cuffed tracheal tubes in children myths and facts

Cuffed Tracheal Tubes Cuffed Tracheal Tubes in Childrenin Children

--Myths and FactsMyths and Facts

PD Dr. Markus Weiss PD Dr. Markus Weiss Department of Anaesthesia Department of Anaesthesia

University Children’s Hospital ZurichUniversity Children’s Hospital ZurichSwitzerlandSwitzerland

PD Dr. Markus Weiss PD Dr. Markus Weiss

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Cuffed Tracheal Tubes In Children Cuffed Tracheal Tubes In Children

PRO PRO

Reduced gas leak, low fresh gas flowReduced gas leak, low fresh gas flowDecreased atmospheric pollutionDecreased atmospheric pollutionConstant controlled ventilationConstant controlled ventilationImproved efficiency of ventilationImproved efficiency of ventilationReliable monitoring of endtidal coReliable monitoring of endtidal co2 and and anaesthetic gasesanaesthetic gasesImproved accuracy of tidal volume and Improved accuracy of tidal volume and lung compliance monitoringlung compliance monitoring


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tracheastracheasCompensation for different shaped Compensation for different shaped tracheastracheasReduction in the requirement to change Reduction in the requirement to change the tubethe tubeDecreased risk of pulmonary aspirationDecreased risk of pulmonary aspirationDecreased use of too large uncuffed Decreased use of too large uncuffed tubestubesDecreased pressure exerted on the Decreased pressure exerted on the cricoid


PRO PRO

cricoid


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PRO PRO

Tracheal TubeTracheal Tube cuffedcuffed uncuffeduncuffed

PostPost--operative Croupoperative Croup 2.4 %2.4 % 2.9 %2.9 %Tube ExchangeTube Exchange 1 %1 %

23 %23 %FGF > 2 FGF > 2 literliter/min/min 1 %1 % 11 11 %%N2O > 10 N2O > 10 ppmppm 0 % 37 %0 % 37 %

Khine HK - Anesthesiology 1997


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CON CON

No Cuff Required In Children < 8 No Cuff Required In Children < 8 yearsyearsLaryngoLaryngo--tracheal injuriestracheal injuriesInadvertent Cuff OverInadvertent Cuff Over--InflationInflationInadequate Designed Paediatric Tube Inadequate Designed Paediatric Tube CuffsCuffsSmaller Internal Tube Diameter Smaller Internal Tube Diameter Increased Costs Increased Costs Not The (G)old Standard !Not The (G)old Standard !


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Yes or No ?Yes or No ?

Democratic Medicine (APA 2002)Democratic Medicine (APA 2002)2/3 Con2/3 Con1/3 Pro1/3 ProHatch 2002: It Is Not Forbidden To Use Hatch 2002: It Is Not Forbidden To Use Cuffed Endotracheal Tubes in Children ...Cuffed Endotracheal Tubes in Children ...

Not EvidenceNot Evidence--Based Medicine !!!Based Medicine !!!


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Myths Myths

Cuffed Tubes Are Not Needed Cuffed Tubes Are Not Needed in Children Because in Children Because

The Circular Cricoid SealsThe Circular Cricoid SealsThe Tracheal TubeThe Tracheal Tube


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Myths and FactsMyths and Facts

Adult LarynxAdult Larynx


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Myths and FactsMyths and Facts

Infantile LarynxInfantile Larynx

Eckenhoff JE - Anesthesiology 1954


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Myths Myths

Cuffed Tracheal Tubes Cuffed Tracheal Tubes In Children Are In Children Are A Major Reason A Major Reason

For Airway For Airway InjurysInjurys


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FactsFacts

Reasons for Airway Injury in ChildrenReasons for Airway Injury in Children

Too Large Endotracheal TubeToo Large Endotracheal TubeTraumatic Intubation Traumatic Intubation Repeated Intubation AttemptsRepeated Intubation AttemptsRepeated Tracheal Tube Repeated Tracheal Tube ExchangeExchange


