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Pediatric Endotracheal Tube Cuff Management at Altitude: Implications for Aeromedical Retrieval and Other Austere
Matthew Desmond1,2, Britta S von Ungern-Sternberg3,4,5,6
1Royal Flying Doctor Service (Queensland Section), Cairns, Australia.
Insights
Pediatric endotracheal tube (ETT) cuff pressure management during air transport lacks standardization. This review highlights the need for an optimal strategy to ensure patient safety during aeromedical retrieval.
Area of Science:
- Pediatric critical care
- Aeromedical transport
- Airway management
Background:
- Environmental pressure changes during aeromedical transport can affect endotracheal tube (ETT) cuff pressure in children.
- Current ETT cuff management practices for pediatric aeromedical retrieval are inconsistent.
- Historical research on ETT cuff pressure primarily focused on adults, excluding pediatric considerations.
Purpose of the Study:
- To review the evolution of endotracheal tube (ETT) cuff management in pediatric aeromedical retrieval.
- To identify gaps in current practices and research.
- To inform the development of an optimal cuff management strategy for children.
Main Methods:
- Historical literature review.
- Analysis of research trends in ETT cuff pressure management.
- Examination of practices in related fields like hyperbaric medicine.
Main Results:
- Adult ETT cuff pressure issues were recognized decades ago, leading to research and device development.
- Pediatric aeromedical transport research involving ETT cuffs is limited.
- Hyperbaric medicine has adopted incompressible liquid for cuff insufflation, but this is not standard in aeromedical retrieval.
Conclusions:
- There is a need for standardized, evidence-based endotracheal tube (ETT) cuff management protocols for pediatric aeromedical transport.
- Further research and discussion are required to establish best practices for pediatric airway management during air evacuation.
- Implementing strategies like incompressible liquid insufflation may improve safety and outcomes.
Background And Objectives:
Children are sometimes transported via fixed or rotary wing aircraft for medical care. If they are intubated with a cuffed endotracheal tube (ETT), changes in environmental pressure during transport can alter cuff pressure. Cuff management in this setting varies widely by region and by organization. In this historical review, we sought to delineate the evolution of ETT cuff management in children undergoing aeromedical retrieval in order to progress the field toward an optimum strategy in the future.
Descriptions And Conclusions:
Problems with extremely high ETT cuff pressures in adults due to altitude gain were identified by the 1970s. During subsequent decades, this topic was the subject of fervent research and device development, with a relative waning in interest more recently. Children, being transported less frequently and almost always with non-cuffed ETTs, were not included in these research efforts. During a similar epoch, the field of hyperbaric medicine also recognized the issue of ETT cuff pressure changes and almost uniformly changed to cuff insufflation with an incompressible liquid. This was based on cuff pressure measurements and deductive reasoning, rather than on evidence from patient outcome trials. Aeromedical retrieval has not consistently adopted this technique. Further investigation and discussion on an optimum strategy of cuff management in aeromedical transport of children is needed to reach an agreement on best practice.
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