Cuffed vs.

Uncuffed Endotracheal Tubes

In the Acutely Ill and Injured Child

Nicole Bayer
I have neither given nor received aid, other than acknowledged, on
this assignment, nor have I seen anyone else do so.

Anatomy
What does the childs larynx look like?
Before the age of 8 years:
It has been said that until the age of eight, children have a funnel-shaped
larynx. There are varying opinions on which portion of the childs larynx
under the age of eight is the narrowest portion, but some areas believed to
be the narrowest include the laryngeal exit and the cricoid cartilage.
After the age of 8 years:
The airway forms into a cylindrical shape and the narrowest portion is the
vocal cords
Another study used MRI images to show that the apex [] is at the level of the
vocal cords, it is cylindrical in the antero-posterior dimension, and it does not
change throughout development (Bhardwaj, 2013).

Background

Are cuffed endotracheal tubes (CETT) safe for children?

Previously CETT were not recommended for children under the age of 8 years. It
was believed that CETT caused sub-glottic mucosal injury. It was later proven
that CETT and UETT (uncuffed endotracheal tubes) could both cause ischemia
that led to ulceration and scar tissue formation in which the final result is glottic or
subglottic stenosis. Neither cuff was associated with higher rates of sub-glottic
injury.

What are the current recommendations?

The current PALS recommendation is that the use of a CETT or UETT are both
acceptable for use in children. The UETT may prove beneficial for specific
patients who have aspiration risk or poor lung compliance. The exception is for
premature infants and neonates where the use of CETT has not been studied.
There is controversy about what age a CETT should be used. It is safe for full
term sized newborns and older however some recommend use in 8 years and
older or 6 years and older. Another author recommends usage of CETT for ages
5 years and older, the equivalent to a size 5.5 mm ID, unless the child is
undergoing a major laparotomy or has diminished lung compliance where CO2
control is therapeutic, then they would consider a child 4 years and older (a size
5.0 mm ID ETT)
(Kleinman, 2010) (Weber, et al., 2009)

Pros and Cons

Cuffed Endotracheal Tube

Pros:
Reduce risk of aspiration and thus
decrease risk of aspiration pneumonia
Provides protection of the airway
Provides the most reliable way to
provide positive pressure ventilation
Provides accurate measurement of
ventilator parameters, exhaled
volumes, end-expiratory gases
Allows for easy pulmonary toileting and
maintenance of oxygenation
Reduced reintubation rates (because
of leaks) when appropriate sized tube
is properly placed because cuff can be
inflated more or less for an appropriate
tracheal seal
Cons:
Cost more

Uncuffed Endotracheal Tube

Pros:
Cost less
Have been used for many years so
many providers are comfortable with
placing them
Cons:
Ventilation leaks around tube
Increased risk of aspiration
Inaccurate capnographic tracing
Inaccurate spirometric tidal volume
measurement
Waste and increased cost of inhaled
anesthetics
Increased airway fire risk (due to air
leaks)
Increased chance endotracheal tube
will need to be changed to a different
size
(Littman, 2013)

Advantages of CETT

Very useful in pediatric patients of most ages during laparoscopic surgeries,

repairs of traumatic rupture of the left mainstem bronchus, to occlude
trachea-esophageal fistulas, to provide sophisticated lung function
measurements, and to provide intensive care for children with severe
pulmonary disease (Bhardwaj, 2013)
1.2% reintubation rate in CETT vs. 23% UETT reintubation rate
Other advantages were listed in the previous slide under Pros

(Bhardwaj, 2013)

What Causes Airway Injury?

The complications resulting from pediatric endotracheal tube use is not greater in
either cuffed or uncuffed tubes.
The complications were often a result of emergency intubation of seriously injured
children, traumatic intubation, prolonged duration of intubation, severe arterial
hypotension and the most common cause of tracheal injury is the result of placement
of an oversized endotracheal tube.
Other causes of damage are a result of: previous intubations, patient movement
(especially of an infants head and neck) and coexisting comorbidities
Neonates in the NICU had the greatest incidence of airway damage to all glottic and
subglottic regions
(Bhardwaj, 2013)

UETT

CETT

CETT

How Can Injury be Avoided?

Correct sizing of the endotracheal tube is key to prevent injury!