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FactsFacts

Reasons for Airway Injury in ChildrenReasons for Airway Injury in Children

Prolonged Intubation Prolonged Intubation Inadequate Tube Fixation Inadequate Tube Fixation (oral/nasal)(oral/nasal)Inadequate SedationInadequate SedationInsufficient Tissue Perfusion Insufficient Tissue Perfusion Local InfectionLocal Infection


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FactsFacts

Free Air Cuff HyperinflationFree Air Cuff Hyperinflation

Free air inflation results in variable cuff pressure with hyperinflation in 39% of

cases. Free inflation of the tracheal tube cuff, controlled only by the palpation of the

pilot balloon, is not reliable and results in extremely variable (and sometimes very high) initial cuff pressures in children.

Felten ML - Anesth Analg 2003


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FactsFacts

Nitrous Oxide and Cuff HyperinflationNitrous Oxide and Cuff Hyperinflation

0

5

10

15

20

25

30

35

40

45

50

1 2 3 4 5gas removal (No)

time

(min

)

A/B A/BA/BA/BA/BC

Gas Removal for Cuff Pressure Release During Nitrous Oxide Exposure

(Set 20 cm H2O / Limit 25 cm H2O)

Dullenkopf A, Gerber AC, Weiss M - Canadian Journal of Anesthesia 2004


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Myths Myths

Cuffed Tracheal Tubes Cuffed Tracheal Tubes Are Are

Inadequately DesignedInadequately Designed


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FactsFacts

Inadequate Depth marks Inadequate Depth marks

Ho AMH, Aun CST, Karmakar MK. The margin of safety associated with the use of cuffed paediatric tracheal tubes. Anaesthesia 2002; 57: 169-182

Goel S, Lim SL. The intubation depth marker: the confusion of the black line.Paediatric Anaesthesia 2003; 13: 579-583

Wallace CJ, Bell Graham TB. Tracheal tube markings. Pediatric Anesthesia 2004; 14: 283-285


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Cuffed Tracheal Tubes In Children Cuffed Tracheal Tubes In Children FactsFacts

Inadequate Design Inadequate Design ID Tracheal tube brand No Cuff 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0

Sheridan Tracheal Tube uncuffed Murphy 1 - 3.6 (3.6) 4.3 (4.2) 4.9 (4.9) 5.5 (5.5) 6.2 (6.2) 6.8 (6.8) 7.5 (7.5) 8.2 (8.2) 8.8 (8.8) 9.6 (9.6)

Sheridan Tracheal Tube cuffed Murphy 2 + NA 4.2 (4.2) 4.9 (4.9) 5.5 (5.5) 6.2 (6.2) 6.8 (6.8) 7.5 (7.5) 8.2 (8.2) 8.8 (8.8) 9.6 (9.6)

Sheridan Tracheal Tube cuffed Magill 3 + NA 4.3 (4.2) NA 5.5 (5.5) NA 6.9 (6.8) NA 8.1 (8.2) 8.9 (8.8) 9.4 (9.6)

Mallinckrodt TT Contour 4 - 3.7 (3.6) 4.4 (4.3) 5.0 (4.9) 5.7 (5.6) 6.2 (6.2) 6.9 (6.9) 7.6 (7.5) 8.1 (8.2) 8.8 (8.9) 9.6 (9.6)

Mallinckrodt TT High – Contour Murphy 5 + NA 4.4 (4.3) 4.9 (4.8) 5.7 (5.6) 6.3 (6.2) 7.0 (6.9) 7.6 (7.5) 8.2 (8.2) 8.9 (8.8) 9.5 (9.6)

Mallinckrodt TT High – Contour Murphy P-Serie 6 + NA 4.3 (4.3) 5.0 (4.9) 5.7 (5.6) 6.4 (6.2) 6.7 (6.9) 7.7 (7.5) 8.1 (8.2) 8.9 (8.8) 9.4 (9.6)

