Prospective randomized controlled multi-centre trial of cuffed or uncuffed endotracheal tubes in small children

The effect of mouth prop on endotracheal tube intracuff pressure in children during dental rehabilitation under general anaesthesia

Although the endotracheal tube (ETT) cuff may be associated with tracheal morbidity, cuffed tubes may reduce the aspiration risk in oral procedures. Dentists must use a mouth prop to facilitate oral visualization and to protect the oral soft tissues during dental rehabilitation under general anaesthesia (DRGA). The aim of this study was to evaluate the effect of mouth prop on endotracheal tube intracuff pressure in children during DRGA. Two-hundred and three ASA I-II patients, <18 years of age (mean: 5.3 ± 2.4 years) were included in the prospective observational study whose comprehensive dental treatment was performed under general anaesthesia. Following the induction of general anaesthesia, placement of a cuffed endotracheal tube which was an appropriate size for children was fixed. The intracuff pressure was measured intermittently after the intubation (baseline) (T0), immediately after the mouth prop (T1), 30 min after the mouth prop (T2), after taking out the mouth prop (T3) and just before extubation (T4). The mean intracuff pressure was 28.3 ± 2.01 cm H₂O at T0. The mean intracuff pressure significantly increased at T1 (30.8 ± 2.7) and T2 (29.6 ± 3.7) compared to T0 (P < 0.001). No significant differences were observed between the duration of the procedure and intracuff pressure or postoperative complications (P > 0.05). Cough, sore throat and nausea were observed in 4, 1 and 5 patients, respectively. Because a mouth prop may increase the intracuff pressure of ETT, strict measurement and readjustment of cuff pressures should be employed when used in children during DRGA.

Ineffective Ventilation in A Neonate with A Large Pre-Carinal Tracheoesophageal Fistula and Bilateral Pneumonitis-Microcuff Endotracheal Tube to Our Rescue!

Tracheoesophageal fistula (TEF) is one of the most common congenital anomaly requiring surgical correction in neonatal period. The important goal of airway management is to avoid excessive gastric distension and ensure adequate ventilation prior to surgical ligation of the fistula. If a large fistula is present close to carina, excessive loss of delivered tidal volume may lead to ineffective ventilation. In addition, gastric distension elevates diaphragm and diminishes the lung compliance. If lung compliance is already impaired due to pre-existing lung pathology, situation becomes much more demanding. We report the successful airway management of a patient with large precarinal fistula and bilateral pneumonitis using the novel Microcuff tube. The unique design of microcuff makes it suitable to be used for this purpose. To the best of our knowledge, the use of microcuff ETT for perioperative airway management in case of a large precarinal fistula in a neonate with respiratory pathology has not been reported in the past.

Cricoid ring: Shape, size, and variability in infants and children

Background:

Knowledge regarding the shape, size, and variability of the cricoid ring is important to properly choose the correct endotracheal tube (ETT) in the pediatric patient. Studies have measured the size of the cricoid ring using methodologies such as moulages, magnetic resonance imaging, and video-bronchoscopy. In the present study, computed tomography (CT) -based images were used to determine the shape, size, and configuration of the cricoid ring in the pediatric population taking into considerations growth and development.

Methods:

This is a retrospective review using 130 CT images of children ranging in age from 1 month to 10 years undergoing radiological evaluation unrelated to airway symptomatology. The CT scans were obtained in spontaneously breathing patients during either natural sleep or procedural sedation. Anteroposterior (AP) and transverse (T) diameters were measured at the cricoid ring using these images.

Results:

The cricoid ring is generally round in children older than 1 year with a T/AP ratio ranging between 0.98 and 1.01. However, in infants (1–12 months of age), the cricoid ring is elliptical with the AP dimension an average of 0.31 mm larger than the T dimension with a T/AP ratio of 0.95. A statistically significant difference between the T and AP dimensions was only observed in infancy (P < 0.05).

Conclusion:

The cricoid ring is round in children older than 1 year of age. In infants, the cricoid shape presents a more elliptical configuration because the T-axis is narrower than the AP dimension. CT is recognized as the most accurate technique to study cricoid ring configuration, and the present data may help clinicians determine the appropriate type, size, and shape of ETTs, particularly in infants.

Comparison of ProSeal laryngeal mask airway (PLMA) with cuffed and uncuffed endotracheal tubes in infants

We aimed to compare cuffed and uncuffed endotracheal tubes (ETTs) with ProSealTM laryngeal mask airway (PLMA) in terms of airway security and extubation, starting out from the hypothesis that PLMA will provide alternative airway safety to the endotracheal tubes, and that airway complications will be less observed. After obtaining approval from the local Ethics Committee and parental informed consent, 120 pediatric patients 1-24 months old, American Society of Anesthesiologists physical status I-II, requiring general anesthesia for elective lower abdominal surgery, were randomized into PLMA (Group P, n = 40), cuffed ETT (Group C, n = 40), and uncuffed ETT (Group UC, n = 40) groups. The number of intubation or PLMA insertion attempts was recorded. Each patient's epigastrium was auscultated for gastric insufflation, leak volumes and air leak fractions (leak volume/inspiratory volume) were recorded. Post-operative adverse events related to airway management were also followed up during the first post-operative hour. Demographic and surgical data were similar among the groups. There were significantly fewer airway manipulations in the Group P than in the other groups (p < 0.01), and leak volume and air leak fractions were greater in the Group UC than in the other two groups (p < 0.01). Laryngospasm was significantly lower in the Group P during extubation and within the first minute of post-extubation than in the other groups (p < 0.01). Based on this study, PLMA may be a good alternative to cuffed and uncuffed ETTs for airway management of infants due to the ease of manipulation and lower incidence of laryngospasm.

Emergency Neurological Life Support: Airway, Ventilation, and Sedation

Airway management and ventilation are central to the resuscitation of the neurologically ill. These patients often have evolving processes that threaten the airway and adequate ventilation. Furthermore, intubation, ventilation, and sedative choices directly affect brain perfusion. Therefore, airway, ventilation, and sedation was chosen as an emergency neurological life support protocol. Topics include airway management, when and how to intubate with special attention to hemodynamics and preservation of cerebral blood flow, mechanical ventilation settings, and the use of sedative agents based on the patient's neurological status.