The formula for a correct sized UETT is Coles formula: UETT [ID (mm) = (age/4) + 4.0] for
children greater than 2 years
The 2 formulas for a correct sized CETT is Khines formula, which underestimates the tube
by 0.5, is [ID (mm) = (age/4) + 3.0], and Motoyamas formula, which has been proven to be
more accurate, [ID (mm) = (age/4) + 3.5]
If a CETT is used for newborns to toddlers: newborns to infants less than a year get a size
ID 3.0 mm CETT and children one year to two years use a size ID 3.5 mm CETT

Frequent monitoring of ETT measurements (depth of tube as well as cuff pressures)

may help to prevent injury by noticing tube displacements right when they occur
Properly securing an ETT may also prevent injury
Proper placement of the ETT in the larynx is also key to prevent injury. The images
below show the proper placement for both UETT and CETT

(Bhardwaj, 2013)

Complications and Long Term

Consequences of ETT Use

The complications as mentioned on a previous slide are:

Sub-glottic mucosal injury starting with ischemia followed by ulceration and scar
tissue formation in which the final result is glottic or subglottic stenosis
Extubated children may experience stridor, dysphonia (difficulty speaking),
hoarse cough and laryngotracheal injury
Life threatening complications may result when using an UETT secondary to the
less accurate and reliable lung function measurements, especially in an unstable
child or a child with diminished lung compliance where precise lung function
measurements are crucial
The Long Term Consequences:
Stenosis would have to be treated, sometimes with surgical procedures, and can
result in lifelong complications

Prevention

Due to the patient already having an acute illness/injury and needing to

have an ETT, there are no primary or secondary preventions
Tertiary prevention include:

Maintaining correct tube placement to prevent injury to the larynx and preventing ventilation
errors
Maintaining proper cuff inflation to prevent leaks and injury to the larynx
Monitoring oxygenation and ventilation to monitor the patients condition
Maintaining tube patency to ensure the patient is being adequately oxygenated and
ventilated
Oral care to prevent infections in intubated patients
Concurrent use of an orogastric or nasogastric tube to prevent aspiration pneumonia
Caregiver hand hygiene to prevent the spread of illnesses
Teaching incentive spirometer use (or other methods for lung expansion, i.e. blowing
bubbles) after extubation to help with lung compliance

Nursing Care for Intubated Child

Patient Care

Frequent monitoring of vital signs, frequent patient assessments, monitoring I&Os

Suctioning as needed, oral hygiene, care for basic needs, talking to child, comfort/ hold child
Making sure child is comfortable and not in significant amounts of pain, proper sedation, pain control
Turning patient
Caring for family
Alert appropriate personnel to changes in patient status and condition
Low stimulating and quiet environment for rest and healing, include patient belongings (ex. teddy bear)

Nursing Interventions

Maintaining correct tube placement- ensure tube is at same depth that has been documented
Maintaining proper cuff pressure at least once a shift, but more often is preferable
Monitoring oxygenation and ventilation- observe breathing pattern and listen to breath sounds
Maintaining tube patency- ensure tube is not kinked or clogged
Oral care, suction at bedside, if ordered the use of NG/OG tubes
Head of bed upright (30- 45 degrees) if possible, ambu bag at bedside
Ensure vent settings are the same as what is ordered, make sure vent alarms are audible
Find way to communicate with child other than verbal communication (i.e. pictures)
Monitoring for signs of anxiety/ stress- ensure sedation is adequate and appropriate and pain is well
controlled
Teaching incentive spirometer use after extubation to help with lung compliance
Proper hand washing and family support

Nursing Care for Intubated Child

Continued

Patient (Parent/ Family) Teaching

Teach family reason for endotracheal tube and ventilator, and let them know that the RN is
available at all times and can be contacted by using the call bell
Encourage family to talk to child and help in childs care (ex. Bathing)
Encourage family to ask questions, call pastoral care as needed
Explain procedures to child even if unresponsive (i.e. we are going to move you, etc.) and
explain reason for ETT (i.e. this tube helps you breathe)
Explain safety measures- reason for restraints, reason all side rails must be up, that there
are back up methods to breathe for their child if something happens to the ventilator (BVM
at bedside), suction is at the bedside and available for immediate use

Hospital Policies

At Cincinnati Childrens Hospital there is a policy to utilize MOV (minimal occluding volumeinflating cuff so there is no air leak heard at peak inspiratory pressure) and measure cuff
pressures with a cuff manometer at least once per shift
(Sexton, 2013)

Recommendation for Nursing

Practice

It is recommended that the use of an CETT is used for children, although the age in
which a child should start using a CETT is still controversial. So when working in the
PICU or Pediatric Emergency Room, the nurse should be prepared to hand the doctor
a CETT or an UETT, whichever the doctor prefers. The code carts should be supplied
with the appropriate type of ETT according to the childs Braslow size/ measurement.
Frequent measurement of the ETT depth and the cuff pressure should be performed
routinely (at least once a shift, but some recommend every 2 hours). The CETT cuff
should have a pressure of <15 cm H2O, but not exceeding 20 cm H2O.
The pediatric critical care nurse, emergency room nurse, and flight nurses, should be
familiar with the appropriate sized tubes based on the childs age, size, and weight.
Ensure the child is comfortable with the appropriate amount of sedation and that the
child is not in pain. Encourage the parents to talk to the intubated child. And update
parents on the childs condition when possible.

References
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