Mallinckrodt TT Lo – Contour Magill 7 + NA 4.5 (4.3) 4.9 (4.8) 5.7 (5.6) 6.2 (6.2) 6.9 (6.9) 7.5 (7.5) 8.3 (8.2) 9.0 (8.8) 9.8 (9.6)

Mallinckrodt TT Lo – Contour Murphy 8 + NA 4.4 (4.3) 5.0 (4.8) 5.6 (5.6) 6.2 (6.2) 7.0 (6.9) 7.5 (7.5) 8.2 (8.2) 8.8 (8.8) 9.4 (9.6)

Mallinckrodt TT Hi-Lo Murphy 9 + NA NA NA NA NA 6.9 (6.9) 7.5 (7.5) 8.1 (8.2) 8.8 (8.8) 9.4 (9.6)

Mallinckrodt TT Safety Flex 10 + NA 5.2 (5.0) 5.5 (5.2) 6.2 (6.2) 6.7 (6.7) 7.2 (6.9) 7.9 (7.5) 8.5 (8.2) 9.2 (8.8) 9.8 (9.6)

Portex TT - Blue Line, Magill, uncuffed 11 - 3.4 (3.5) 4.2 (4.2) 4.8 (4.8) 5.5 (5.5) 6.1 (6.2) 6.8 (6.9) 7.5 (7.6) 8.2 (8.2) 9.0 (8.9) 9.7 (9.6)

Portex TT - Profile Soft Seal Cuff, Murphy 12 + NA NA NA NA NA 7.0 (6.9) 7.6 (7.6) 8.3 (8.2) 8.8 (8.9) 9.6 (9.6)

Rüsch Ruschelit Safety Clear 13 - 3.4 (3.3) 4.0 (4.0) 4.8 (4.7) 5.3 (5.3) 6.0 (6.0) 6.7 (6.7)** 7.3 (7.3) 8.0 (8.0) 8.8 (8.9) 9.4 (9.3)

Rüsch Ruschelit Super Safety Clear Magill 14 + 4.0 (4.0) 5.1 (5.0) 5.3 (5.3) 5.9 (6.0) 6.2 (6.3) 6.7 (6.7)** 7.2 (7.3) 8.0 (8.0) 8.7 (8.7) 9.0 (9.0)

Ou

ter

diam

eter

(O

D)

(mm

)

Rüsch Ruschelit Super Safety Clear Murphy 15 + NA NA NA NA NA 6.7 (6.7) 7.3 (7.3) 8.0 (8.0) 8.8 (8.7) 9.2 (9.0)

ID (mm) 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0

Age related PCETT ID according to the formula of Khine4 PrematureNeonate

FulltermNeonate

1 year 3 years 5 year 7 years 9 years 11 years 13 years 15 years

Age related 95 % range of internal tracheal diameter (mm)20,21

Age related 95 % range of internal tracheal diameter (mm)20,22

3.6 - 7.8

3.5 – 8.2

4.1 – 8.3

3.9 – 8.8

5.2 – 9.5

4.7 – 9.9

6.3 – 10.6

5.5 – 11.1

7.4 – 11.7

6.3 – 12.2

8.5 – 12.8

7.1 – 13.3

9.6 – 13.9

7.9 – 14.5

10.8 – 15.0

8.7 – 15.6

11.9 – 16.3

9.5 – 16.7

Age related PCETT ID according to the formula of Motoyama19 PrematureNeonate

FulltermNeonate

1 year 2 year 4 year 6 years 8 years 10 years 12 years 14 years

Trac

hea

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ers

and

PC

ETT

ID

Age related 95 % range of internal tracheal diameter (mm) 20,21

Age related 95 % range of internal tracheal diameter (mm) 20,22

3.6 – 7.8

3.5 – 8.2

4.1 – 8.3

3.9 – 8.8

4.7 – 8.9

4.3 – 4.9

5.8 – 9.8

5.1 – 10.5

6.9 – 11.1

5.9 – 11.6

8.0 – 12.2

6.7 – 12.8

9.1 – 13.3

7.5 – 13.9

10.2 – 14.4

8.3 – 15.0

11.3 – 15.5

9.1 –16.2

Weiss M - British Journal of Anaesthesia 2004


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FactsFacts

Inadequate Design Inadequate Design ID Tracheal tube brand No Cuff 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0

