Paradigm Shift - Cuffed ETT for Children

Spoon Feed
Cuffed endotracheal tubes (ETT) in children had better ventilation characteristics and fewer complications during routine surgery than uncuffed.

Why does this matter?
Traditionally, we have used uncuffed ETTs in children because the cricoid ring is narrower inferiorly, like an ice cream cone.  So the ETT will fit more snugly in the subglottic space than it appears when passing through the vocal cords.  The thought is to prevent subglottic irritation and possible scarring by not placing an oversized ETT and causing pressure necrosis.  But over the past decade, many have started using a slightly smaller ETT size with a cuff.  This gives the option to add a little air to the cuff in the event of a large air leak, especially if the lungs are very stiff and PEEP is needed.

Cuff 'em
This was a RCT of 104 children aged 0-16 years undergoing routine surgery.  They were randomized 52 to a group to either cuffed or uncuffed ETT.  They used the following ETT sizes.

 From cited article

From cited article

They found a much bigger air leak across the spectrum of ages in the uncuffed group.  They also noted that, "80% were successfully intubated with a correctly-sized ETT at first attempt compared with only about 30% in the uncuffed group."  Complications of persistent cough, desaturation, sore throat, or hoarseness were much more common in the uncuffed group.  The authors concluded, "The results of this randomised controlled trial add to the growing body of evidence that cuffed ETTs may be associated with superior outcomes when compared with uncuffed ETTs in children."

My practice is to use the ETT = (16+age)/4 formula and select 0.5 size smaller with a cuff.

Cuffed vs. uncuffed tracheal tubes in children: a randomised controlled trial comparing leak, tidal volume and complications.  Anaesthesia. 2017 Nov 23. doi: 10.1111/anae.14113. [Epub ahead of print]

Peer reviewed by Thomas Davis, MD.  

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