Ventilator Associated Pneumonia in Children

Ventilator associated pneumonia (VAP) is a common complication in mechanically ventilated children and adults. There remains much controversy in the literature over the definition, treatment and prevention of VAP. The incidence of VAP is variable, depending on the definition used and can effect up to 12% of ventilated children. For the prevention and reduction of the incidence of VAP, ventilation care bundles are suggested, which include vigorous hand hygiene, head elevation and use of non-invasive ventilation strategies. Diagnosis is mainly based on the clinical presentation with a lung infection occurring after 48hours of mechanical ventilation requiring a change in ventilator settings (mainly increased oxygen requirement, a positive culture of a specimen taken preferentially using a sterile sampling technique either using a bronchoscope or a blind lavage of the airways). A new infiltrate on a chest X ray supports the diagnosis of VAP. For the treatment of VAP, initial broad-spectrum antibiotics should be used followed by a specific antibiotic therapy with a narrow target once the bacterium is confirmed.

Use of cuffed tracheal tubes in neonates, infants and children: A practice survey of members of the Society of Pediatric Anesthesia

STUDY OBJECTIVE

This study aimed to characterize the current practice patterns with cuffed tracheal tubes (CTT) in neonates, infants, and children among members of the Society of Pediatric Anesthesia (SPA).

DESIGN AND SETTING

An electronic mail survey was distributed using Survey Monkey to members of SPA between December 2013 and February 2014. Each member was permitted one response.

PATIENTS/INTERVENTION/MEASUREMENTS

Not applicable as this is a practice survey study.

MAIN RESULTS

A total of 805 (28%) of the 2901 members of the SPA responded. Of the respondents, 88% were from the US, 83% were fellowship trained, 82% practiced pediatric anesthesia >50% of the time, and 65% practiced in academic centers. Eighty-five percent used CTT >50% of the time in children >2 years and 60% used CTT in full-term neonates >50% of the time. Twenty-nine percent reported always using CTT whereas 5% reported never using CTT. Those in practice <5 years, who were fellowship trained or in academic practice used CTT more often in neonates compared with those in practice >20 years, not fellowship trained or in private practice (P< .0001, P= .0003 and P= .0005, respectively). The most common reason for avoiding CTT was concern about post-extubation stridor (39%). Almost 70% of respondents accept the TT if it passes the subglottis without resistance and has a leak at 15 to 20 cmH2O. More than 60% of respondents do not monitor cuff pressures in CTT.

CONCLUSION

A majority of SPA members routinely use CTT in neonates, infants and children.

Special considerations for the management of pediatric acute respiratory distress syndrome

INTRODUCTION

Pediatric acute respiratory distress syndrome (ARDS) remains a diagnostic and therapeutic challenge with significant mortality and morbidity. There are limited data to guide identification and management.

AREAS COVERED

The Pediatric Acute Lung Injury Consensus Conference recently proposed pediatric-specific definitions for ARDS and management recommendations. In this review, we discuss aspects of pediatric ARDS that have received more attention over the past few years: high frequency oscillatory ventilation, administration of corticosteroids and functional outcomes. We conducted searches on PubMed, ClinicalKey and Google Scholar using medical subject heading terms and text words related to acute lung injury and ARDS. Expert commentary: The newly proposed definition for pediatric ARDS requires validation for efficacy in diagnosis and risk stratification. At present, there is insufficient evidence to support routine use of high frequency oscillatory ventilation or corticosteroids in pediatric ARDS. Further studies are required to determine the impact of pediatric ARDS on functional outcomes.

Impact of monitoring endotracheal tube cuff leak pressure on postextubation stridor in children

PURPOSE

To determine if implementing a protocol maintaining an air leak when using cuffed endotracheal tubes (ETT) throughout the course of mechanical ventilation (MV) in children would decrease the rate of postextubation stridor (PES).

METHODS

All children requiring MV through a cuffed ETT were included, except those with (1) upper airway anomaly, (2) died while on MV, (3) received tracheostomy before extubation, and (4) transferred before extubation. We implemented a protocol limiting the volume of air instilled into the cuff, allowing an air leak by 25 cm H₂O pressure or by peak inspiratory pressure, whichever was higher. Monitoring occurred every 6 hours, adjusting cuff volumes if necessary. Patients receiving nebulized racemic epinephrine within 24 hours of extubation for upper airway obstruction were defined as having PES.

RESULTS

At baseline, 110 patients received cuffed ETTs. The proportion of patients who had an air leak at the time of extubation was 47.3%, and that who developed PES was 21.8%. During the intervention, 101 patients received cuffed ETTs. Most (72.3%) had an air leak at the time of extubation (P< .01), and 9.9% developed PES, a 54.6% relative decrease (relative risk, 0.45; 95% confidence interval, 0.22-0.90; P= .018).

CONCLUSIONS

Maintaining an appropriate air leak throughout the course of MV using cuffed ETT decreases the rate of PES in children.

Cuffed endotracheal tubes in neonates and infants undergoing cardiac surgery are not associated with airway complications

STUDY OBJECTIVE

To determine the incidence of postoperative airway complications in infants <5kg in weight undergoing cardiac surgery intubated with Microcuff (Kimberley-Clark, Roswell, GA) endotracheal tubes (ETTs).

DESIGN

Retrospective review of infants weighing <5.0 kg with congenital heart disease (CHD) presenting for cardiac surgery.

SETTING

Single-center, tertiary pediatric cardiac critical care unit at a university hospital.

PATIENTS

A total of 208 infants weighing <5 kg underwent cardiac surgery for CHD from 2008 to 2013.

INTERVENTION

Intubation with Microcuff (Kimberley-Clark) ETTs.

STUDY DESIGN

Retrospective review of infants weighing <5.0 kg with CHD presenting for cardiac surgery to a single-center tertiary care university hospital.