Sheridan Tracheal Tube uncuffed Murphy 1 -/-/21 -/-/22 -/-/24 -/-/27 -/-/29 -/-/31 -/-/31 -/-/35 -/-/37 -/-/41

Sheridan Tracheal Tube cuffed Murphy 2 + NA 12/25/- 13/32/- 13/32/- 15/35/- 20/42/- 20/46/- 21/48/- 23/55/- 25/60/-

Sheridan Tracheal Tube cuffed Magill 3 + NA 10/23/- NA 10/27/- NA 12/35/- NA 14/40/- 14/47/- 16/50/-

Mallinckrodt TT Contour 4 -/-/30 -/-/30 -/-/30 -/-/30 -/-/30 -/-/29 -/-/30 -/-/29 -/-/31 -/-/31

Mallinckrodt TT High – Contour Murphy 5 + NA 14/26/- 13/26/- 16/30/- 19/37/- 20/40/- 20/44/- 21/51/- 21/49/- 26/54/-

Mallinckrodt TT High – Contour Murphy P-Serie 6 + NA 13/24/42 16/29/50 17/30/49 22/39/57 20/37/59 22/43/62 18/40/60 24/49/67 19/46/67

Mallinckrodt TT Lo – Contour Magill 7 + NA 11/21/- 11/23/- 12/27/- 12/29/- 12/43/- 17/50/- 17/50/- 17/50/- 19/60/-

Mallinckrodt TT Lo – Contour Murphy 8 + NA 14/24/- 16/27/- 15/29/- 18/36/- 19/49/- 21/53/- 21/54/- 24/57/- 26/66/-

Mallinckrodt TT Hi-Lo Murphy 9 + NA NA NA NA NA 19/46/- 19/47/- 18/48/- 19/51/- 20/53/-

Mallinckrodt TT Safety Flex 10 + NA 10/21/42 11/26/44 11/26/47 12/30/53 17/45/68 15/50/70 18/50/70 18/52/72 18/56/80

Portex TT - Blue Line, Magill, uncuffed 11 - -/19/22 -/21/27 -/21/32 -/22/37 -/21/42 -/22/47 -/21/52 -/22/59 -/-/- -/-/-

Portex TT - Profile Soft Seal Cuff, Murphy 12 + NA NA NA NA NA 20/42/76 21/45/79 23/53/84 22/51/85 24/58/92

Rüsch Rüschelit Safety Clear 13 - -/-/20 -/-/20 -/-/21 -/-/30 -/-/30 -/-/40 -/-/39 -/-/40 -/-/41 -/-/-

Rüsch Rüschelit Super Safety Clear Magill 14 + 9/21/36 12/28/40 11/30/44 14/33/47 13/32/48 17/42/70 16/42/70 16/48/79 18/52/80 18/54/84

Dis

tan

ces

A/C

/D (

mm

)

Rüsch Rüschelit Super Safety Clear Murphy 15 + NA NA NA NA NA 21/47/76 20/47/76 22/55/82 23/57/84 25/63/88

