Users Online: 15 Home Print this page Email this page Small font sizeDefault font sizeIncrease font size  
Home | About us | Editorial board | Search | Ahead of print | Current issue | Archives | Submit article | Instructions | Subscribe | Contacts | Login 
 

 
Table of Contents
REVIEW ARTICLE
Year : 2013  |  Volume : 29  |  Issue : 1  |  Page : 13-18

Pediatric cuffed endotracheal tubes


Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication10-Jan-2013

Correspondence Address:
Neerja Bhardwaj
Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
India
Login to access the Email id


DOI: 10.4103/0970-9185.105786

PMID: 23492803

Get Permissions

  Abstract 

Endotracheal intubation in children is usually performed utilizing uncuffed endotracheal tubes for conduct of anesthesia as well as for prolonged ventilation in critical care units. However, uncuffed tubes may require multiple changes to avoid excessive air leak, with subsequent environmental pollution making the technique uneconomical. In addition, monitoring of ventilatory parameters, exhaled volumes, and end-expiratory gases may be unreliable. All these problems can be avoided by use of cuffed endotracheal tubes. Besides, cuffed endotracheal tubes may be of advantage in special situations like laparoscopic surgery and in surgical conditions at risk of aspiration. Magnetic resonance imaging (MRI) scans in children have found the narrowest portion of larynx at rima glottides. Cuffed endotracheal tubes, therefore, will form a complete seal with low cuff pressure of <15 cm H 2 O without any increase in airway complications. Till recently, the use of cuffed endotracheal tubes was limited by variations in the tube design marketed by different manufacturers. The introduction of a new cuffed endotracheal tube in the market with improved tracheal sealing characteristics may encourage increased safe use of these tubes in clinical practice. A literature search using search words "cuffed endotracheal tube" and "children" from 1980 to January 2012 in PUBMED was conducted. Based on the search, the advantages and potential benefits of cuffed ETT are reviewed in this article.

Keywords: Children, cuffed endotracheal tube, microcuff tube


How to cite this article:
Bhardwaj N. Pediatric cuffed endotracheal tubes. J Anaesthesiol Clin Pharmacol 2013;29:13-8

How to cite this URL:
Bhardwaj N. Pediatric cuffed endotracheal tubes. J Anaesthesiol Clin Pharmacol [serial online] 2013 [cited 2014 Aug 22];29:13-8. Available from: http://www.joacp.org/text.asp?2013/29/1/13/105786


  Introduction Top


Endotracheal intubation is a routinely performed technique in the conduct of anesthesia as well as for critical care management in children for protection of the airway, ease of positive pressure ventilation, pulmonary toileting, and maintenance of oxygenation. The use of uncuffed or cuffed endotracheal tubes in children have their own advantages and disadvantages [Table 1]. Uncuffed endotracheal tubes (UETTs) are traditionally used for intubation in all children under 8 years of age, irrespective of the indication and duration of intubation. [1],[2] Cuffed endotracheal tubes (CETTs) in children undergoing surgery have not been very popular because of the fear that the cuff will cause airway mucosal injury, leading to sub-glottic stenosis. [3],[4],[5] Cuffed tubes are more expensive, and their benefit remains unproven. [6] Based on recent studies using magnetic resonance imaging (MRI) scans, it has been postulated that CETTs with low pressure, high volume cuff will seal the airway at the upper trachea where the posterior membranous wall can stretch and produce a complete seal with low cuff pressure of <15 cm H 2 O without any increase in airway complications. [7],[8],[9],[10] The manufacture of new endotracheal tubes with high volume low pressure (HPLV) cuff and continuing research in this field has also renewed interest in the use of cuffed tubes in children. This review will enable the readers to weigh the pros and cons of the cuffed tracheal tubes and to make a decision regarding their utility in day to day practice of pediatric anesthesia and intensive care. [11],[12],[13],[14]
Table 1: Advantages of uncuffed and cuffed endotracheal tubes

Click here to view


The search strategies for this review included search of electronic database PUBMED as well as manual search of cross references. A literature search was carried out using search words "cuffed endotracheal tube" and "children," and various articles (English) comparing UETT and CETT in children till January 2012 were reviewed. There were 5 editorials, 5 review articles, and 15 randomized controlled trials comparing UETT and CETT in children as well as those mentioning any side-effects.

