The document discusses the debate around using cuffed versus uncuffed endotracheal tubes in pediatric anesthesia. It summarizes the traditional view that uncuffed tubes should be used in children under 8-10 years old due to laryngeal anatomy. However, recent research shows the pediatric airway is more cylindrical than funnel-shaped, and the glottis is usually narrower than the cricoid. Studies find cuffed tubes can create a reliable seal, reduce the need for tube changes, and do not increase risk of post-extubation stridor compared to uncuffed tubes. Most textbooks now acknowledge cuffed tubes can be used safely in children of all ages if appropriately sized and monitored. The author concludes cuffed tubes should be

1. Cuffed or Uncuffed Endotracheal Tubes
in Pediatric Anesthesia
The Debate Should Finally End
By Dr. Magdy Fathy FRCA

3. 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

4. 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.

5. The History

6. 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,

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

8. 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.

9. ANESTHESIA & ANALGESIA
 Pediatric Laryngeal
Dimensions: An Age-
Based Analysis
 Vol. 108, No. 5, May
2009

10. 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

11. Figure 1. Measuring laryngeal dimensions.
Dalal P G et al. Anesth Analg 2009;108:1475-1479
©2009 by Lippincott Williams & Wilkins

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

14. 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

15. Examination of the literature
What does the research say ?

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. Weiss M, et al and the European Paediatric Endotracheal
Intubation Study Group. British Journal of Anaesthesia

23. 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

24. Textbook recommendations

25. Textbook recommendations
 5th2000
 Uncuffed < 10 years
 6th2005
 Uncuffed < 6 years
 7th2009
 Cuffed OK even in
infants

26. Textbook recommendations
 3rd2001
 Uncuffed < 8 years
 4th2009
 Traditional
teaching…Uncuffed <
8 years
 Recent data …

27. Textbook recommendations
 6th1996
 Uncuffed < 8 years
 7th2006
 Uncuffed tubes may
be OK

28. Textbook recommendations
 3rd1996
 Uncuffed < 8 years
 4th2008
 No mention in text
 Charts indicate cuffed
OK down to 2 years

29. Textbook recommendations
 5th2002
 Uncuffed < 6 –8 yrs
 6th2006
 Uncuffed < 6 –8 yrs
 7th2010
 Recent evidence …
safe for all ages

30. Excellent Insight
 As far back as the
3rdEdition in 1994 the
use of cuffed tubes is
considered.
 Chapter by Dennis
Fisher, MD

31. 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

32. Cuffed Endotracheal Tubes in
Pediatric Anesthesia
The Debate

33. 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

34. 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

35.  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

36. 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

37. 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

38. 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

39. 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 pediatric
anesthesia, or in chronically ventilated children beyond the neonatal
period.