MEASUREMENTS

Perioperative data were collected. Primary outcome was development of tracheal stenosis and/or reintubation for stridor. Stridor was defined as mild (≤2 doses of racemic epinephrine), moderate (>2 doses of racemic epinephrine), or severe (requiring reintubation). Secondary outcomes were variables possibly contributing to postextubation stridor. Infants with a tracheostomy, airway anomalies, and death prior to initial extubation were excluded. Logistic regression analysis was performed to evaluate the association between clinical risk factors and the incidence of postextubation stridor.

RESULTS

A total of 208 infants weighing <5 kg underwent cardiac surgery for CHD from 2008 to 2013; 12 subjects were excluded for death prior to initial extubation. No infant developed tracheal stenosis. The incidence of any stridor was 20.9% (95% confidence interval, 15.8%-27.1%) with severe stridor in 2 cases (1%). Age at surgery, weight, duration of intubation, dexamethasone use, and ETT size were not significantly associated with postextubation stridor. Presence of a comorbidity was significantly associated with stridor (P=.01).

CONCLUSIONS

Microcuff ETTs in infants <5.0 kg in weight undergoing cardiac surgery are associated with a low incidence of severe postextubation stridor. Because cuffed ETTs allow for improved control of ventilation/oxygenation and decreased risk of aspiration, they should be considered for use in this high-risk population. Larger studies are needed to confirm these results.

"Post intubation Laryngeal injuries in a pediatric intensive care unit of tertiary hospital in India: A Fibreoptic endoscopic study"

STUDY OBJECTIVES

To identify acute laryngeal injuries among pediatric patients intubated for more than 48hours, and to correlate these injuries with clinical variables.

SETTING

Pediatric Intensive Care Unit (PICU) of a tertiary level hospital in India.

PATIENTS AND METHODS

Prospective, observational study. Thirty-four children meeting the inclusion and exclusion criteria were recruited into the study after obtaining informed consent from the parents. A bedside, flexible, fiberoptic laryngoscopy was done within the first 24hours of extubation. Laryngeal injuries were documented and graded. Individual types of laryngeal injuries were correlated to the duration of intubation, size of the tube, the experience of the intubator and the patient's demographics. A repeat endoscopy was done in the outpatient department, 3-4 weeks after extubation, and findings noted.

RESULTS

97% had acute laryngeal injury, of which 88% were significant. Erythema was the most common form of injury. Duration of intubation, with a mean of 4.5 days, showed a trend towards significance (p=0.06) for association with subglottic narrowing. Laryngeal injuries were similar with both cuffed and uncuffed tubes. Age of the subject, size of the tube and skill level of the intubator did not correlate with the laryngeal injuries. 18% required intervention for post-extubation laryngeal lesions. Three (10%) children had post-extubation stridor, and of these, two needed surgical intervention (6%).

CONCLUSION

Post-extubation laryngeal injuries are not uncommon. Fiberoptic endoscopy is an inexpensive and cost-effective tool for bedside evaluation of post-intubation status in pediatric larynx. Early diagnosis of post-intubation laryngeal injuries in children can prevent long term sequelae. Hence, post-extubation fiberoptic laryngoscopy should be done routinely in pediatric population.

Changes in uncuffed endotracheal tube leak during laparoscopic inguinal herniorrhaphy in children

The present study was conducted to investigate changes in uncuffed endotracheal tube (ETT) leak during laparoscopic surgery. The study included 31 patients aged between 1 and 6 years scheduled for elective laparoscopic inguinal herniorrhaphy. Inspiratory and expiratory tidal volumes (TVi and TVe) were measured during mechanical ventilation, and ETT leak was calculated using the formula-ETT leak = (TVi - TVe)/TVi × 100 (%), assessed at the following time-points-5 min after the start of mechanical ventilation (T1, baseline), just before the start of surgery (T2), 5 min after the induction of pneumoperitoneum with 15° Trendelenburg tilt (T3), and at the end of surgery (T4). Additionally, leak pressure was assessed after successful tracheal intubation (T0, baseline) at T2, T3 and T4. Uncuffed ETT leak significantly decreased at T3 compared with T1 (baseline). Leak pressure significantly increased at T3 and T4 compared with T0 (baseline). Further studies are needed in order to determine whether the results are universal and associated with clinically significant outcomes.

Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals: 2014 Update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format to assist acute care hospitals in implementing and prioritizing strategies to prevent ventilator-associated pneumonia (VAP) and other ventilator-associated events (VAEs) and to improve outcomes for mechanically ventilated adults, children, and neonates. This document updates "Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals," published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Changes in intracuff pressure of cuffed endotracheal tubes while positioning for adenotonsillectomy in children

BACKGROUND

When using cuffed endotracheal tubes (cETTs), changes in head and neck position can lead to changes in intracuff pressure.

AIM

The aim of this study was to assess the combined effect of neck extension, shoulder roll placement, and Crowe-Davis retractor use during adenotonsillectomy on the intracuff pressure of cETTs in children.

METHODS

Patients <18 years of age undergoing adenotonsillectomy under general anesthesia following the placement of a cETT were included in the study. After inflation of the cuff to seal the trachea, using the leak test, baseline intracuff pressure was recorded and then continuously monitored. After neck extension, placement of a shoulder roll, insertion of the Crow-Davis retractor, suspension from a Mayo stand, and positioning for surgery, the intracuff pressure was recorded again.

RESULTS

The study cohort included 84 patients, ranging in age from 0.9 to 17 years (5.7 ± 3.9 years). In 46 patients (54.8%), the intracuff pressure increased from baseline after positioning for adenotonsillectomy. In 12 of these patients (14.3%), the intracuff pressure was >30 cm H2O. The intracuff pressure decreased in 28 patients (33.3%), while no change was noted in 10 patients (11.9%). Overall, the general trend was an increase in intracuff pressure from 15.9 ± 7.8 cm H2O to 18.9 ± 11.6 cm H2O.

