Cuffed endotracheal tubes in neonates and infants of less than 3 kg body weight-A retrospective audit

A view on pediatric airway management: a cross sectional survey study

BACKGROUND

This survey aimed to investigate routine practices and approaches of clinicians on pediatric airway in anesthesia and intensive care medicine.

METHODS

A 20-question multiple-choice questionnaire with the possibility to provide open text answers was developed and sent. The survey was sent to the members of European Airway Management Society via a web-based platform. Responses were analyzed thematically. Only the answers from one representative of the pediatric service of each hospital was included into the analysis.

RESULTS

Among the members, 143 physicians responded the survey, being anesthesiologists (83.2%), intensivists (11.9%), emergency medicine physicians (2.1%), and (2.8%) pain medicine practitioners. A straight blade was preferred by 115 participants (80.4%) in newborns, whereas in infants 86 (60.1%) indicated a curved blade and 55 (38.5%) a straight blade. Uncuffed tracheal tube were preferred by 115 participants (80.4%) in newborns, whereas 24 (16.8%) used cuffed tubes. Approximately 2/3 of the participants (89, 62.2%) reported not to use routinely a cuff manometer in their clinical practice, whereas 54 participants (37.8%) use it routinely in pediatric patients. Direct laryngoscopy for routine pediatric tracheal intubation was reported by 127 participants (88.8%), while 16 (11.2%) reported using videolaryngoscopes routinely. Interestingly, 39 (27.3%) had never performed neither videolaryngoscopy nor flexible bronchoscopy in children. These results were significantly less in hospitals with a dedicated pediatric anesthesiologist.

CONCLUSIONS

This survey on airway management in pediatric anesthesia revealed that the use of cuffed tubes and the routine monitoring of cuff pressure are rare. In addition, the rate of videolaryngoscopy or flexible optical intubation was low for expected difficult intubation. Our survey highlights the need for properly trained pediatric anesthesiologists working in-line with updated scientific evidence.

Airway Management in Pediatric Patients: Cuff-Solved Problem?

Traditionally, uncuffed tubes were used in pediatric patients under 8 years in pursuit of reducing the risk of postextubation stridor. Although computed tomography and magnetic resonance imaging studies confirmed that the subglottic area remains the narrowest part of pediatric airway, the use of uncuffed tubes failed to reduce the risk of subglottic swelling. Properly used cuffed tubes (correct size and correct cuff management) are currently recommended as the first option in emergency, anesthesiology and intensive care in all pediatric patients. Clinical practice particularly in the intensive care area remains variable. This review aims to analyze the current recommendation for airway management in children in emergency, anesthesiology and intensive care settings.

Cuffed versus uncuffed endotracheal tubes for neonates

BACKGROUND

Endotracheal intubation is a commonly performed procedure in neonates, the risks of which are well-described. Some endotracheal tubes (ETT) are equipped with a cuff that can be inflated after insertion of the ETT in the airway to limit leak or aspiration. Cuffed ETTs have been shown in larger children and adults to reduce gas leak around the ETT, ETT exchange, accidental extubation, and exposure of healthcare workers to anesthetic gas during surgery. With improved understanding of neonatal airway anatomy and the widespread use of cuffed ETTs by anesthesiologists, the use of cuffed tubes is increasing in neonates.

OBJECTIVES

To assess the benefits and harms of cuffed ETTs (inflated or non-inflated) compared to uncuffed ETTs for respiratory support in neonates.

SEARCH METHODS

We searched CENTRAL, PubMed, and CINAHL on 20 August 2021; we also searched trial registers and checked reference lists to identify additional studies.

SELECTION CRITERIA

We included randomized controlled trials (RCTs), quasi-RCTs, and cluster-randomized trials comparing cuffed (inflated and non-inflated) versus uncuffed ETTs in newborns. We sought to compare 1. inflated, cuffed versus uncuffed ETT; 2. non-inflated, cuffed versus uncuffed ETT; and 3. inflated, cuffed versus non-inflated, cuffed ETT.

DATA COLLECTION AND ANALYSIS

We used the standard methods of Cochrane Neonatal. Two review authors independently assessed studies identified by the search strategy for inclusion, extracted data, and assessed risk of bias. We used the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

We identified one eligible RCT for inclusion that compared the use of cuffed (inflated if ETT leak greater than 20% with cuff pressure 20 cm H₂O or less) versus uncuffed ETT. The author provided a spreadsheet with individual data. Among 76 infants in the original manuscript, 69 met the inclusion and exclusion criteria for this Cochrane Review. We found possible bias due to lack of blinding and other bias. We are very uncertain about frequency of postextubation stridor, because the confidence intervals (CI) of the risk ratio (RR) were very wide (RR 1.36, 95% CI 0.35 to 5.25; risk difference (RD) 0.03, -0.11 to 0.18; 1 study, 69 participants; very low-certainty evidence). No neonate was diagnosed with postextubation subglottic stenosis; however, endoscopy was not available to confirm the clinical diagnosis. We are very uncertain about reintubation for stridor or subglottic stenosis because the CIs of the RR were very wide (RR 0.27, 95% CI 0.01 to 6.49; RD -0.03, 95% CI -0.11 to 0.05; 1 study, 69 participants; very low-certainty evidence). No neonate had surgical intervention (e.g. endoscopic balloon dilation, cricoid split, tracheostomy) for stridor or subglottic stenosis (1 study, 69 participants). Neonates randomized to cuffed ETT may be less likely to have a reintubation for any reason (RR 0.06, 95% CI 0.01 to 0.45; RD -0.39, 95% CI -0.57 to -0.21; number needed to treat for an additional beneficial outcome 3, 95% CI 2 to 5; 1 study, 69 participants; very low-certainty evidence). We are very uncertain about accidental extubation because the CIs of the RR were wide (RR 0.82, 95% CI 0.12 to 5.46; RD -0.01, 95% CI -0.12 to 0.10; 1 study, 69 participants; very low-certainty evidence). We are very uncertain about all-cause mortality during initial hospitalization because the CIs of the RR were extremely wide (RR 2.46, 95% CI 0.10 to 58.39; RD 0.03, 95% CI -0.05 to 0.10; 1 study, 69 participants; very low-certainty evidence). There is one ongoing trial. We classified two studies as awaiting classification because outcome data were not reported separately for newborns and older infants.

AUTHORS' CONCLUSIONS

Evidence for comparing cuffed versus uncuffed ETTs in neonates is limited by a small number of babies in a single RCT with possible bias. There is very low certainty evidence for all outcomes of this review. CIs of the estimate for postextubation stridor were wide. No neonate had clinical evidence for subglottic stenosis; however, endoscopy results were not available to assess the anatomy. Additional RCTs are necessary to evaluate the benefits and harms of cuffed ETTs (inflated and non-inflated) in the neonatal population. These studies must include neonates and be conducted both for short-term use (in the setting of the operating room) and chronic use (in the setting of chronic lung disease) of cuffed ETTs.