Changes in Pediatric-Sized Endotracheal Tube Cuff Pressure With Elevation Gain: Observations in Ex Vivo Simulations and In Vivo Air Medical Transport

Comparison of the efficacy and safety of cuffed versus uncuffed endotracheal tubes for infants in the intensive care setting: a pilot, unblinded RCT

OBJECTIVE

To study effectiveness and safety of cuffed versus uncuffed endotracheal tubes (ETTs) in small infants in the intensive care unit (ICU).

DESIGN

Pilot RCT.

SETTING

Neonatal and paediatric ICUs of children's hospital in Western Australia.

PARTICIPANTS

Seventy-six infants ≥35 weeks gestation and infants <3 months of age, ≥3 kg.

INTERVENTIONS

Patients randomly assigned to Microcuff cuffed or Portex uncuffed ETT.

MAIN OUTCOMES MEASURES

Primary outcome was achievement of optimal ETT leak in target range (10%-20%). Secondary outcomes included: reintubations, ventilatory parameters, ventilatory complications, postextubation complications and long-term follow-up.

RESULTS

Success rate (achievement of mean leak in the range 10%-20%) was 13/42 (30.9%) in the cuffed ETT group and 6/34 (17.6%) in uncuffed ETT group (OR=2.09; 95% CI (0.71 to 6.08); p=0.28). Mean percentage time within target leak range in cuffed ETT group 28% (IQR: 9-42) versus 15% (IQR: 0-28) in uncuffed ETT group (p=0.01). There were less reintubations to optimise size in cuffed ETT group 0/40 versus 10/36 (p<0.001). No differences were found in gaseous exchange, ventilator parameters or postextubation complications. There were fewer episodes of atelectasis in cuffed ETT group 0/42 versus 4/34 (p=0.03). No patient had been diagnosed with subglottic stenosis at long-term follow-up.

CONCLUSIONS

There was no difference in the primary outcome, though percentage time spent in optimal leak range was significantly higher in cuffed ETT group. Cuffed ETTs reduced reintubations to optimise ETT size and episodes of atelectasis. Cuffed ETTs may be a feasible alternative to uncuffed ETTs in this group of patients.

TRIAL REGISTRATION NUMBER

ACTRN12615000081516.

Length of the Cricoid and Trachea in Children: Predicting Intubation Depth to Prevent Subglottic Stenosis

OBJECTIVE

Define the length of the subglottis and trachea in children to predict a safe intubation depth.

METHODS

Patients <18 years undergoing rigid bronchoscopy from 2013 to 2020 were included. The carina and inferior borders of the cricoid and true vocal folds were marked on a bronchoscope and distances were measured. Patient age, weight, height, and chest height were recorded. Four styles of cuffed pediatric endotracheal tubes (ETT) were measured and potential positions of each cuff and tip were calculated within each trachea using five depth of intubation scenarios. Multivariate linear regression was performed to identify predictors of subglottic and tracheal length.

RESULTS

Measurements were obtained from 210 children (141 male, 69 female), mean (SD) age 3.21 (3.66) years. Patient height was the best predictor of subglottic length (R² : 0.418): Length_sg (mm) = 0.058 * height (cm) + 2.8, and tracheal length (R² : 0.733): Length_t (mm) = 0.485 * height (cm) + 21.3. None of the depth of intubation scenarios maintained a cuff-free subglottis for all ETT styles investigated. A formula for depth of intubation: Length_di (mm) = 0.06 * height (cm) + 8.8 found that no ETT cuffs would be in the subglottis and all tips would be above the carina.

CONCLUSION

Current strategies for determining appropriate depth of intubation pose a high risk of subglottic ETT cuff placement. Placing the inferior border of the vocal cords 0.06 * height (cm) + 8.8 from the superior border of the inflated ETT cuff may prevent subglottic cuff placement and endobronchial intubation.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.