CONCLUSION

Both increases and decreases in the intracuff pressure may occur following positioning of the pediatric patient for adenotonsillectomy. An increase in intracuff pressure may result in a higher risk of damage to the tracheal mucosa. A decrease in the intracuff pressure can result in an air leak resulting in inadequate ventilation, increased risk of aspiration, and even predispose to airway fire if oxygen-enriched gases are used. Continuous intracuff pressure monitoring or rechecking the intracuff pressure after positioning for adenotonsillectomy may be indicated.

Clinical performance of cuffed versus uncuffed preformed endotracheal tube in pediatric patients undergoing cleft palate surgery

Background:

Uncuffed endotracheal tubes are commonly used in children but due to several decade preferred in paediatric oral surgery. Due to lack of conclusive evidences in this regard, we have conducted this study to compare post-operative morbidity following use of cuffed and uncuffed endotracheal tubes in paediatric patients undergoing cleft lip-palate surgery.

Methods:

This randomised controlled trial was conducted on children aged 2 to 12 years.110 patients were allocated in two parallel groups using computer generated list of random numbers. Post operative extubation stridor, sore throat, time to first oral intake and regaining of normal voice were compared between two groups.

Results:

The incidence of sore throat was significantly more (P value > 0.005) in patients of uncuffed group compared to cuffed group. The time to first oral intake and time to regain normal voice were significantly earlier in cuffed group compared to the other.

Conclusion:

With standard care, preformed cuffed ET tube has shown reduced incidence of post operative sore throat. Cuffed group has earlier oral intake and normal voice regain compared to uncuffed group.

Ease and difficulty of pre-hospital airway management in 425 paediatric patients treated by a helicopter emergency medical service: a retrospective analysis

Background

Pre-hospital paediatric airway management is complex. A variety of pitfalls need prompt response to establish and maintain adequate ventilation and oxygenation. Anatomical disparity render laryngoscopy different compared to the adult. The correct choice of endotracheal tube size and depth of insertion is not trivial and often challenged due to the initially unknown age of child.

Methods

Data from 425 paediatric patients (<17 years of age) with any airway manipulation treated by a Swiss Air-Ambulance crew between June 2010 and December 2013 were retrospectively analysed. Endpoints were: 1) Endotracheal intubation success rate and incidence of difficult airway management in primary missions. 2) Correlation of endotracheal tube size and depth of insertion with patient’s age in all (primary and secondary) missions.

Results

In primary missions, the first laryngoscopy-guided endotracheal intubation attempt was successful in 95.3% of cases, with an overall success rate of 98.6%. Difficult airway management was reported in 10 (4.7%) patients. Endotracheal tube size was frequently chosen inadequately large (overall 50 of 343 patients: 14.6%), especially and statistically significant in the age group below 1 year (19 of 33 patients; p < 0.001). Tubes were frequently and distinctively more deeply inserted (38.9%) than recommended by current formulae.

Conclusion

Difficult airway management, including cannot intubate and cannot ventilate situations during pre-hospital paediatric emergency treatment was rare. In contrast, the success rate of endotracheal intubation at the first attempt was very high. High numbers of inadequate endotracheal tube size and deep placement according to patient age require further analysis. Practical algorithms need to be found to prevent potentially harmful treatment.

Cuffed endotracheal tubes for neonates and young infants: a comprehensive review

Traditionally, uncuffed endotracheal tubes (ETTs) have been used for artificial ventilation of infants and children. More recently, newer designed high-volume low-pressure (HVLP) cuffed ETTs are being used with increasing frequency in infants from birth. Considering that many paediatric anaesthetists and intensivists are already using cuffed ETTs in infants >3 kg from birth, should neonatologists be doing the same? This review examines the reasons behind the traditional use of uncuffed ETTs and the problems associated with their use; newer HVLP cuffed ETTs and what they can potentially offer neonates; and reviews evidence from studies comparing the use of cuffed and uncuffed ETTs in neonates and small infants.

Age-based analysis of pediatric upper airway dimensions using computed tomography imaging

BACKGROUND

Recent studies have challenged the historically accepted fact that the larynx is cone-shaped in infants and children. The present study used computed tomography (CT)-based measurements to evaluate airway dimensions. The purpose of this investigation was to determine the dimensional transition between the subglottic area and the cricoid ring in children.

METHODS

This is a retrospective review of 220 CT scans of children aged 1 month to 10 years undergoing radiological evaluation unrelated to airways symptomatology. The CT scans were evaluated in children either sleeping naturally or sedated throughout the study period. Anteroposterior (AP) and Transverse (T) diameters were measured at the subglottic level and at the cricoid ring.

RESULTS

The mean (±SD) age was 47.4 ± 33.1 months. The mean AP and transverse diameters were 9.2 ± 1.9 and 7.5 ± 1.6 mm at the subglottic area and 8.5 ± 1.7 and 8.3 ± 1.5 mm at the cricoid. AP dimension showed a decrease from the subglottis to the cricoid ring. A more rapid enlargement of the airway from the subglottis to cricoid ring is observed in the transverse dimension (P < 0.05). A linear progression in the size of airway dimensions between both levels was observed with age (r > 0.7).

CONCLUSION

The narrower transverse dimension compared to the AP diameter suggests that the airway is elliptical immediately below the vocal cords. The present study demonstrates that the airway characteristics in children between the subglottic area and the cricoid change from an elliptical to a round (circular) shape. The cone-shaped airway characteristic, which has been historically proposed, was not observed. Given that subglottic transverse diameter is the smallest area dimension, one must assume this is the most likely area of resistance to the passage of an endotracheal tube rather than only the cricoid.

Essential ultrasound techniques of the pediatric airway

Ultrasound of the airways is a technique which has been described in a number of recent articles and reviews highlighting the diagnostic possibilities and simple methodology. However, there is a paucity of information focusing specifically on such methods in children where equipment, technique, and challenges are different. This review article gives a general overview of the equipment considerations, scanning protocols, and clinical applications in children.

