Cuffed vs Uncuffed Endotrachael Tubes in Pediatric Anesthesia

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Presentation of Dr.Magdy Lotfy at First Pediatric Anesthesia Conference held at Cairo Egypt on 20 June, 2013

Presentation of Dr.Magdy Lotfy at First Pediatric Anesthesia Conference held at Cairo Egypt on 20 June, 2013

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  • 1. Cuffed or Uncuffed Endotracheal Tubes in Pediatric Anesthesia The Debate Should Finally End By Dr. Magdy Fathy FRCA
  • 2. 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
  • 3. 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.
  • 4. The History
  • 5. 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,
  • 6. much of our basic understanding of the physiology and anatomy of the paediatric airway has changed
  • 7. 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.
  • 8. ANESTHESIA & ANALGESIA  Pediatric Laryngeal Dimensions: An Age- Based Analysis  Vol. 108, No. 5, May 2009
  • 9. 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
  • 10. Figure 1. Measuring laryngeal dimensions. Dalal P G et al. Anesth Analg 2009;108:1475-1479 ©2009 by Lippincott Williams & Wilkins
  • 11.  Paediatric airway management: What is new?Ramesh S, Jayanthi R, Archana SR.Indian J Anaesth. 2012 Sep; 56(5):448-53.
  • 12. 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
  • 13. Examination of the literature What does the research say ?
  • 14. 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
  • 15. 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
  • 16. 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
  • 17. 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
  • 18. 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
  • 19. 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
  • 20. Weiss M, et al and the European Paediatric Endotracheal Intubation Study Group. British Journal of Anaesthesia
  • 21. 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
  • 22. Textbook recommendations
  • 23. Textbook recommendations  5th2000  Uncuffed < 10 years  6th2005  Uncuffed < 6 years  7th2009  Cuffed OK even in infants
  • 24. Textbook recommendations  3rd2001  Uncuffed < 8 years  4th2009  Traditional teaching…Uncuffed < 8 years  Recent data …
  • 25. Textbook recommendations  6th1996  Uncuffed < 8 years  7th2006  Uncuffed tubes may be OK
  • 26. Textbook recommendations  3rd1996  Uncuffed < 8 years  4th2008  No mention in text  Charts indicate cuffed OK down to 2 years
  • 27. Textbook recommendations  5th2002  Uncuffed < 6 –8 yrs  6th2006  Uncuffed < 6 –8 yrs  7th2010  Recent evidence … safe for all ages
  • 28. Excellent Insight  As far back as the 3rdEdition in 1994 the use of cuffed tubes is considered.  Chapter by Dennis Fisher, MD
  • 29. 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
  • 30. Cuffed Endotracheal Tubes in Pediatric Anesthesia The Debate
  • 31. 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
  • 32. 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
  • 33.  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
  • 34. 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
  • 35. 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
  • 36. 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
  • 37. 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.