Why do we need cuffed endotracheal tubes for the pediatric age group?

Selecting the correct size of an UETT is difficult in spite of availability of numerous formulae. Many a times, the introduced tube does not fit properly, leading to a large air leak, necessitating a tube change. [15] This air leak may not be evident immediately after intubation and usually manifests as the anesthetic depth increases or the patient's head is moved. An excessive air leak around the tube leads to unreliable monitoring of ventilatory parameters, exhaled volumes, and end-expiratory gases, which may be especially important in intensive care management of a child on ventilator. [16] The need to use high fresh gas flows leads to atmospheric pollution by anesthetic gases increasing the health risk to operation theater personnel. [17],[18] The increased consumption of anesthetic gases also has economic implications. [19] The risk of aspiration, especially in children undergoing emergency abdominal surgeries, is also increased. [20],[21] CETTs circumvent all the disadvantages of UETTs mentioned above.

The importance and need for CETTs is also dictated by the anatomy of the pediatric larynx. In a cadaveric study in infants and children, Eckenhoff et al. showed that the larynx is funnel-shaped with the narrowest portion of the funnel at the laryngeal exit. They also demonstrated that in children younger than 8 years, the cricoid cartilage is the narrowest point of the airway. As the child grows, the airway becomes more cylindrical, and the narrowest portion of the airway lies at the vocal cords. [9] Based on this, it was recommended that an ETT should be large enough to seal the cricoid ring but small enough to allow an air leak at pressures of 20-30 cm H 2 O to ensure adequate positive pressure ventilation without causing undue pressure on the tracheal mucosa. However, Litman et al., using magnetic resonance imaging (MRI) scans in spontaneously breathing children, found that the shape of the pediatric larynx was conical in the transverse dimension. [7] They demonstrated that the apex of the cone is at the level of the vocal cords, it is cylindrical in the antero-posterior (AP) dimension, and it does not change throughout development. Dalal et al., using video-bronchoscopic imaging in anesthetized and paralyzed children between the age group of 6 months and 13 years, found the narrowest portion of the larynx in children to be the rima glottidis and not the cricoid cartilage. [8] Motoyama found that the rigid cricoid aperture is not entirely circular but slightly elliptical, and a tight fitting ETT causes more compression and ischemia on lateral or transverse mucosa rather than on the mucosa lining the antero-posterior segments of the cricoid ring. [10] He recommended that UETTs with smaller external diameter should be chosen rather than UETTs, which fit the cricoid opening. [10]

Using CETTs with low pressure-high volume cuff, the airway is sealed at upper trachea where the posterior membranous wall can stretch and produce a complete seal with low cuff pressure of <15 cm H 2 O without any increase in airway complications. Studies have shown a decreased incidence of post-intubation croup with CETTs when the chosen tubes are 1-2 sizes smaller than UETTs. [15],[22]

Why are cuffed endotracheal tubes not popular?

Poor design

CETTs are not routinely used by pediatric anesthesiologists because most of these tubes are not properly designed. [15],[23],[24],[25],[26],[27] Ho et al. found reduced margin of safety of approximately 50% with CETTs, owing to the short tracheas of children. [25] According to the authors, for an UETT, the carina and the vocal cords represent the limits, within which the tracheal tube can be placed without causing carinal stimulation/endobronchial intubation and inadvertent extubation, respectively [Figure 1]. When a CETT is used, the distal limit of placement of the tracheal tube is the carina while the proximal limit is where the proximal edge of the cuff impinges on the vocal cord. [25]
Figure 1: Placement of uncuffed endotracheal tube in the trachea

Click here to view


Realizing that the data available to compare the design of CETT for neonates, infants, and children in relation to age-related anatomic data is limited, Weiss et al. evaluated the design of pediatric CETTs from different manufacturers. [5] The authors found that the outer diameters (OD) of the CETTs varied markedly for a given internal diameter (ID), both between tubes of different manufacturers and between UETT and CETT of the same manufacturer. This variation in tracheal tube wall thickness is related to the material used for constructing the tube (PVC, polyurethane, or red rubber). Since most anesthesiologists select tube size based on ID, it is possible to force oversized tubes with risk of sub-glottic damage. In addition, the deflated cuff adds to the outer tracheal tube diameter, which may vary with cuff type and manufacturer.