Pediatric Endotracheal Tube Cuff Pressures During Aeromedical Transport

OBJECTIVES

Cuffed endotracheal tubes (ETTs) are frequently used in children, allowing fewer air leaks and helping prevent ventilator-associated pneumonia. Tracheal mucosal perfusion is compromised at an ETT cuff pressure (ETTCP) of 30 cm H2O with blood flow completely absent above 50 cm H2O. Our objective was to compare multiple pediatric-sized ETTCPs at ground level and various altitudes during aeromedical transport.

METHODS

Simulating the transport environment, 4 pediatric-sized mannequin heads were intubated with appropriately sized cuffed ETTs (3.0, 4.0, 5.0, 6.0) and transported by helicopter or nonpressurized fixed-wing aircraft 20 times each. The ETTCP was set to 10 cm H2O before transport, and the pressure was measured with a standard manometer at 1000-ft intervals until reaching peak altitude or CP greater than 60 cm H2O. Ground elevation ranged from 400-650 ft mean sea level (MSL) and peak altitude from 3500 to 5000 ft MSL.

RESULTS

Increased altitude caused a significant increase in ETTCP of all ETT sizes (P < 0.001). However, there is no statistical difference in pressures between ETT sizes (P = 0.28). On average, ETTCP in 3.0, 4.0, and 6.0 ETTs surpassed 30 cm H2O at approximately 1500 ft MSL and 50 cm H2O at approximately 2800 ft MSL. In the 5.0 ETT, the CP reached 30 cm H2O at 2000 ft MSL and 50 cm H2O at 3700 ft MSL.

CONCLUSIONS

The ETTCP in pediatric-sized ETTs regularly exceed recommended pressure limits at relatively low altitudes. There is no additional pressure increase related to ETT size. This has the potential to decrease mucosal blood flow, possibly increasing risk of subsequent tracheal stenosis, rupture, and other complications.

[Pediatric emergencies in the emergency medical service]

Out-of-hospital pediatric emergencies occur rarely but are feared among medical personnel. The particular characteristics of pediatric cases, especially the unaccustomed anatomy of the child as well as the necessity to adapt the drug doses to the little patient's body weight, produce high cognitive and emotional pressure. In an emergency standardized algorithms can facilitate a structured diagnostic and therapeutic approach. The aim of this article is to provide standardized procedures for the most common pediatric emergencies. In Germany, respiratory problems, seizures and analgesia due to trauma represent the most common emergency responses. This article provides a practical approach concerning the diagnostics and therapy of emergencies involving children.

Comparisons of recursive partitioning analysis and conventional methods for selection of uncuffed endotracheal tubes for pediatric patients

BACKGROUND

Numerous studies have investigated the best method of selecting the appropriate size of endotracheal tube (ETT) for children. However, none of the methods or formulae for selection of ETT size have shown better prediction over another, and they have required complex formulae calculation or even use of cumbersome equipment. Recursive partitioning analysis creates a decision tree that is more likely to enable clearer and easier visualization of decision charts compared to other data mining methods.

OBJECTIVES

The aim of the current study was to develop a clinically practical and intuitive chart for prediction of ETT size.

METHODS

Pediatric patients aged 2-9 years undergoing general anesthesia were intubated with uncuffed ETT. The tube size was considered optimal when a tracheal leak was detected at an inflation pressure between 10 and 25 cmH2 O. The observed ETT size was compared with the predicted ETT size calculated using Cole's formula, multivariate regression analysis, ultrasonographic measurements, and recursive partitioning tree structure analysis. Preference among the prediction methods was also investigated by asking physicians about their preference of methods.

RESULTS

Correct prediction rates were 33.3%, 50%, 61.9%, and 59.5%, and close prediction rates were 61.9%, 83.3%, 88.1%, and 93.7% for Cole's formulae, multivariate regression analysis, ultrasonographic measurements, and recursive partitioning tree model, respectively. Fourteen of 16 physicians prefer to use the easy-to-interpret tree model.

CONCLUSIONS

Analysis of the tree model by recursive partitioning structure analysis accomplished a high correct and close prediction rate for selection of an appropriate ETT size. The intuitive and easy-to-interpret tree model would be a quick and helpful tool for selection of an ETT tube for pediatric patients.

Changes in intracuff pressure of a cuffed endotracheal tube during surgery for congenital heart disease using cardiopulmonary bypass

BACKGROUND

With the development of newer polyurethane cuffed endotracheal tubes (cETTs), there has been a shift in clinical practice among pediatric anesthesiologists. Despite improvements in design, excessive inflation of the cuff can still compromise tracheal mucosal perfusion. Several perioperative factors can affect the intracuff pressure (CP), and there is no consensus on safe CP in pediatric patients undergoing repair of congenital cardiac disease (CHD) utilizing cardiopulmonary bypass (CPB). In the current study, the CP was continuously monitored in pediatric patients undergoing surgery for CHD.

METHODS

After IRB approval, this observational study was conducted on pediatric patients who underwent repair of CHD using CPB with a cETT in place. After anesthetic induction and endotracheal intubation, the cuff was inflated using the air leak technique while maintaining a continuous positive airway pressure of 20 cmH2 O. After inflation, the CP was continuously monitored throughout the procedure. In addition, temperature and mean arterial pressure (MAP) were also recorded.

RESULTS

The study included 33 patients who ranged in age from 1 month to 15.3 years. Their weight ranged from 4.0 to 83.6 kg. Six patients were excluded from the analysis due to the need to add or remove air from the cuff, leaving 27 patients for data analysis for cuff pressure over time. The baseline CP at the time of inflation was 16.1 ± 7.6 cmH2 O. With the use of CPB and initiation of hypothermia, when compared to the baseline, the CP decreased by -0.7 ± 5.8 cmH2 O at 35-37°C, -9.1 ± 8.4 cmH2 O at 31-33°C, -7.8 ± 6.2 cmH2 O at 27-29°C, and -11.1 ± 6.0 cmH2 O at <27°C. With rewarming, the CP increased back to the baseline level (-3.5 ± 7.0 cmH2 O).

