during General Anesthesia [Anaesthesiology 1997; 86(3): 627-631]
- James 2001: Cuffed tubes in Children (Editorial) [Paediatric Anaesthesia 2001; 11: 259-263]
- Fine 2004: The future of the cuffed endotracheal tube [Pediatric Anesthesia 2004; 14: 38-42]
- Newth 2004: The use of cuffed versus uncuffed endotracheal tubes in pediatric intensive care [Journal of Pediatrics 2004; 144: 333–337]
- Ashtekar 2005: Do cuffed endotracheal tubes increase the risk of airway mucosal injury and post-extubation stridor in children? [Archives of Disease in Childhood 2005; 90(11): 1198-9] OR [ http://bestBETs.org/bets/bet.php?id=1088 ]
- Engelhardt 2006: Comparison of cuffed, uncuffed tracheal tubes and laryngeal mask airways in low flow pressure controlled ventilation in children [Pediatric Anesthesia 2006; 16: 140-143]
- Clements 2007: Cuffed endotracheal tube use in paediatric prehospital intubation: challenging the doctrine? [Emergency Medicine Journal 2007; 24: 57-58]
- Randolph 2009: A Quality Assurance project to assess optimal endotracheal tube selection in children [from proceedings of the 2009 Annual Meeting of the American Society Anesthesiologists, October 2009]
Word around the Campfire:
I went up to chat to Alan Duncan on PICU.
His perspective is:
Historically, cuffed tubes got a bad rep because of tracheal stenosis in adults, using the older rubber tubes which had smaller, higher-pressure cuffs. The newer low-pressure cuffs are much better.
cuffed tubes (+):
- minimise leak – good for decreased lung compliance eg asthma
- better protection against micro-aspiration (but not absolute protection)
- can be used in a situation where difficulty finding an in-between size, eg 5.5 cuffed tube with cuff deflated = 5 3/4
cuffed tubes (-):
- uninflated cuff - irregular surface can contribute to trauma during intubation esp nasal intubation
- requires monitoring of cuff pressure (manometer in PICU, otherwise deflate until just leaking, then re-inflate)
Alan reckons we’re not looking at routinely using cuffed tubes for all comers at this stage or anytime soon, but he would definitely use a cuffed ETT for a child with asthma or another reason for decreased lung compliance eg one collapsed/consolidated lung (can often re-inflate with PEEP).
We spoke a bit about naso-tracheal vs oro-tracheal intubation and agreed that in ED, oral intubation is quickest and safest and allows quick control of airway protection, oxygenation and ventilation. Changing to a nasal tube in PICU can be done semi-electively in a more controlled fashion.