None of the CETTs examined up to an ID of 4.5 mm met the requirements of high volume low pressure (HVLP) cuffs based on measurement of cuff diameters and cross-sectional cuff area at 20 cm H 2 O cuff pressure. [5] To avoid high cuff pressures, HVLP cuffs are the standard of care in adults. They are based on the principle that at 20 cm H 2 O cuff pressure, the cross-sectional area of the cuff corresponds to about 150% of the internal cross-sectional area of the trachea. [28] The upper limit of safety for cuff pressure in adults is 25-30 cm H 2 O, but there is no data in children regarding perfusion pressures of the tracheal mucous membrane, and it is speculated that a lower cuff pressure would possibly be safe. Cuff pressures vary due to temperature, gas exchange, cuff movement, and anesthetic depth. Cuff inflation by air produces a variable intracuff pressure, which increases during the course of nitrous oxide anesthesia. [29] Bernet et al. in an in vitro study found that the external diameter of pediatric CETTs can expand to more than twice the age-corresponding tracheal internal diameter when overinflated, leading to considerable increases in cuff pressure and cuff volume. [26]

In most of the cuffed tubes, the upper border of the cuff corresponds to the upper border of the depth marking of the next larger sized UETT. Also, depth markings on different CETTs are either missing or are too high up on the shaft of the tube. [30] Thus, the cuff would lie between the vocal cords or even in the sub-glottic space if the tubes are placed according to age - related formulae for predicting depth of tube insertion. Ideally, the cuff should be located below the cricoid ring at the level of tracheal rings to avoid sub-glottic mucosal injury and its sequlae [Figure 2]. If a tube is placed below the cricoid ring and there is a long cuff, it carries the risk of endobronchial intubation. To ensure a cuff-free distance below the vocal cords to the cricoid level, the CETT should have a short cuff without a Murphy eye. Similar design problems have been encountered with preformed UETT and CETT for children. [31] These tubes may lead to trans-vocal cord cuff placement when the tracheal tube is placed according to the bend because of reduced bend-to-tracheal tube tip distance and the presence of a Murphy eye and longer cuffs.
Figure 2: Ideal position of cuffed endotracheal tube

Click here to view


Airway injury

Holzki et al. reported several cases of laryngeal injury in children with CETT and according to them, incidence of airway trauma in pediatrics is high with 82% of these cases related to the use of an excessively large ETT, rather than the intubation procedure. [4] However, no study has demonstrated that a CETT, compared to UETT, causes an increased risk of airway complications provided an appropriate size is chosen and the cuff pressure is monitored. Khine et al. did not find an increased incidence of croup (evidence of laryngotracheal injury) in children with CETTs compared to UETTs. [15] Similarly, Murat et al. also could not demonstrate that CETTs were associated with increased respiratory complications. [22] Duracher et al. reported 6 cases of complications (dysphonia, hoarse cough, and laryngeal dyspnea) out of 204 analyzed (2.9%); 3 cases required treatment with epinephrine or corticosteroids, but none of them required tracheal intubation. In 3 cases, the cause of stridor was use of incorrectly predicted larger tube size. [32]

The chances of airway injury are high if there is a long duration of tracheal intubation. In critically-ill children admitted in PICU, Newth et al. did not find any difference in the incidence of post-extubation croup between the CETT and UETT groups with mean duration of ventilation being 13 days and 8 days, respectively. [14] Deakers et al. prospectively studied 243 patients in a pediatric intensive care unit and found that the overall incidence of post-extubation stridor was 14.9%, with no significant difference between children with UETT and CETT. They concluded that CETT intubation is not associated with an increased risk of post-extubation stridor or significant long-term sequelae. [13] However, Holzki et al. believe that stridor and croup are not adequate determinants of tracheal mucosal injury, and ideally all airway complications should be evaluated with endoscopy. [33] Laryngotracheal injury may be related to several risk factors like traumatic intubation, prolonged duration of intubation, use of an oversized tracheal tube, and severe hypotension during laryngoscopy.

