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Laryngeal damage due to an unexpectedly large and inappropriately designed cuffed pediatric tracheal tube in a 13-month-old child

[Lésion laryngée causée par un tube trachéal pédiatrique à ballonnet, mal conçu et trop grand, utilisé chez un enfant de 13 mois]

Claudia M. Dillier, MD^*, Daniel Trachsel, MD, Werner Baulig, MD, Claudine Gysin, MD, Andreas C. Gerber, MD^* and Markus Weiss, MD^*

^* From the Departments of Anesthesia,
Intensive Care and Neonatology,
and Otorhinolaryngology, University Children’s Hospital;
and the Institute of Anesthesiology, University Hospital, Zurich, Switzerland.

Address correspondence to: Dr. Markus Weiss, Department of Anesthesia, University Children’s Hospital, Steinwiesstrasse 75, CH-8032 Zurich. Phone: +41 1 266 71 11; Fax: +41 1 266 79 94 ; E-mail: markus.weiss{at}kispi.unizh.ch

	Abstract

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Purpose: To present a case of laryngeal damage in an infant caused by a too large and inappropriately designed cuffed tracheal tube.

Clinical features: A 13-month-old child undergoing cardiac surgery was intubated with an uncuffed endotracheal tube with an internal diameter (ID) of 4.0 mm. Because of an important air leak around the tracheal tube during mechanical ventilation, a cuffed endotracheal tube ID 4.0 mm was inserted. The air leak with the tube cuff not inflated was acceptable at 25 cm H₂O airway pressure. After extubation on the third postoperative day, the patient showed increasing stridor and respiratory deterioration. Fibreoptic laryngoscopy of the spontaneously breathing patient showed a large intra-laryngeal web. After surgical removal of the web, the child rapidly recovered and was discharged from the hospital on the 12th postoperative day.

Inspection of the 4.0 mm (ID) cuffed tracheal tube revealed a cuff positioned inappropriately high and an increase of 0.7 mm in outer tube diameter compared to the 4.0 mm (ID) uncuffed tracheal tube from the same manufacturer. The tube cuff is likely to be situated within the larynx when placed in accordance to insertion depth formulas or radiological criteria, as used for uncuffed tracheal tubes in children.

Conclusion: The larger than expected tracheal tube with its intra-laryngeal cuff position in a 13-month-old child likely caused mucosal damage and an inflammatory reaction within the larynx resulting in granulation tissue formation and fibrous healing around the tracheal tube.

	Introduction

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IN the last decade, the use of cuffed tracheal tubes in children younger than eight to ten years has been reported by several authors.^1–3 The advantages mentioned are improved efficiency of ventilation, reduced atmospheric pollution, more reliable end-tidal CO₂ monitoring, ability to use low flow anesthesia, reduced need to replace an ill-fitting tracheal tube and a decreased use of too large uncuffed tubes, the main reason for subglottic stenosis.^4,5 However, serious concerns have been raised regarding inadvertent cuff hyperinflation causing airway damage with the risk of post-extubation morbidity (stridor, subglottic stenosis).^5–7 We report a case of laryngeal damage in a child due to a too large and inadequately designed cuffed tracheal tube.

	Case report

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A 13-month-old boy (weight 7.4 kg/ length 69 cm) with multiple ventricular septal defects and an anomalous return of the right upper pulmonary vein into the superior vena cava was scheduled for cardiac surgery. One year earlier, a coarctation of the aorta had been repaired and a pulmonary artery banding inserted. Half a year later it had been necessary to dilate the pulmonary banding. On these occasions, the boy never displayed any sings of stridor or respiratory obstruction.

After iv induction of anesthesia and muscle paralysis the trachea was intubated with an uncuffed tracheal tube internal diameter (ID) 4.0 mm (Rüschelit, Rüsch, Kernen, Germany). Direct laryngoscopy was uneventful without detection of laryngeal abnormalities. Because of an important air leak around the uncuffed tracheal tube during mechanical ventilation, the tracheal tube was replaced. A cuffed tracheal tube ID 4.0 mm (Rüsch Super Safety Clear, Rüsch, Kernen, Germany) was inserted with the cuff placed below the vocal cords. The air leak with the tube cuff not inflated was acceptable at 25 cm H₂O airway pressure. Ventilation and oxygenation during surgery and in the cardiac intensive care unit were unremarkable. The boy was transferred to the pediatric intensive care unit (PICU) of the University Children’s Hospital on the second postoperative day.