CONCLUSION

There was a significant decrease in the CP during CPB and associated hypothermia. This may offer some protection for mucosal perfusion during CPB which is usually associated with lower than normal MAP. However, the decrease in the CP may compromise the tracheal seal which may not offer the intended protection for the airway from aspiration.

Risk factors for post-extubation stridor in children: the role of orotracheal cannula

Objective

To determine the risk factors associated with stridor, with special attention to the role of the cuffed orotracheal cannula.

Methods

Prospective analysis of all the intubated patients submitted to mechanical ventilator support from January 2008 to April 2011. The relevant factors for stridor collected were age, weight, size and type of airway tube, diagnosis, and duration of mechanical ventilation. The effects of variables on stridor were evaluated using uni- and multivariate logistic regression models.

Results

A total of 136 patients were included. Mean age was 1.4 year (3 days to 17 years). The mean duration of mechanical ventilation was 73.5 hours. Fifty-six patients (41.2%) presented with stridor after extubation. The total reintubation rate was 19.6% and 12.5 in patients with and without stridor, respectively. The duration of mechanical ventilation (>72 hours) was associated with a greater risk for stridor (odds ratio of 8.60; 95% confidence interval of 2.98-24.82; p<0.001). The presence of the cuffed orotracheal cannula was not associated with stridor (odds ratio of 98; 95% confidence interval of 0.46-2.06; p=0.953).

Conclusion

The main risk factor for stridor after extubation in our population was duration of mechanical ventilation. The presence of the cuffed orotracheal cannula was not associated with increased risk for stridor, reinforcing the use of the cuffed orotracheal cannula in children with respiratory distress.

Determination of the 95% effective dose of remifentanil for the prevention of coughing during extubation in children undergoing tonsillectomy (with or without adenoidectomy)

BACKGROUND

Limited data are available regarding the 95% effective dose (ED95 ) of remifentanil to prevent the cough response during emergence from general anesthesia in children.

METHODS

This study included 40 patients aged 3-12 years who underwent elective tonsillectomy with or without adenoidectomy. A predetermined remifentanil dose was infused continuously with desflurane during surgery and was continued until extubation. In the emergence period, the cough response during awake extubation was assessed to determine the remifentanil dose for the next patient. The first patient received remifentanil at the rate of 0.01 μg·kg(-1) ·min(-1) , and subsequent patients received a 0.01 μg·kg(-1) ·min(-1) higher dose than the previous patient if there was more than moderate coughing detected, and the patient after those with less than mild coughing received either the same dose (95% probability) or a 0.01 μg·kg(-1) ·min(-1) lower dose (5% probability) using the biased coin design. Times to extubation and adverse events were recorded. The ED95 was calculated using the maximum-likelihood estimation.

RESULTS

The ED95 of remifentanil for preventing coughing during extubation was 0.060 μg·kg(-1) ·min(-1) (95% confidence interval, 0.037-0.068). There was moderate coughing in all groups receiving 0.01-0.06 μg·kg(-1) ·min(-1) of remifentanil, but no cough response occurred in the group receiving remifentanil 0.07 μg·kg(-1) ·min(-1) . Time to extubation was weakly correlated with remifentanil infusion rate (r = 0.331). One patient who received remifentanil 0.07 μg·kg(-1) ·min(-1) showed desaturation over 5 s immediately after extubation, but recovered after receiving 100% oxygen.

CONCLUSION

The ED95 of the continuous remifentanil infusion rate was 0.060 μg·kg(-1) ·min(-1) to prevent the cough response during extubation in children after tonsillectomy.

Ventilatory support in children with pediatric acute respiratory distress syndrome: proceedings from the Pediatric Acute Lung Injury Consensus Conference

OBJECTIVE

To describe the recommendations of the Pediatric Acute Lung Injury Consensus Conference for mechanical ventilation management of pediatric patients with acute respiratory distress syndrome.

DESIGN

Consensus Conference of experts in pediatric acute lung injury.

METHODS

The Pediatric Acute Lung Injury Consensus Conference experts developed and voted on a total of 27 recommendations focused on the optimal mechanical ventilation approach of the patient with pediatric acute respiratory distress syndrome. Topics included ventilator mode, tidal volume delivery, inspiratory plateau pressure, high-frequency ventilation, cuffed endotracheal tubes, and gas exchange goals. When experimental data were lacking, a modified Delphi approach emphasizing the strong professional agreement was used.

RESULTS

There were 17 recommendations with strong agreement and 10 recommendations with weak agreement. There were no recommendations with equipoise or disagreement. There was weak agreement on recommendations concerning approach to tidal volume and inspiratory pressure limitation (88% to 72% agreement, respectively), whereas strong agreement could be achieved for accepting permissive hypercapnia. Using positive end-expiratory pressure levels greater than 15 cm H2O in severe pediatric acute respiratory distress syndrome, under the condition that the markers of oxygen delivery, respiratory system compliance, and hemodynamics are closely monitored as positive end-expiratory pressure is increased, is strongly recommended. The concept of exploring the effects of careful recruitment maneuvers during conventional ventilation met an agreement level of 88%, whereas the use of recruitment maneuvers during rescue high-frequency oscillatory ventilation is highly recommended (strong agreement).

CONCLUSIONS

The Consensus Conference developed pediatric-specific recommendations regarding mechanical ventilation of the patient with pediatric acute respiratory distress syndrome as well as future research priorities. These recommendations are intended to initiate discussion regarding optimal mechanical ventilation management for children with pediatric acute respiratory distress syndrome and identify areas of controversy requiring further investigation.

Paediatric ventilation treatment of acute lung injury in Nordic intensive care units

Background

Treatment of acute respiratory distress syndrome (ARDS) in children is largely based on extrapolated knowledge obtained from adults and which varies between different hospitals. This study explores ventilation treatment strategies for children with ARDS in the Nordic countries, and compares these with international practice.

Methods

In October 2012, a questionnaire covering ventilation treatment strategies for children aged 1 month to 6 years of age with ARDS was sent to 21 large Nordic intensive care units that treat children with ARDS. Pre‐terms and children with congenital conditions were excluded.

