It used to always be recommended that cuffed ETT tubes be used in children age 8 and older. A properly placed uncuffed ETT makes an adequate seal as it is passed through the cricoid cartilage in children less than 8 years old. Evidence now shows a cuffed ETT is as safe as an uncuffed ETT in infants beyond the newborn period and in children. More recently the American Heart Association in Pediatric Advanced Life Support recommends the use of cuffed ETTs in certain circumstances such as reduced lung compliance, high airway resistance, or a large glottic leak (1).
An article recently published ahead of print in Pediatric Critical Care Medicine looked at the complications with uncuffed ETTs in seriously burned children (2). A retrospective review was done of acutely burned children requiring urgent replacement of uncuffed ETTs with cuffed ETTs from January 1, 2000 to December 31, 2004 by the Massachusetts General Hospital.
During the 5-yr interval, 5 out of 137 (approximately 4%) children required urgent replacement of an uncuffed ETT with a cuffed ETT. For all the children the reason for the urgent tube change was uncontrollable air leak as respiratory failure and compliance worsened, requiring higher ventilation pressures. All of the children had facial burns, three had inhalation injury, one had an aspiration injury, and one had a large surface burn with no inhalation injury. The urgent ETT change was required and average 64.2 ± 43.8 hours after arrival to the burn unit and 87.6 ± 49.4 hours after injury.
Tubes were changed with a tube changer (or a cut-off nasogastric tube), with surgical standby for tracheostomy available in all children. Tracheostomy is unwise at this time because there is usually considerable edema of the neck, making performing a trach more difficult and the use of standard trach tubes too short. This sort of potential intervention would never have been necessary if cuffed ETTs had been placed initially.
Low-pressure high-volume cuffed ETTs are not associated with an increased risk of post-extubation stridor or need for tracheostomy in pediatrics. It seems that cuffed ETTs should be possibly considered more often and may need to be thought of as necessary when intubating seriously burned children.
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(1) American Heart Association: Pediatric Advanced Life Support. Circulation 2005; 112: IV-167 - IV-187.
(2) Sheridan RL: Uncuffed endotreacheal tubes should not be used in seriously burned children. Pediatr Crit Care Med 2006; Mar 28: [Epub ahead of print].