On PICU admission the child was intubated nasally with the tracheal tube cuff fully deflated. According to our PICU guidelines for the use of cuffed endotracheal tubes, the cuff was set at ambient pressure by connecting a syringe without plunger to the pilot balloon. After weaning from mechanical ventilation the child was extubated on the third postoperative day. Shortly after extubation he developed stridor with increasing oxygen requirement and laboured breathing. Because of persisting stridor and respiratory distress, a nasal fibreoptic laryngoscopy through the face mask was performed in the PICU on the fifth postoperative day. It revealed an intra-laryngeal transverse web which obstructed the glottic opening (Figure 1, left; Video, available as additional material at www.cja-jca.org). On the same day, the boy was transferred to the operating theatre for surgical removal of the laryngeal web. Direct laryngoscopy with a no. 1 Miller blade laryngoscope and a rigid endoscope confirmed the diagnosis of laryngeal web. Tracheal intubation was achieved with an uncuffed tube ID 2.5 mm through the posterior glottic opening (Figure 1, right). The laryngeal web was successfully removed by the pediatric otorhinolaryngologist. At the end of the intervention the child was extubated and transferred to the PICU. At the time of transfer stridor had significantly decreased, the child had minimal respiratory distress and was able to maintain oxygen saturation The patient was later transferred to a regular ward and was discharged on the 12th postoperative day. Three weeks later, he presented for an ambulatory control by the otorhinolaryngologist. The boy was free of respiratory symptoms and showed no signs of residual laryngeal pathology.

View larger version (76K): [in this window] [in a new window]   FIGURE 1 Left, fibreoptic laryngoscopy revealed symmetrical vocal cord activity with an intra-laryngeal fibrous web below the glottic level. The posterior glottic opening corresponds to the initial endotracheal tube pathway. Right, rigid laryngoscopy after nasotracheal intubation with a 2.5 mm uncuffed endotracheal tube through the posterior glottic opening.

	Discussion

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Active deflation of a tube cuff results in sharp folds and edges of the cuff membrane which lead to mucosal damage within the airway by "cutting" the mucosa with every tube movement during the respiratory cycle (Figure 3). In addition, as demonstrated in Figure 2 the cuff of the Rüsch cuffed tube ID 4.0 mm is positioned higher on the tube shaft (33 mm) compared to the level of the depth markings of the ID 4.0 mm or ID 4.5 mm uncuffed tube (30 mm) of the same manufacturer. It could be considered that the high position of the cuff results from the inappropriate selection of tube size, however, in a similar fashion, the cuff of the ID 3.5 mm Rüsch tube is positioned too high (30 mm) compared to an ID 4.0 or ID 4.5 mm uncuffed tracheal tube (Figure 2).

View larger version (113K): [in this window] [in a new window]   FIGURE 3 Active deflation from the tracheal tube cuff leads to sharp folds and edges. (ID 4.0 mm Rüschelit® Super Safety Clear tube).

View larger version (107K): [in this window] [in a new window]   FIGURE 2 Comparison of the 4.0 and 4.5 mm uncuffed tracheal tubes (Rüschelit, Rüsch, Kernen, Germany – outer diameter (OD) 5.3/6.0 mm) with the 3.5 and 4.0 mm cuffed tracheal tubes (Rüsch Super Safety Clear, Rüsch, Kernen, Germany – OD 5.3/6.0 mm).

Lessons are to be learned for both anesthesiologists and manufacturers: (1) Many anesthesiologists may not be aware of differences in outer tube diameter between uncuffed and cuffed tracheal tubes, in particular those rarely caring for children. This can lead to the unnecessary insertion of ill-fitting tubes and the need to change the tube while risking airway damage. Because differences occur even in tubes provided by the same manufacturer, age-ranges for the selection of uncuffed, cuffed or wire-inforced tracheal tubes should be provided by the manufacturer or the anesthesia department. (2) The appropriate selection of cuffed tracheal tubes in infants and children necessitates an air leak at 20 cm H₂O with the cuff not inflated, if not, the tube should be changed to a smaller size. (3) Active deflation of the endotracheal tube cuff must be avoided except prior to tracheal extubation and must not be used to achieve an air leak in an overly large tube, otherwise mucosal airway damage may occur. If it is decided to keep the tube cuff not inflated during surgery or in the ICU, cuff pressure should be released and set to ambient pressure by a cuff pressure manometer or a syringe without plunger. (4) Anesthesiologists should be aware that not all available cuffed pediatric tubes can be assumed to be without flaw. To select a cuff that will have the least chance of causing airway damage, OD and cuff position should be checked and compared to the OD of uncuffed tubes and to the estimated length of the trachea. Depth markings should be compared with those of the next size uncuffed tracheal tube.¹² (5) Manufacturers should revise the design of their cuffed tubes in accordance to age-related anatomical measurements in particular regarding height of the cuff position and depth markings.

In conclusion, the larger than expected tracheal tube with its intra-laryngeal cuff position in a 13-month-old child likely caused mucosal damage and an inflammatory reaction within the larynx resulting in granulation tissue formation and fibrous healing around the tracheal tube.

	Footnotes

 
Accepted for publication May 12, 2003. Revision accepted October 22, 2003.

	References

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