ID (mm) 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0

Age related PCETT ID according to the formula of Khine4 PrematureNeonate

FulltermNeonate


Age-related 95 % range of tracheal length (mm) 20,21

Tracheal length (mm) 23

39.4-60.5

40

43.0 – 65.8

45

50.2 – 76.4

53

57.4 – 87.1

56

64.6 – 97.7

59

71.8 – 108.3

61

78.9 - 119 86.1 – 129.6 93.3 – 140.2


FulltermNeonate


Trac

hea

l dia

met

ers

and

PC

ETT

ID

Age-related 95 % range of tracheal length (mm) 20,21

Tracheal length (mm) 23

39.4-60.5

40

43.0 – 65.8

45

46.6 – 71.1

50

53.8 – 81.8

54

61.0 – 92.4

57

68.2 – 103.0

60

75.4 – 113.7

63

82.5 – 124.5 89.7 – 134.9


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FactsFacts

Inadequate Design Inadequate Design ID Tracheal Tube Brand No Cuff 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0

Sheridan Tracheal Tube cuffed Murphy 2 + NA 7.0 (7.3) 8.8 (8.9) 8.8 (8.9) 11 (11) 13 (13) 16 (16) 16 (16) 19 (19) 19 (19)

Sheridan Tracheal Tube cuffed Magill 3 + NA 7.1 (7.3) NA 8.5 (8.9) NA 13 (13) NA 16 (16) 18 (19) 18 (19)

Mallinckrodt TT High – Contour Murphy 5 + NA 6 (6) 7 (7) 8 (8) 11 (11) 20 (18) 21 (21) 23 (22) 24 (23) 28 (25)

Mallinckrodt TT High – Contour Murphy P-Serie 6 + NA 6.5 (6) 7 (7) 8 (8) 12 (12) 20 (18) 22 (21) 23 (22) 24 (23) 28 (25)

Mallinckrodt TT Lo – Contour Magill 7 + NA 6 (6) 7 (7) 8 (8) 11 (11) 17 (17) 19 (19) 21 (21) 22 (22) 24 (24)

Mallinckrodt TT Lo – Contour Murphy 8 + NA 6 (6) 7 (7) 8 (8) 11 (11) 17 (17) 19 (19) 21 (21) 22 (22) 24 (24)

Mallinckrodt TT Hi-Lo Murphy 9 + NA NA NA NA NA 20.5 (20) 21 (21) 23 (23) 25 (25) 28 (28)

Mallinckrodt TT Safety Flex 10 + NA 7 (6) 8 (7) 9 (8) 11 (11) 17 (17) 19 (19) 21 (21) 22 (22) 24 (24)

Portex TT - Profile Soft Seal Cuff, Murphy 12 + NA NA NA NA NA 16 (17) 17 (17) 23 (23) 23 (23) 30 (30)

Rüsch Rüschelit Super Safety Clear Magill 14 + 8 (8) 8 (8) 8 (8) 10 (10) 10 (11) 12 (13) 14.5 (16.5) 16.5 (18.5) 18.5 (20.5) 24 (24)Cuf

f di

amet

er (

mm

)at

20

H2O

cuf

fpr

essu

re

Rüsch Rüschelit Super Safety Clear Murphy 15 + NA NA NA NA NA 11 (13) 16.5 (16.5) 16 (18.5) 20.5 (20.5) 23 (24)

Sheridan Tracheal Tube cuffed Murphy 2 + NA 42 62 62 95 133 201 201 283 283

Sheridan Tracheal Tube cuffed Magill 3 + NA 42 NA 62 NA 133 NA 201 283 283

Mallinckrodt TT High – Contour Murphy 5 + NA 28 38 50 95 254 346 380 415 491

Mallinckrodt TT High – Contour Murphy P-Serie 6 + NA 28 38 50 113 254 346 380 415 491

Mallinckrodt TT Lo – Contour Magill 7 + NA 28 38 50 95 227 283 346 380 452

Mallinckrodt TT Lo – Contour Murphy 8 + NA 28 38 50 95 227 283 346 380 452

Mallinckrodt TT Hi-Lo Murphy 9 + NA NA NA NA NA 314 346 415 490 615

Mallinckrodt TT Safety Flex 10 + NA 28 38 50 95 227 283 346 380 452

Portex TT - Profile Soft Seal Cuff, Murphy 12 + NA NA NA NA NA 201 227 415 415 707