Microcuff - a newly designed cuffed tube for pediatric patients

New cuffed endotracheal tubes (Microcuff Pediatric Tracheal Tube, Microcuff GmbH, Weinheim, Germany and Microcuff® PET; Kimberly Clark, Health Care, Atlanta, GA, USA) with improved tracheal sealing characteristics and a recommendation chart for tube size selection has been introduced in the market and will probably circumvent the above-mentioned problems. [34],[35],[36],[37],[38],[39],[40],[41] This tube consists of an ultra-thin polyurethane cuff (10 μm), which does not form folds and channels between the cuff and the tracheal wall. The Murphy eye has been eliminated, which has allowed the cuff to be moved more distally on the CETT shaft. The cuff is short and when inflated, it expands below the sub-glottis, providing a seal with cuff pressure less than 10 cm H 2 O. It has correctly placed depth markings and has low tube exchange rate [Figure 3]. [37],[38],[39] A prospective, randomized, controlled multi-center trial by Weiss et al. has demonstrated the benefits of this tube in terms of number of tube exchanges, post-extubation stridor, and aspiration. [40] However, the cost of pediatric ETT with microcuff is several times more than those in routine use without cuff.
Figure 3: Microcuff endotracheal tube

Click here to view


What do you need to do while using cuffed endotracheal tubes?

  1. Selection of an appropriately-sized CETT to prevent airway mucosal injury is important. CETT should be 0.5-1.0 mm smaller than the UETT. In children >2 years, Cole's formula is used to select an UETT [ID (mm) = (age/4) + 4.0]. [40] For a CETT, the most commonly used formula is that used by Khine [ID (mm) = [age/4] +3] and Motoyama [ID (mm) = (age/4) +3.5]. [1],[15] In newborns to infants <1 year, ID 3.0 mm CETT and in children from 1-2 years, ID 3.5 mm CETT should be used. [15] When using second-generation Microcuff PETs, Salgo et al. proposed a new recommendation, which allows selection of larger ID cuffed tracheal tubes than previously recommended [Table 2]. [41]
  2. Ideally, one should select a pediatric CETT (Microcuff tube) with a high-volume-low-pressure cuff of short length, with adequate depth markings. [38]
  3. The most important aspect of CETT use in children is monitoring of intracuff pressure (P cuff ). [42],[43],[44] When nitrous oxide is used during anesthesia, it diffuses into the cuff leading to an increase in pressure in cuff and subsequent decrease in the tracheal perfusion pressure. Mucosal capillary pressure may be less in children (adult values are between 25-30 mmHg) because the mean arterial pressure is less in children. It becomes very important to monitor P cuff during the intra-operative period and maintain it at or below 20 cm H 2 O by removing excess gas. The evaluation of performance of cuff pressure pop off valve has shown that this novel device reliably prevents cuff pressure exceeding the pre-determined level of 20 cm H 2 O. [45]
Table 2: Recommendations for age-based cuffed endotracheal tube size selection (mm)

Click here to view


CETT are especially useful in laparoscopic surgeries, [46] in conditions of full stomach to avoid aspiration, repair of a traumatic rupture of the left mainstem bronchus, [47] to occlude tracheo-esophageal fistula, [48] performance of sophisticated lung function measurement, and in the intensive care of children with severe pulmonary disease. [49]


  Conclusion Top


CETTs offer a large number of advantages for their routine use in pediatric patients. Their use requires selection of correct-sized tracheal tube, its correct placement, and cuff pressure monitoring during the conduct of anesthesia. The increased cost of CETTS is compensated by the decrease in rate of tracheal re-intubation with different sizes of UETTs as well as a reduction in consumption of halogenated agents by ability to use low-flow anesthesia.

