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Correspondence |
The Chinese University of Hong Kong, Hong Kong, SAR, E-mail: hoamb{at}cuhk.edu.hk
To the Editor:
We read with interest the editorial by Dr. Cox on cuffed vs uncuffed endotracheal tubes in children,1 and offer the following comments.
While there are advantages to using cuffed tubes for laparoscopic surgery, the small margin of safety associated with cuffed pediatric tube placement2 (a problem partially solved by the Microcuff® Pediatric Tube)3 is further reduced during laparoscopy, especially with the child in Trendelenberg position. The cephalad movement of the carina relative to the tube in those situations has led to endobronchial intubation in adults4 and children. For this reason, if a cuffed tube is used during laparoscopy, we believe that the "ideal" position of the cuff being distal to the cricoid cartilage5 is unrealistic; instead, it should be passed just distal to the vocal cords. Conversely, when a child needs to be positioned prone, provision should be made for the tendency of the tube to move cephalad relative to the trachea.6
We agree with Dr. Cox that pulmonary compliance is an important consideration in the choice of tubes. Indeed, pediatric burn victims intubated with uncuffed tubes not uncommonly require tube change because of gas leak.7
For the many cases in which the choice of cuffed or uncuffed endotracheal tube makes little difference, and there is not a recent intubation record to act as a reference, it is more cost-effective to use a cuffed tube. The reason is that even though uncuffed tubes typically cost 10% less than cuffed tubes, 23%8 of uncuffed tubes need to be changed because of poor fit (1% for cuffed tubes8). The difference is small, but the extra time incurred by tube change and the higher gas flow required when using uncuffed tubes8 also adds cost, not to mention the stress of tube change on the patient. Finally, there is always a higher theoretical risk of dispersion of infectious droplets when ventilating with an uncuffed tube a child with a highly communicable respiratory ailment. This was a consideration during the SARS outbreak in Hong Kong in 2003.
The availability of cuffed pediatric endotracheal tubes adds versatility to anesthesia practice. There is no doubt that cuffed pediatric tracheal tubes will continue to improve and their full potential will be realized. Meanwhile, we agree with Dr. Cox that the choice between cuffed and uncuffed pediatric endotracheal tubes should not be routine; that is just another reason why pediatric anesthesia can be so challenging and interesting.
Footnotes
Accepted for publication September 9, 2005.
References
1 Cox RG. Should cuffed endotracheal tubes be used routinely in children? (Editorial). Can J Anesth 2005; 52: 669–74.
2 Ho AM, Aun CS, Karmakar MK. The margin of safety associated with the use of cuffed paediatric tracheal tubes. Anaesthesia 2002; 57: 173–5.[Medline]
3 Weiss M, Balmer C, Dullenkopf A, et al. Intubation depth markings allow an improved positioning of endotracheal tubes in children. Can J Anesth 2005; 52: 721–6.
4 MacKenzie M, MacLeod K. Repeated inadvertent endo-bronchial intubation during laparoscopy. Br J Anaesth 2003; 91: 297–8.
5 James I. Cuffed tubes in children (Letter). Paediatr Anaesth 2001; 11: 259–63.[Medline]
6 Marcano BV, Silver P, Sagy M. Cephalad movement of endotracheal tubes caused by prone positioning pediatric patients with acute respiratory distress syndrome. Pediatr Crit Care Med 2003; 4: 186–9.[Medline]
7 Silver GM, Freiburg C, Halerz M, Tojong J, Supple K, Gamelli RL. A survey of airway and ventilator management strategies in North American pediatric burn units. J Burn Care Rehabil 2004; 25: 435–40.[Medline]
8 Khine HH, Corddry DH, Kettrick RG, et al. Comparison of cuffed and uncuffed endotracheal tubes in young children during general anesthesia. Anesthesiology 1997; 86: 627–31.[Medline]
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