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Pediatric Endotracheal Tube Cuff Pressures During Aeromedical Transport
Jonathan Orsborn1, James Graham, Michele Moss
1From the *Department of Pediatrics, Section of Emergency Medicine, †College of Medicine, ‡Department of Pediatrics, Section of Critical Care, and §Department of Pediatrics, Biostatistics Program, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR.
Insights
Pediatric endotracheal tube cuff pressures increase significantly with altitude, exceeding safe limits even at low altitudes. This risk is independent of endotracheal tube size, potentially harming children during aeromedical transport.
Area of Science:
- Pediatric critical care medicine
- Aeromedical transport safety
- Respiratory care
Background:
- Cuffed endotracheal tubes (ETTs) are vital in pediatric care to minimize air leaks and prevent ventilator-associated pneumonia.
- Elevated ETT cuff pressure (ETTCP) above 30 cm H2O compromises tracheal mucosal perfusion, with complete blood flow absence above 50 cm H2O.
Purpose of the Study:
- To compare endotracheal tube cuff pressures (ETTCPs) in pediatric-sized ETTs at ground level and various altitudes during simulated aeromedical transport.
- To assess the impact of altitude on ETTCP in different pediatric ETT sizes.
Main Methods:
- Four pediatric-sized mannequin heads were intubated with cuffed ETTs (3.0-6.0 mm).
- Simulated aeromedical transport via helicopter and fixed-wing aircraft was conducted 20 times each.
- ETTCP was measured at 1000-ft intervals from ground level (400-650 ft MSL) to peak altitudes (3500-5000 ft MSL).
Main Results:
- Increased altitude significantly elevated ETTCP across all tested ETT sizes (P < 0.001).
- No statistical difference in pressure increases was observed between different ETT sizes (P = 0.28).
- ETTCP exceeded 30 cm H2O around 1500 ft MSL and 50 cm H2O around 2800 ft MSL for most ETT sizes.
Conclusions:
- Pediatric ETTCP frequently surpasses recommended safety limits at relatively low altitudes during aeromedical transport.
- The risk of elevated ETTCP is not influenced by ETT size.
- Exceeding pressure limits can reduce tracheal mucosal blood flow, potentially leading to stenosis, rupture, and other complications.
Objectives:
Cuffed endotracheal tubes (ETTs) are frequently used in children, allowing fewer air leaks and helping prevent ventilator-associated pneumonia. Tracheal mucosal perfusion is compromised at an ETT cuff pressure (ETTCP) of 30 cm H2O with blood flow completely absent above 50 cm H2O. Our objective was to compare multiple pediatric-sized ETTCPs at ground level and various altitudes during aeromedical transport.
Methods:
Simulating the transport environment, 4 pediatric-sized mannequin heads were intubated with appropriately sized cuffed ETTs (3.0, 4.0, 5.0, 6.0) and transported by helicopter or nonpressurized fixed-wing aircraft 20 times each. The ETTCP was set to 10 cm H2O before transport, and the pressure was measured with a standard manometer at 1000-ft intervals until reaching peak altitude or CP greater than 60 cm H2O. Ground elevation ranged from 400-650 ft mean sea level (MSL) and peak altitude from 3500 to 5000 ft MSL.
Results:
Increased altitude caused a significant increase in ETTCP of all ETT sizes (P < 0.001). However, there is no statistical difference in pressures between ETT sizes (P = 0.28). On average, ETTCP in 3.0, 4.0, and 6.0 ETTs surpassed 30 cm H2O at approximately 1500 ft MSL and 50 cm H2O at approximately 2800 ft MSL. In the 5.0 ETT, the CP reached 30 cm H2O at 2000 ft MSL and 50 cm H2O at 3700 ft MSL.
Conclusions:
The ETTCP in pediatric-sized ETTs regularly exceed recommended pressure limits at relatively low altitudes. There is no additional pressure increase related to ETT size. This has the potential to decrease mucosal blood flow, possibly increasing risk of subsequent tracheal stenosis, rupture, and other complications.
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