Results

Eighteen of the 21 (86%) targeted intensive care units responded to the questionnaire. Fifty per cent of these facilities were paediatric intensive care units. Written guidelines existed in 44% of the units. Fifty per cent of the units frequently used cuffed endotracheal tubes. Ventilation was achieved by pressure control for 89% vs. volume control for 11% of units. Bronchodilators were used by all units, whereas steroids usage was 83% and surfactant 39%. Inhaled nitric oxide and high frequency oscillation were available in 94% of the units. Neurally adjusted ventilator assist was used by 44% of the units. Extracorporeal membrane oxygenation could be started in 44% of the units.

Conclusion

Ventilation treatment strategies for paediatric ARDS in the Nordic countries are relatively uniform and largely in accordance with international practice. The use of steroids and surfactant is more frequent than shown in other studies.

Assessment of three placement techniques for individualized positioning of the tip of the tracheal tube in children under the age of 4 years

BACKGROUND

Accurate positioning of the tip of the tracheal tube (tube tip) is challenging in young children. Prevalent clinical methods include placement of intubation depth marks, palpation of the tube cuff in the suprasternal notch, or deliberate mainstem intubation with subsequent withdrawal. To compare the predictability of tube tip positions, variability of the resulting positions in relation to the carina was determined applying the three techniques in each patient.

METHODS

In 68 healthy children aged ≤4 years, intubation was performed with an age-adapted, high-volume low-pressure cuffed tube adjusting the imprinted depth mark to the level of the vocal cords. The tube tip-to-carina distance was measured endoscopically. Thereafter, placements using (I) cuff palpation in the suprasternal notch and (II) auscultation to determine change in breath sounds during withdrawal after bronchial mainstem intubation were completed in random order.

RESULTS

Tube tip position above the carina was higher when using depth marks (mean = 36.8 mm) compared with cuff palpation in the suprasternal notch (mean = 19.0 mm). Variability, expressed as sd, was lowest with the mainstem intubation technique (5.2 mm) followed by the cuff palpation (7.4 mm) and the depth mark technique (11.2 mm) (P < 0.005).

CONCLUSION

Auscultation after deliberate mainstem intubation and cuff palpation resulted in a tube tip position above the carina that was shorter and more predictable than placement of the tube using depth markings.

Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format to assist acute care hospitals in implementing and prioritizing strategies to prevent ventilator-associated pneumonia (VAP) and other ventilator-associated events (VAEs) and to improve outcomes for mechanically ventilated adults, children, and neonates. This document updates “Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Use of Microcuff(®) endotracheal tubes in paediatric laparoscopic surgeries

BACKGROUND AND AIMS

Traditionally, uncuffed endotracheal tubes have been used in children. Cuffed tubes may be useful in special situations like laparoscopy. Microcuff(®) endotracheal tube is a specifically designed cuffed endotracheal tube for the paediatric airway. We studied the appropriateness of Microcuff(®) tube size selection, efficacy of ventilation, and complications, in children undergoing laparoscopy.

METHODS

In a prospective, observational study, 100 children undergoing elective laparoscopy were intubated with Microcuff(®) tube as per recommended size. We studied appropriateness of size selection, sealing pressure, ability to ventilate with low flow, quality of capnography and post-extubation laryngospasm or stridor.

RESULTS

Mean age of the patients was 5.44 years (range 8 months 5 days-9 years 11 months). There was no resistance for tube passage during intubation in any patient. Leak on intermittent positive pressure ventilation at airway pressure ≤20 cm H2O was present in all patients. Mean sealing pressure was 11.72 (1.9 standard deviation [SD]) cm H2 O. With the creation of pnemoperitoneum, mean intracuff pressure increased to 12.48 (3.12 SD) cm H2 O. With head low positioning, mean cuff pressure recorded was 13.32 (2.92 SD). Ventilation at low flow (mean flow 1 L/min), plateau-type capnography was noted in all patients. Mean duration of intubation was 83.50 min. Coughing at extubation occurred in 6 patients. Partial laryngospasm occurred in 4 patients, which responded to continuous positive airway pressure via face mask. Severe laryngospasm or stridor was not seen in any patient.

CONCLUSION

Microcuff(®) tubes can be safely used in children if size selection recommendations are followed and cuff pressure is strictly monitored. Advantages are better airway seal and effective ventilation, permitting use of low flows.

Are new supraglottic airway devices, tracheal tubes and airway viewing devices cost-effective?

Over the past two decades, a plethora of new airway devices has become available to the pediatric anesthetist. While all have the laudable intention of improving patient care and some have proven clinical benefits, these devices are often costly and at times claims of an advantage over current equipment and techniques are marginal. Supraglottic airway devices are used in the majority of pediatric anesthetics delivered in the U.K., and airway-viewing devices provide an alternative for routine intubation as well as an option in the management of the difficult airway. Yet hidden beneath the convenience of the former and the technology of the latter, the impact on basic airway skills with a facemask and the lack of opportunities to fine-tune the core skill of intubation represent an unrecognised and unquantifiable cost. A judgement on this value must be factored into the absolute purchase cost and any potential benefits to the quality of patient care, thus blurring any judgement on cost-effectiveness that we might have. An overall value on cost-effectiveness though not in strict monetary terms can then be ascribed. In this review, we evaluate the role of these devices in the care of the pediatric patient and attempt to balance the advantages they offer against the cost they incur, both financial and environmental, and in any quality improvement they might offer in clinical care.