 
  References Top

1.Motoyama EK. Endotracheal intubation. In: Motoyama EK, Davis PJ, editors. Smith's Anesthesia for Infants and Children. 5 th ed. St Louis, MO: C.V. Mosby; 1990. p. 269-75.  Back to cited text no. 1
[PUBMED]    
2.Fisher DM. Anesthesia equipment for pediatrics. In: Gregory GA, editor. Pediatric Anesthesia, 3 rd ed. New York: Churchill Livingstone; 1994. p. 197-25.  Back to cited text no. 2
    
3.Uejima T. Cuffed endotracheal tubes in pediatric patients. Anesth Analg 1989;68:423.  Back to cited text no. 3
[PUBMED]    
4.Holzki J. Laryngeal damage from tracheal intubation. Paediatr Anesth 1997;7:435-7.  Back to cited text no. 4
[PUBMED]    
5.Weiss M, Dullenkopf A, Gysin C, Dillier CM, Gerber AC. Shortcomings of cuffed paediatric tracheal tubes. Br J Anaesth 2004;92:78-88.  Back to cited text no. 5
[PUBMED]    
6.Weber T, Salvi N, Orliaguet G. Cuffed vs non-cuffed endotracheal tubes for pediatric anesthesia. Pediatr Anesth 2009;19:46-54.  Back to cited text no. 6
    
7.Litman RS, Weissend EE, Shibata D, Westesson PL. Developmental changes of laryngeal dimensions in unparalyzed, sedated children. Anesth Analg 2003;98:41-5.  Back to cited text no. 7
[PUBMED]    
8.Dalal PG, Murray D, Messner AH, Feng A, McAllister J, Molter D. Pediatric laryngeal dimensions an age-based analysis. Anesth Analg 2009;108:1475-9.  Back to cited text no. 8
[PUBMED]    
9.Eckenhoff JE. Some anatomic considerations of the infant larynx influencing endotracheal anesthesia. Anesthesiology 1951;12:401-10.  Back to cited text no. 9
[PUBMED]    
10.Motoyama EK. The shape of the pediatric larynx: Cylindrical or funnel shaped? Anesth Analg 2009;108:1379-81.  Back to cited text no. 10
[PUBMED]    
11.Dorsey DP, Bowman SM, Klein MB, Archer D, Sharar SR. Perioperative use of cuffed endotracheal tubes is advantageous in young pediatric burn patients. Burns 2010;36:856-60.  Back to cited text no. 11
[PUBMED]    
12.Clements RS, Steel AG, Bates AT, Mackenzie R. Cuffed endotracheal tube in pediatric prehospital intubation: Challenging the doctrine? Emerg Med J 2007;24:57-8.  Back to cited text no. 12
[PUBMED]    
13.Deakers TW, Reynolds G, Stretton M, Newth CJL. Cuffed endotracheal tubes in pediatric intensive care. J Pediatr 1994;125:57-62.  Back to cited text no. 13
    
14.Newth CJ, Rachman B, Patel N, Hammer J. The use of cuffed versus uncuffed endotracheal tubes in pediatric intensive care. J Pediatr 2004;144:333-7.  Back to cited text no. 14
[PUBMED]    
15.Khine HH, Corddry DH, Kettrick RG, Martin TM, McCloskey JJ, Rose JB, et al. Comparison of cuffed and uncuffed endotracheal tubes in young children during general anaesthesia. Anesthesiology 1997;86:627-31.  Back to cited text no. 15
[PUBMED]    
16.Main E, Castle R, Stocks J, Hames I, Hatch D. The influence of tracheal tube leak on the assessment of respiratory function in ventilated children. Intensive Care Med 2001;27:1788-97.  Back to cited text no. 16
    
17.Chang WP, Kau C, Hseu S. Exposure of anesthesiologists to nitrous oxide during pediatric anesthesia. Ind Health 1997;35:112-8.  Back to cited text no. 17
    
18.Hoerauf KH, Wallner T, Akca O, Taslimi R, Sessler DI. Exposure to sevoflurane and nitrous oxide during four different methods of anesthetic induction. Anesth Analg 1999;88:925-9.  Back to cited text no. 18
    
