Cuffed Endotracheal Tubes for Children: ReBaked Morsel

While doing literature review for my scholarly project it dawned on me that it might be time to dust off a classic morsel from the bottom of the cookie jar. On this 10 year anniversary, we chose to throw this one back in the oven to include some even more delicious data on cuffed endotracheal tube (ETT) use. No matter whether you have the wisdom of many years of practice (old doc like Dr. Fox) or are just a young buck (like myself), straight out of training, you should be appetized by this rebaked morsel on using Cuffed Entotracheal Tubes in children

Cuffed Endotracheal Tubes: Evolution of Thought and Technology

Why did we historically use uncuffed endotracheal tubes in kids younger than 8?
  • A single cadaveric study from the 1950s showed that the pediatric subglottic space approximated a circular funnel with the narrowest portion at the cricoid level
    • This study included only 15 children aged 4 months–14 years
But why was this a problem?
  • It was thought that high pressures associated with cuffed ETT would cause undue pressure and lead to immediate (post-extubation stridor) and long-term (subglottic stenosis) complications. 
That sounds reasonable, so what has changed?
  • Clinical outcomes
    • PICU study from 1994 (yes, that long ago) showing no difference in post-intubation stridor and long-term complications
    • Multiple studies showing cuffed tubes provide better seal between tube and airway
    • Less use of medical gas in the operating rooms
    • Less environmental contamination with medical gas
    • Allowed higher airway pressures in poor lung compliance
    • Less frequent tube exchange 
    • More accurate capnography
    • Reduced pulmonary aspiration
    • Decreased sore throat
    • In a systematic review of 10 RCTs comparing cuffed vs. uncuffed ETTs Cuffed endotracheal tubes were changed one-sixth as often as uncuffed tubes, relative risk (95%CI) 0.17 (0.07–0.41), p < 0.001
  • Anatomy
    • Imaging studies from early 2000s to present show subglottic region is actually elliptical in section and cylindrical in shape (kind of like an adult…. don’t tell Dr. Fox)
      •  The immediate subglottic region is the most narrow portion of the airway
  • Technology
    • Tube cuff changed from polyvinylchloride to polyurethane, allowing cuff to be inflated with lower pressures
      • This allowed cuff pressure to be lower than the tissue perfusion pressure of the subglottic region (~20-30 mmhg), decreasing concern for tissue injury
Do uncuffed ETTs cause harm?
  • In a systematic review of 10 RCTs comparing cuffed vs. uncuffed ETTs. The rates of laryngospasm and stridor were similar between cuffed or uncuffed tubes, RR (95%) 1.20 (0.85–1.70) and 0.78 (0.46–1.35), p = 0.64 and p = 0.19, respectively.
  • In a meta-analysis, (which included: three systematic reviews, two guidelines, four textbooks, 13 narrative reviews, seven randomized controlled trials, 12 experimental studies, 14 observational studies, four surveys, five editorials, one letter, and one case report) Post-extubation symptoms occurred comparably in both type of ETTs (cuffed 2.4-4.4% vs uncuffed 3.0-4.7%)
  • In a cohort of all neonates admitted to two NICUs in Austria over a 7 year span, the use of uncuffed ETTs does not exhibit higher risk for the acquired subglottic stenosis
Cons of cuffed endotracheal tubes: Nothing is perfect…
  • Have to be ½ size smaller than uncuffed—leading to more airway resistance (most modern ventilators have no problem compensating for this)
  • Small size can make in-line tracheal suctioning and bronchoscopy difficult/impossible in small infants
  • While a Cochrane review of cuffed endotracheal tube use in neonates showed no neonate was diagnosed with postextubation subglottic stenosis, there remains uncertainty and a paucity of data regarding long term adverse effects of cuffed ETT use 

Moral of the Morsel

  • Maybe this is what Beyoncé meant by “Cuff it”? – Cuffed Endotracheal Tubes offer multiple advantages over uncuffed ETTs.
  • Risk was Overstated! Cuffed Endotracheal Tubes show no difference in immediate post-extubation adverse events (i.e post-extubation stridor) and likely have no long term adverse effects when compared to uncuffed endotracheal tubes.
  • You have options, but one is more right!! If you have the option, choose cuffed endotracheal tube in children.