Pediatric airway anatomy may not be what we thought: implications for clinical practice and the use of cuffed endotracheal tubes

One of the long held tenets of pediatric anesthesia has been the notion that the pediatric airway is conical shape with the narrowest area being the cricoid region. However, recent studies using radiologic imaging techniques (magnetic resonance imaging and computed tomography) or direct bronchoscopic observation have questioned this suggesting that the narrowest segment may be at or just below the glottic opening. More importantly, it has been clearly demonstrated that the airway is elliptical in shape rather than circular with the anterior-posterior dimension being greater than the transverse dimension. These findings coupled with the development of a new generation of cuffed endotracheal tubes (ETTs) with a thin, polyurethane cuff have caused a transition in the practice of pediatric anesthesiology with an increased use of cuffed ETTs, even in neonates and infants. The following article reviews the historical data leading to the assumption that the pediatric airway is conical as well as the more recent imaging and direct bronchoscopic observational studies which refute this tenet. The transition to the use of cuffed ETTs is discussed and potential advantages presented in both the operating room and the intensive care unit. Issues regarding the monitoring of intracuff pressure and techniques to limit potential morbidity related to a high intracuff pressure are outlined.

Changes in intracuff pressure of a cuffed endotracheal tube during prolonged surgical procedures

BACKGROUND

With the introduction of redesigned cuffed endotracheal tubes (ETTs), there has been an increasing trend toward their use in pediatric patients. Despite improvements in design, an unintended and prolonged hyperinflation of the cuff can compromise tracheal mucosal perfusion. The current study prospectively monitors changes in intracuff pressure continuously in pediatric patients undergoing prolonged surgical procedures.

METHODS

The study was conducted on pediatric patients who were scheduled to undergo prolonged surgical procedures (more than 4h) with a cuffed ETT. After placement of the cuffed ETT, the cuff was inflated using the air-leak test with a CPAP of 20cmH2O in the anesthesia circuit. After inflation, the inflating port of the pilot balloon was connected to the transducer of the invasive pressure monitoring device using our previously described technique to continuously measure the intracuff pressure. Measurements were recorded every 15min for the first 1h, and then every 30min throughout the surgical procedure.

RESULTS

The study cohort included 30 patients who ranged in age from 1.2 to 17.6 years and in weight from 9.4 to 113.4kg. There were 16 boys and 14 girls. The size of the cuffed ETT ranged from 3.5mm to 8.0mm ID. The baseline intracuff pressure at the time of inflation was 17.6±8.8cmH2O. The absolute change in the intraoperative intracuff pressure when compared to the baseline intracuff pressure ranged from -25.8 to +16.3cmH2O. In 9 patients (30%), the decrease of the intracuff pressure was ≥10cmH2O. In 6 patients (20%), the increase of the intracuff pressure was ≥10cmH2O. In 5 of 30 patients (17%), the absolute intracuff pressure was greater than 30cmH2O at least once intraoperatively. In no patient, did the intracuff pressure remain the same as the baseline throughout the procedure.

CONCLUSION

We noted significant variations in the intracuff pressure during prolonged surgical procedures. These unintended changes, both increases and decreases, may impact the perioperative course of patients. Our study suggests the need for continuously monitoring intracuff pressure if a cuffed ETT is used in children for prolonged surgical procedures.

A randomized, single-blinded, prospective study that compares complications between cuffed and uncuffed nasal endotracheal tubes of different sizes and brands in pediatric patients

STUDY OBJECTIVE

To compare any association between the problematic distal placement of cuffed and uncuffed nasal endotracheal tubes (NETTs) of different sizes and brands in pediatric patients.

DESIGN

Randomized, single-blinded, prospective study.

SETTING

Operating room at The Children's Hospital.

PATIENTS

Pediatric patients (aged 2-18 years) scheduled for dental surgery under general anesthesia whose American Society of Anesthesiologists physical status is not greater than 2.

INTERVENTION

Patients were randomly assigned to preformed cuffed (1) RAE (Ring-Adair-Elwyn) endotracheal tube by Mallinckrodt or (2) nasal AGT NETT by Rüsch.

MEASUREMENTS

The distance between the tube's distal end and the carina was measured using a fiber optic bronchoscope. Problematic placements were defined where the tip of the tubes was within 0.5 cm of carina.

MAIN RESULTS

The odds of a problematic placement was 7 times higher (95% confidence interval of odds ratio, 2.06, 23.4) in patients managed with cuffed tubes than those with uncuffed tubes (P = .002). The distance between the tip of cuffed NETT tubes and carina was significantly less than with uncuffed tubes.

CONCLUSIONS

The chances of possible complications were significantly higher with cuffed NETT. The NETT should be kept at least 0.5 cm above carina to avoid possible complications.

Comparison of the air-Q intubating laryngeal airway and the cobra perilaryngeal airway as conduits for fiber optic-guided intubation in pediatric patients

BACKGROUND

One of the methods proposed in cases of difficult airway management in children is using a supraglottic airway device as a conduit for tracheal intubation. The aim of this study was to compare the efficacy of the Air-Q Intubating Laryngeal Airway (Air-Q) and the Cobra Perilaryngeal Airway (CobraPLA) to function as a conduit for fiber optic-guided tracheal intubation in pediatric patients.

MATERIALS AND METHODS

A total of 60 children with ages ranging from 1 to 6 years, undergoing elective surgery, were randomized to have their airway managed with either an Air-Q or CobraPLA. Outcomes recorded were the success rate, time and number of attempts required for fiber optic-guided intubation and the time required for device removal after intubation. We also recorded airway leak pressure (ALP), fiber optic grade of glottic view and occurrence of complications.

RESULTS

Both devices were successfully inserted in all patients. The intubation success rate was comparable with the Air-Q and the CobraPLA (96.7% vs. 90%), as was the first attempt success rate (90% vs. 80%). The intubation time was significantly longer with the CobraPLA (29.5 ± 10.9 s vs. 23.2 ± 9.8 s; P < 0.05), but the device removal time was comparable in the two groups. The CobraPLA showed a significantly higher ALP (20.8 ± 5.2 cmH2O vs. 16.3 ± 4.5 cmH2O; P < 0.001), but the fiber optic grade of glottic view was comparable with the two devices. The CobraPLA was associated with a significantly higher incidence of blood staining of the device on removal and post-operative sore throat.

CONCLUSION

Both the Air-Q and CobraPLA can be used effectively as a conduit for fiber optic-guided tracheal intubation in children. However, the Air-Q proved to be superior due to a shorter intubation time and less airway morbidity compared with the CobraPLA.