19.Eschertzhuber S, Salgo B, Schmitz A, Roth W, Frotzler A, Keller CH, et al. Cuffed endotracheal tubes in children reduce sevoflurane and medical gas consumption and related costs. Acta Anaesthesiol Scand 2010;54:855-8.  Back to cited text no. 19
[PUBMED]    
20.Gopalareddy V, He Z, Sounder S, Bolling L, Shah M, Penfil S, et al. Assessment of the prevalence of microaspiration by gastric pepsin in the airway of ventilated children. Acta Paediatr 2008;97:55-60.  Back to cited text no. 20
    
21.Browning DH, Graves SA. Incidence of aspiration with endotracheal tubes in children. J Pediatr 1983;102:582-4.  Back to cited text no. 21
[PUBMED]    
22.Murat I. Cuffed tubes in children: A 3-year experience in a single institution. Paediatr Anaesth 2001;11:748-9.  Back to cited text no. 22
[PUBMED]    
23.Flynn PE, Black AE, Mitchell V. The use of cuffed tracheal tubes for paediatric tracheal intubation, a survey of specialist practice in the United Kingdom. Eur J Anaesth 2008;25:685-8.  Back to cited text no. 23
[PUBMED]    
24.Orliaguet GA, Renaud E, Lejay M, Meyer PG, Schmautz E, Telion C, et al. Postal survey of cuffed or uncuffed tracheal tubes used for paediatric tracheal intubation. Paediatr Anesth 2001;11:277-81.  Back to cited text no. 24
[PUBMED]    
25.Ho AM, Aun CS, Karmakar MK. The margin of safety associated with the use of cuffed paediatric tracheal tubes. Anaesthesia 2002;57:169-82.  Back to cited text no. 25
    
26.Bernet V, Dullenkopf A, Maino P, Weiss M. Outer diameter and shape of paediatric tracheal tube cuffs at higher inflation pressures. Anaesthesia 2005;60:1123-8.  Back to cited text no. 26
[PUBMED]    
27.Moehrlen U, Ziegler U, Weiss M. Scanning electron-microscopic evaluation of cuff shoulders in pediatric tracheal tubes. Paediatr Anesth 2008;18:240-4.  Back to cited text no. 27
[PUBMED]    
28.Latto P. The cuff. In: Latto IP, Vaughan RS, editors. Difficulties in tracheal intubation. London: WB Saunders Co; 1997. p. 51-78.  Back to cited text no. 28
    
29.Felten ML, Schmautz E, Delaporte-Cerceau S, Orliaguet GA, Carli PA. Endotracheal tube cuff pressure is unpredictable in children. Anesth Analg 2003;97:1612-6.  Back to cited text no. 29
[PUBMED]    
30.Goel S, Lim SL. The intubation depth marker: The confusion of the black line. Paediatr Anaesth 2003;13:579-83.  Back to cited text no. 30
[PUBMED]    
31.Weiss M, Bernet V, Stutz K, Dullenkopf A, Maino P. Comparison of cuffed and uncuffed preformed oral pediatric tracheal tubes. Paediatr Anesth 2006;16:734-42.  Back to cited text no. 31
    
32.Duracher C, Schmautz E, Martinon C, Faivre J, Carli P, Orliaguet G. Evaluation of cuffed tracheal tube size predicted using the Khine formula in children. Paediatr Anaesth 2008;18:113-8.  Back to cited text no. 32
[PUBMED]    
33.Holzki J, Laschat M, Puder C. Stridor is not a scientifically valid outcome measure for assessing airway injury. Paediatr Anaesth 2009;19:180-97.  Back to cited text no. 33
[PUBMED]    
34.Dullenkopf A, Schmitz A, Gerber A, Weiss M. Tracheal sealing characteristics of pediatric cuffed tracheal tubes. Paediatr Anaesth 2004;14:825-30.  Back to cited text no. 34
    