References:

To YH, Ong YG, Chong SL, Ang PH, Bte Zakaria ND, Lee KP, Pek JH. Differences in intubation outcomes for pediatric patients between pediatric and general Emergency Departments. Paediatr Anaesth. 2021 Jun;31(6):713-719. doi: 10.1111/pan.14185. Epub 2021 Apr 11. PMID: 33774880.

Bibl K, Pracher L, Küng E, Wagner M, Roesner I, Berger A, Hermon M, Werther T. Incidence of Post-extubation Stridor in Infants With Cuffed vs. Uncuffed Endotracheal Tube: A Retrospective Cohort Analysis. Front Pediatr. 2022 May 11;10:864766. doi: 10.3389/fped.2022.864766. PMID: 35633947; PMCID: PMC9130697.

Capone CA, Emerson B, Sweberg T, Polikoff L, Turner DA, Adu-Darko M, Li S, Glater-Welt LB, Howell J, Brown CA 3rd, Donoghue A, Krawiec C, Shults J, Breuer R, Swain K, Shenoi A, Krishna AS, Al-Subu A, Harwayne-Gidansky I, Biagas KV, Kelly SP, Nuthall G, Panisello J, Napolitano N, Giuliano JS Jr, Emeriaud G, Toedt-Pingel I, Lee A, Page-Goertz C, Kimura D, Kasagi M, D’Mello J, Parsons SJ, Mallory P, Gima M, Bysani GK, Motomura M, Tarquinio KM, Nett S, Ikeyama T, Shetty R, Sanders RC Jr, Lee JH, Pinto M, Orioles A, Jung P, Shlomovich M, Nadkarni V, Nishisaki A; National Emergency Airway Registry for Children (NEAR4KIDS) Investigators, Pediatric Acute Lung Injury, Sepsis Investigators (PALISI). Intubation practice and outcomes among pediatric emergency departments: A report from National Emergency Airway Registry for Children (NEAR4KIDS). Acad Emerg Med. 2022 Apr;29(4):406-414. doi: 10.1111/acem.14431. Epub 2022 Jan 12. PMID: 34923705.

Deakers TW, Reynolds G, Stretton M, Newth CJ. Cuffed endotracheal tubes in pediatric intensive care. J Pediatr. 1994 Jul;125(1):57-62. doi: 10.1016/s0022-3476(94)70121-0. PMID: 8021785.

de Wit M, Peelen LM, van Wolfswinkel L, de Graaff JC. The incidence of postoperative respiratory complications: A retrospective analysis of cuffed vs uncuffed tracheal tubes in children 0-7 years of age. Paediatr Anaesth. 2018 Mar;28(3):210-217. doi: 10.1111/pan.13340. PMID: 29436138.

Kim JH, Ahn JH, Chae YJ. Pediatric Application of Cuffed Endotracheal Tube. West J Emerg Med. 2023 Apr 28;24(3):579-587. doi: 10.5811/westjem.59560. PMID: 37278787; PMCID: PMC10284523.

Shah A, Carlisle JB. Cuffed tracheal tubes: guilty now proven innocent. Anaesthesia. 2019 Sep;74(9):1186-1190. doi: 10.1111/anae.14787. Epub 2019 Jul 16. PMID: 31313280.

Shi F, Xiao Y, Xiong W, Zhou Q, Huang X. Cuffed versus uncuffed endotracheal tubes in children: a meta-analysis. J Anesth. 2016 Feb;30(1):3-11. doi: 10.1007/s00540-015-2062-4. Epub 2015 Aug 22. PMID: 26296534.

Zach Gibson
Zach Gibson
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