Rüsch Rüschelit Super Safety Clear Magill 14 + 8 (50) 50 50 79 95 133 214 269 330 452

Cro

ss-s

ecti

onal

cuf

far

ea (

mm

2)a

t 2

0 c

mH

2O c

uff

pres

sure

Rüsch Rüschelit Super Safety Clear Murphy 15 + NA NA NA NA NA 133 214 269 330 452

ID ( mm) 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0Age related PCETT ID according to the formula of Khine4 Premature

NeonateNeonate to1st birthday

1 to3rd birthday

3 to5th birthday

5 to7th birthday

7 to9th birthday

9 to11th birthday

11 to13th birthday

13 to15th birthday

15 to16th birthday

Maximal (95%) age-related internal tracheal diameter (mm) 20,21 8.3 9.5 10.6 11.7 12.8 13.9 15.0 16.3 17.3

Maximal (95%) age-related cross-sectional tracheal area (mm2)20,22

47.1 63.6 81.7 102.0 124.6 149.5 176.6 206.0 234.9


Neonate to1st birthday

1 to2nd birthday

2 to4th birthday

4 to6th birthday

6 to8th birthday

8 to10th birthday

10 to12th birthday

12 to14th birthday

14 to16th birthday

Maximal (95%) age-related internal tracheal diameter (mm) 20,21 8.3 8.9 10 11.1 12.2 13.3 14.4 15.7 17.3

Trac

hea

l dia

met

ers

and

PC

ETT

ID

Maximal (95%) age-related cross-sectional tracheal area (mm2)20,22

47.1 55.4 72.3 91.6 113.0 136.8 162.8 191.0 234.9


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FactsFacts

Injury Due To Wrong Tube Cuff Design Injury Due To Wrong Tube Cuff Design

11 months old boy11 months old boyCardiac surgical procedure with Cardiac surgical procedure with cpbcpbTracheal intubation: Tracheal intubation: rueschruesch tttt id 4.0 cufflessid 4.0 cufflessUnacceptable high air leak around the tubeUnacceptable high air leak around the tubeTracheal intubation: Tracheal intubation: rueschruesch tttt id 4.0 with cuffid 4.0 with cuffTight fit Tight fit -- small leak with active deflated cuffsmall leak with active deflated cuff


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rich


FactsFacts

Injury Due To Wrong Tube Cuff Design Injury Due To Wrong Tube Cuff Design

CicuCicu: ventilation with active deflated cuff : ventilation with active deflated cuff (2 (2 days) days)

Transfer to Transfer to picupicu uchuchCuff pressure set to ambient pressureCuff pressure set to ambient pressureExtubation 3Extubation 3rdrd postoperative daypostoperative dayPostextubationPostextubation stridorstridorIncreasing oxygen requirementsIncreasing oxygen requirements


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CuffCuff--Free Subglottic Tube Shaft Free Subglottic Tube Shaft No Murphy Eye No Murphy Eye Short High Volume Short High Volume -- Low Pressure Cuff (HVLP)Low Pressure Cuff (HVLP)Adequately Positioned Depth MarkingAdequately Positioned Depth Marking

Minimal Thickness of The CuffMinimal Thickness of The Cuff--Membrane Membrane Automatic Cuff Pressure Release ValveAutomatic Cuff Pressure Release ValveRecommendations for AgeRecommendations for Age--Related UseRelated Use


FactsFacts

Ideal Design of Cuffed Pediatric Tubes Ideal Design of Cuffed Pediatric Tubes


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FactsFacts

Ideal Design of Cuffed Pediatric Tubes Ideal Design of Cuffed Pediatric Tubes

Inte

rnal

tub

e di

amet

er

(ID; m

m)

