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Cuffed endotracheal tubes in infants and children: should we routinely measure the cuff pressure?
Joseph D Tobias1, Lawrence Schwartz, Julie Rice
1Department of Anesthesiology, Nationwide Children's Hospital and Ohio State University, Columbus, OH 43205, United States. Joseph.Tobias@Nationwidechildrens.org
Insights
Pediatric patients often have high endotracheal tube cuff pressures exceeding recommended limits. This study highlights the need for better monitoring and management of intracuff pressures in pediatric anesthesia.
Area of Science:
- Anesthesiology
- Pediatric Medicine
- Medical Devices
Background:
- Cuffed endotracheal tubes (ETT) are increasingly used in pediatric anesthesia.
- Current practices for inflating these cuffs and maintaining intracuff pressures are not well-evaluated.
Purpose of the Study:
- To assess current intracuff pressure levels in pediatric patients receiving cuffed ETTs.
- To identify factors associated with elevated intracuff pressures.
Main Methods:
- A prospective study measured intracuff pressures in 200 pediatric patients.
- Data collected included patient demographics, ETT size, ventilation mode, and anesthesia provider type.
Main Results:
- The average intracuff pressure was 23 ± 22 cmH2O, with 23.5% of patients exceeding 30 cmH2O.
- Higher pressures were observed in older children (≥ 8 years).
- Trainee anesthesia providers showed a higher incidence of excessive cuff pressures (≥ 60 cmH2O) compared to staff providers.
Conclusions:
- A significant proportion of pediatric patients experience intracuff pressures above the recommended 30 cmH2O limit.
- Age and provider experience may influence intracuff pressure management.
Objective:
Over the past 5 years, there has been a change in the clinical practice of pediatric anesthesiology with a transition to the use of cuffed instead of uncuffed endotracheal tubes in infants and children. However, there are few studies evaluating the current practices of inflation of these cuffs and the intracuff pressures.
Method:
There was no change dictated in clinical practice for these patients. During the first 30 min of the case, the pressure in the cuff was measured using a hand held manometer. Additional data collected included the patient's demographic data (age, weight, and gender), the size of the ETT, whether nitrous oxide was in use, whether the patient was breathing spontaneously or undergoing positive pressure ventilation, and the type of anesthesia provider (resident, fellow, CRNA or SRNA).
Results:
The cohort for the study included 200 patients ranging in age from 1 month to 17 years and in weight from 3.5 to 99.1 kg. The average cuff pressure was 23 ± 22 cmH(2)O in the total cohort of 200 patients. The cuff pressure was ≥ 30 cmH(2)O in 47 of the 200 patients (23.5%). The average cuff pressure was significantly higher in patients who were 8 years of age or greater compared to younger patients. Additionally, there were significantly more patients with a cuff pressure ≥ 30 cmH(2)O in the ≥ 8 year old age group. Although no difference in the mean cuff pressure was noted when comparing staff anesthesia providers (pediatric anesthesiologist or CRNA) versus trainees (SRNA, anesthesiology resident, medical student or pediatric anesthesiology fellow), the incidence of significantly excessive cuff pressures (≥ 60 cmH(2)O) was higher in the trainee group versus the faculty group (12 of 99 versus 2 of 101, p<0.0001).
Conclusions:
Using current clinical practice to inflate the cuff, a significant percentage of pediatric patients have an intracuff pressure greater than the generally recommended upper limit of 30 cmH(2)O.
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