Why We Do What We Do: Cuffed Tubes versus Uncuffed Tubes in Pediatrics

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In choosing the tube size, one must consider choosing between cuffed and uncuffed tubes. For many years, uncuffed tubes have been recommended for children under 8 yrs of age. The uncuffed tube is to be positioned to form a seal at the cricoid ring; the narrowest portion of the child’s airway. However, a great debate has developed in the world of anesthesia when choosing between a cuffed tube and uncuffed tube. Those who are against cuffed tubes note the paucity of randomized control trials justifying their use. In a pro-con paper discussing the issue, Weber (2009) noted the internal diameter of the cuffed tube will inevitably be smaller due to its thicker wall coupled by the diameter that the cuff adds to create the seal within the trachea. Further, the variability of size from different manufactures may cause for overestimation in size and subsequent subglottic stenosis. Following intubation in the ED, prehospital setting and ICU, intracuff pressure is something that can be variable and frequently overlooked. Inadvertent high pressures due to overinflation may cause for tissue ischemia (Ho et al., 2002). In the pediatric populations, it is recommended to maintain cuffs at a high volume and a low pressure around 25 mmHg (Leong & Black, 2009). Ho et al also described variability when describing the margin of safety in pediatric intubations looking at two different types of cuffed tubes. The margin of safety is defined as the distance from the vocal cords to the point of the carina where the tube is to be positioned. Using cuffed pediatric tubes, the researchers noted a 50% reduction in that margin of safety with cuffed tubes compared to uncuffed tubes. These results were more pronounced at younger ages. The study suggests that this may result in “obstruction of upper lobe bronchi” and possible suboptimal position with migration of the tube with any significant neck movement.

Advocates of the cuffed tubes combat these arguments sighting a number of papers associated with advantages and clinical experience. Khine et al (1997) in his landmark study, was the first to note no difference in the incidence of post-intubation stridor between cuffed and uncuffed intubated patients. He also noted the incidence of reintubation due to air leak was reduced in the cuffed cohort (5.5%) compared to the uncuffed cohort (17%). Murat (2001) responding to an editorial on cuffed endotracheal tubes (James 2001), reported that 15000 pediatric patients (including 904 under the age of 1) had been intubated at his institution using cuffed tubes. Of those 15000, there were no reports of subglottic stenosis or respiratory complications associated with the type of tube used. Echoing these findings from the operating room, Meyer et al (2000) and Newth et al (2004) both reported on experience in both the emergency department and PICU respectively and found no significant complications associated with cuffed endotracheal tubes. James (2001) noted that a reduction of airleak as an important quality ascribed to cuffed endotracheal tubes. A sealed system allows for consistency in administration of tidal volumes and positive end expiratory pressure as well as provides for better measurement of lung compliance and airway resistance. Eschertzhuber et al (2010) noted that cuffed tubes reduce the amount of leaked anesthetic gases in the operating room. This gas leak has both environmental pollution implications as well as financial implications as anesthetics are being wasted. Another added advantage of the cuff is a reduction in gastric contents being aspirated. Gopalareddy et al (2007) demonstrated a reduction in tracheal aspirates containing gastric pepsin found in patients with cuffed tubes (53%) vs uncuffed (100%). The study, however, did not demonstrate an increase in chest xray findings associated with increased tracheal aspiration.

Although the debate regarding cuffed vs uncuffed is still up in the air, most literature seems to suggest that the use of a cuffed tube in pediatric patients above 1 year of age can use is not inferior to the use of uncuffed tubes and may actually have some advantage. Ultimately it is the provider’s comfort with the various tools that will navigate his or her practice.

Reference:

Bae et al., Usefulness of ultrasound for selecting a correctly sized uncuffed tracheal tube for paediatric patients, Anaesthesia, 2011; 66:994-98.

Eschertzhuber et al., Cuffed endotracheal tubes in children reduce sevoflurane and medical gas consumption and related costs. Acta Anesthesiol Scand 2010; 54:855-58.

Gopalareddy et al., Assessment of the prevalence of microaspiration by gastric pepsin in the airway of ventilated children, Acta Paediatrica 2008; 97:55-60.

Ho et al., The Margin of safety associated with the use of cuffed paediatric tracheal tubes, Anaesthesia, 2002; 57:169-82.

Hofer et al., How reliable is length-based determination of body weight and tracheal tube size in the paediatric age group? The Broselow tape reconsidered, Br J Anaesth 2002; 88:283-5.

James, I, Editorial: Cuffed Tubes in Children, Paediatric Anaesthesia 2001; 11:259-263.

Khine et al., Comparison of cuffed and Uncuffed Endotracheal Tubes in Young Children during General Anesthesia, Anesthesiology 1997; 86:627-13

Leong L & Black AE, The design of pediatric tracheal tubes, Ped Anesthesia 2009; 19(Suppl. 1):38-45.

Meyer et al., Comlpications of emergency tracheal intubation in severely head-injured children. Ped Anaesthesia 2000; 10:253-260.

Murat, I, Cuffed tubes in children: a 3-year experience in a single institution. Ped Anaesthesia 2001; 11:745-750.
Newth et al., The use of cuffed versus uncuffed endotracheal tubes in pediatric intensive care, J Pediatr 2004; 144:333-7.

Weber, T et al., Pro-Con Debate: Cuffed vs non-cuffed endotracheal tubes for pediatric anesthesia, Ped Anesthesia 2009; 19*Suppl. 1): 46-54.

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