Age

grou

p (y

ears

)

Sm

alle

st tra

chea

l dia

met

er o

f

age

gro

up (

mm

)

Out

er tub

e di

amet

er (

OD; m

m)

Cuf

f di

amet

er (

mm

) at

20

cm H

2O

cuf

f pr

essu

re

Cro

ss-s

ectio

nal c

uff ar

ea (

mm

2 )

Lar

gest

inte

rnal

tra

chea

l are

a

cro

ss-s

ectio

nal o

f ag

e gr

oup

(mm

2 )

Rat

io o

f cu

ff-t

o-la

rges

t tr

ache

a lc

ross

-sec

tiona

l are

a (%

)

3.0 Full term neonates to 1st birthday year 3.6 4.1 10 78.5 35.3 222.4

3.5 1 year to 2nd birthday 4.1 4.8 12 113.0 46.8 241.5

4.0 2 years to 4th birthday 4.7 5.4 12 113.0 70 161.5

4.5 4 years to 6th birthday 5.8 6.1 14 153.9 93.1 165.3


5.5 8 years to 10th birthday 8 7.3 16 201.0 139.4 144.2




Weiss M, Dullenkopf, Gerber AC - Anaesthesist 2004


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FactsFacts

Microcuff Pediatric Tracheal Tube Microcuff Pediatric Tracheal Tube Mean Mean Mean Mean Mean Mean Mean Mean Mean

ID Age Height Weight Leak P Seal P Lips Tip-Carina D Trachea L % Trachea Tubeyrs cm kg cmH2O cmH2O cm dm cm %

3 0.4 60.9 6.7 12.4 9.9 10.0 2.3 4.7 51.33.5 1.4 78.8 10.5 12.5 9.8 11.6 2.8 5.5 50.14 2.9 93.9 13.9 8.6 10.0 12.9 3.1 6.1 49.8

4.5 4.9 107.9 17.6 8.6 9.7 13.7 3.3 6.7 51.95 6.9 120.8 23.6 8.0 9.6 14.9 3.3 7.1 54.4

5.5 8.9 131.3 27.6 8.8 9.7 15.7 3.6 8.1 55.86 11.0 144.5 39.0 7.2 9.6 16.4 3.9 8.9 56.7

6.5 13.0 153.8 44.7 7.8 9.5 17.4 4.3 9.7 56.57 15.0 165.3 56.9 6.1 9.6 18.4 5.1 10.9 53.9

Dullenkopf A, Gerber AC, Weiss M - European Journal of Anaesthesiology 2004; in press


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FactsFacts

Microcuff Pediatric Tracheal Tube Microcuff Pediatric Tracheal Tube

0

5

10

15

20

25

30

35

40

45

50

Patie

nts

(%)

< 5 < 10 < 15 < 20 > 20 > 25 > 35

Leak Pressure Groups (cm H2O)

Frequency Distribution of Leak Pressures

All (%)

Boys (%)

Girls (%)

Dullenkopf A, Gerber AC, Weiss M - Anesthesiology; submitted


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FactsFacts


0

5

10

15

20

25

30

35

40

n Pa

tient

s (%

)

0 2 4 6 8 10 12 14 16 18 20Sealing Pressures (cm H2O)

Frequency D istribution of Sealing Pressures

All (% )

Boys (% )

Girls (% )

Dullenkopf A, Gerber AC, Weiss M - Anesthesiology; submitted


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FactsFacts


Tracheal Tube Insertion based on Intubation Depth Marks(Children 0-16 years)

-2

0

2

4

6

8

0 2 4 6 8 10 12 14 16 18

Age (years)

Dis

tan

ce T

ube

Tip

to

Car

ina

(cm

)

Dullenkopf A, Gerber AC, Weiss M - British Journal of Anaesthesia; submitted


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FactsFacts


Oral Tube Insertion Depth Correction to cm = 12 + (Age/2)(Children > 2 years)