35.Dullenkopf A, Gerber A, Weiss M. Fluid leakage past tracheal tube cuffs: Evaluation of the new Microcuff endotracheal tube. Intensive Care Med 2003;29:1849-53.  Back to cited text no. 35
[PUBMED]    
36.Dullenkopf A, Gerber AC, Weiss M. Fit and seal characteristics of a new paediatric tracheal tube with high-volume-low pressure polyurethane cuff. Acta Anaesthesiol Scand 2005;49:232-7.  Back to cited text no. 36
[PUBMED]    
37.Weiss M, Gerber AC, Dullenkopf A. Appropriate placement of intubation depth marks in a new cuffed paediatric tracheal tube. Br J Anaesth 2005;94:80-7.  Back to cited text no. 37
[PUBMED]    
38.Weiss M, Balmer C, Dullenkopf A, Knirsch W, Gerber AC, Bauersfeld U, et al. Insertion depth markings allow an improved positioning of endotracheal tubes in children. Can J Anaesth 2005;52:721-6.  Back to cited text no. 38
[PUBMED]    
39.Weiss M, Dullenkopf A, Bottcher S, Schmitz A, Stutz K, Gysin C, et al. Clinical evaluation of cuff and tube tip position in a newly designed paediatric preformed oral cuffed tracheal tube. Br J Anaesth 2006;97:695-700.  Back to cited text no. 39
    
40.Weiss M, Dullenkopf A, Fischer JE, Keller C, Gerber AC. Prospective randomized controlled multi-centre trial of cuffed or uncuffed endotracheal tubes in small children. Br J Anaesth 2009;103:867-73.  Back to cited text no. 40
    
41.Salgo B, Schmitz A, Henze G, Stutz K, Dullenkopf A, Neff S, et al. Evaluation of a new recommendation for improved cuffed tracheal tube size selection in infants and small children. Acta Anaesthesiol Scand 2006;50:557-61.  Back to cited text no. 41
[PUBMED]    
42.Tu HN, Saidi N, Lieutaud T, Bensaid S, Menival V, Duvaldestin P. Nitrous oxide increases endotracheal cuff pressure and the incidence of tracheal lesions in anesthetized patients. Anesth Analg 1999;89:187-90.  Back to cited text no. 42
    
43.Tollefsen WW, Chapman J, Frakes M, Gallagher M, Shear M, Thomas SH. Endotracheal tube cuff pressures in pediatric patients intubated before aeromedical transport. Pediatr Emerg Care 2010;26:361-3.  Back to cited text no. 43
    
44.Tobias JD, Schwartz L, Rice J, Jatana K, Kang DR. Cuffed endotracheal tubes in infants and children: Should we routinely measure the cuff pressure. Int J Pediatr Otorhinolaryngol 2012;76:61-3.  Back to cited text no. 44
[PUBMED]    
45.Dullenkopf A, Bernet-Buettiker V, Maino P, Weiss M. Performance of a novel pressure release valve for cuff pressure control in pediatric tracheal tubes. Paediatr Anaesth 2006;16:19-24.  Back to cited text no. 45
[PUBMED]    
46.Rayman R, Girotti M, Armstrong K, Inman KJ, Lee R, Girvan D. Assessing the safety of pediatric laparoscopic surgery. Surg Laparosc Endosc 1995;5:437-43.  Back to cited text no. 46
[PUBMED]    
47.Oh AY, Kwon WK, Kim KO, Kim HS, Kim CS. Single-lung ventilation with a cuffed endotracheal tube in a child with a left mainstem bronchus disruption. Anesth Analg 2003;96:696-7.  Back to cited text no. 47
[PUBMED]    
48.Lucking-Famira KM, Schulzke S, Hammer J. Cuffed endotracheal tube for occlusion of a trachea-oesophageal fistula in an extremely low birth-weight infant. Intensive Care Med 2004;30:1249.  Back to cited text no. 48
    
49.Werner HA. Status asthmaticus in children. A review. Chest 2001;119:1913-29.  Back to cited text no. 49
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]


This article has been cited by
1 A technique to measure the intracuff pressure continuously: anin vivodemonstration of its accuracy
Senthil G. Krishna,Archana S. Ramesh,Kris R. Jatana,Charles Elmaraghy,Meredith Merz,James Ruda,Joseph D. Tobias,Brian Anderson
Pediatric Anesthesia. 2014; : n/a
[Pubmed]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
   Abstract
  Introduction
  Conclusion
   References
   Article Figures
   Article Tables

 Article Access Statistics
    Viewed4211    
    Printed145    
    Emailed7    
    PDF Downloaded1216    
    Comments [Add]    
    Cited by others 1    

Recommend this journal