-2

0

2

4

6

8

0 2 4 6 8 10 12 14 16 18

Age (years)

Tube

Tip

Cor

rect

ion

/

Dis

tan

ce T

ube

Tip

to

Car

ina

(cm

)

Dullenkopf A, Gerber AC, Weiss M - British Journal of Anaesthesia; submitted


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FactsFacts


Mic

r oc u

f fI D

4.0

mm

Ma l

li nc k

r odt

I D 4

.0 m

m

R üe s

chI D

4.0

mm

Sher

idan

I D 4

.0 m

m

Picture:Comparison of 4 tracheal cuffed pediatric tubes

Dullenkopf A, Gerber AC, Weiss M - Pediatric Anesthesia 2004


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FactsFacts


High Volume - Low Pressure Cuff Sealing Characteristics


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Myths Myths

Smaller Diameters inSmaller Diameters inCuffed Tracheal TubesCuffed Tracheal Tubes

Increase Work of Breathing Increase Work of Breathing and Cause Difficulties With and Cause Difficulties With

Tracheal SuctioningTracheal Suctioning


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FactsFacts

Smaller Diameters Smaller Diameters

Not A Problem During IPPV or Pressure Not A Problem During IPPV or Pressure SupportSupportRare Suctioning During AnaesthesiaRare Suctioning During AnaesthesiaProblems In The ICUProblems In The ICUProblems In Tubes Sizes ID 3.0 and 3.5 Problems In Tubes Sizes ID 3.0 and 3.5 mm mm


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Myths Myths

Cuffed Tracheal Tubes Cuffed Tracheal Tubes Cause Cause

Increased CostsIncreased Costs


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FactsFacts

Increased Costs Increased Costs 22--4 Times More Expensive Than Uncuffed 4 Times More Expensive Than Uncuffed Tubes Tubes Reduced Overall Costs by:Reduced Overall Costs by:

Less Tube Exchange ( up to 28 % )Less Tube Exchange ( up to 28 % )Less Fresh Gas Flow ConsumptionLess Fresh Gas Flow ConsumptionLess Volatile Anaesthetic ConsumptionLess Volatile Anaesthetic ConsumptionNo No EnviromentalEnviromental Pollution (Health !)Pollution (Health !)Other Advantages (ETCO2 Monitoring, Other Advantages (ETCO2 Monitoring, Oxygenation, Loss of Time by Tube Exchange, ... )Oxygenation, Loss of Time by Tube Exchange, ... )


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Myths Myths

There Is LimitedThere Is LimitedExperience With Experience With

Cuffed Tracheal TubesCuffed Tracheal TubesIn Small ChildrenIn Small Children


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FactsFacts

Experience Experience

Large Experience from Single Large Experience from Single CentersCentersParisParisZurichZurichLund Lund PittsburghPittsburgh

Limited MultiLimited Multi--Centre ExperienceCentre ExperienceLimited Randomised Prospective StudiesLimited Randomised Prospective Studies


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Myths Myths

Uncuffed Tracheal TubesUncuffed Tracheal TubesAre The GOLD Standard Are The GOLD Standard

For Children Below For Children Below 8 Years Of Age8 Years Of Age


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Facts Facts

Uncuffed Tracheal TubesUncuffed Tracheal TubesBecomes The OLD Standard Becomes The OLD Standard

For Children Below For Children Below 8 Years Of Age8 Years Of Age


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ConclusionsConclusions

Cuffed Tracheal Tubes Can Cuffed Tracheal Tubes Can Be Safely Used in Children:Be Safely Used in Children:

Air Leak Control (<20 cm HAir Leak Control (<20 cm H220)0)Cuff Pressure Control (<20 cm HCuff Pressure Control (<20 cm H220)0)Adequate Designed Cuffed TubesAdequate Designed Cuffed Tubes

cuffed tracheal tubes in children myths and facts

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