Should cuffed endotracheal tubes be the first-line choice for intubation in pediatric intensive care units?

Author: Süha Demirakca, Reviewer: David Grooms

Tracheal intubation practice and safety in international and North American PICU’s were recently compared by means of a prospective, multicenter pediatric tracheal intubation database (1). A total of 10,510 tracheal intubations were reported and analyzed between the years 2014 and 2017.

Takeaway messages

  • The reasoning that prevailed historically against the use of cuffed tubes in pediatrics because the cuff may cause subglottic edema has since been refuted in various contexts.
  • Advantages of using cuffed tubes include a lower reintubation rate and clinically significant reduction of leakage.
  • A growing body of evidence supports the use of cuffed tubes as the primary choice in pediatric patients.
  • If a cuffed tube is used, pre-extubation leakage testing may help predict a subglottic upper airway obstruction.

Results of that analysis showed that primary tracheal intubations were mainly indicated by respiratory causes (64%). Desaturation (SpO2 < 80%) during intubation was reported less commonly in international PICU’s with 13% versus North American PICU’s 17%; p = 0.001. In international PICU’s, cuffed endotracheal tubes were used less frequently (52% vs 95%; p < 0.001), while the proportion of tracheal intubations for endotracheal tube change was greater (37% vs 11%; p < 0.001). The proportion of cuffed endotracheal tube use per PICU was inversely correlated with the rate of tube change (r = –0.67; p < 0.001).

Holzki et al. have recently reviewed the development of upper airway anatomy in early childhood (age < 8 years) in a meta-analysis, and confirmed that the functional narrowest tracheal region is subglottic in the cricoid area (2). This circumstance leads to a higher risk of harm in the subglottic area caused by insertion of an endotracheal tube. Upper airway obstruction caused by subglottic edema is the most common cause of pediatric extubation failure. Historically, the opinion prevailed that cuffed tubes should not be applied in childhood, because the cuff was assumed to be the cause of subglottic edema. This reasoning was refuted for both short-term (in pediatric anesthesia) and long-term use (in PICU’s) in several studies, as well as for term newborns (3, 4). Newth et al. examined 597 children from newborn to the age of 5 years. Of those, 210 children were treated with a cuffed tube for the entire duration of mechanical ventilation. There were no differences between the groups in terms of the need for post-extubation adrenaline inhalation and the proportion of successful extubations (5).

Summary of advantages of cuffed tubes modified from (4):

Advantages with high evidence

  • Reduced reintubation rate
  • Clinically significant reduction of leakage
  • Reduction of aspiration and VAP

Potential advantages
Through reduced leakage:

  • Better ventilation?
  • Maintain PEEP?
  • Less atelectasis?
  • Vt measurement and application

Through less airway trauma:

  • Less traumatic intubation
  • Less damage to the anterior tracheal wall
  • Less accidental extubation

In a single-center prospective study, Khemani et al. analyzed 409 children before and after extubation. Ninety-eight children (25%) had post-extubation upper airway obstruction and 49 (12%) were subglottic. Again, there was no difference in the rate of subglottic upper airway obstruction in the cuffed versus uncuffed tube groups. The reintubation rate was 34 (8.3%). The authors demonstrated that objective tools (RIP bands, esophageal manometry) used 5 minutes post-extubation were better than clinical assessment for identifying and differentiating subglottic from supraglottic upper airway obstruction. They were able to identify risk factors for subglottic upper airway obstruction that differed depending on whether a cuffed or uncuffed tube was used. For cuffed tubes, low leak pressure (≤ 25 mbar) in a pre-extubation test, poor sedation, and a pre-existing upper airway obstruction were associated with subglottic stenosis. For uncuffed tubes, an age of between 1 month and 5 years was associated with subglottic stenosis.  The presence or absence of a leak pre-extubation (regardless of pressure) was not associated with subglottic upper airway obstruction.

In conclusion, there is growing evidence to support the use of cuffed tubes as the primary choice in pediatric patients, starting from term newborns to upper age-groups. Pre-extubation leakage testing to predict a subglottic upper airway obstruction is only helpful if cuffed tubes are used. Objective tools like RIP bands and esophageal manometry may help us to recognize subglottic stenosis soon after extubation and thus facilitate early treatment.

The automatic cuff pressure controller, IntelliCuff, continuously monitors and optimizes cuff pressure to help you protect your patients from VAP and tracheal injuries. Whether in the hospital or during patient transport (road or air), the IntelliCuff is designed for immediate use and requires no calibration. All you need do is set the desired cuff pressure, which is then maintained automatically, eliminating the need for repeated manual adjustments. The IntelliCuff is available as a standalone device or as an integrated feature on the HAMILTON-G5 (optional).


  1. Lee JH, Nuthall G, Ikeyama T, Saito O, Mok YH, Shepherd M, Jung P, Shetty R, Thyagarajan S, Nett S, Napolitano N, Nadkarni V, Nishisaki A; National Emergency Airway Registry for Children (NEAR4KIDS) and Pediatric Acute Lung Injury and Sepsis Investigators (PALISI). Tracheal Intubation Practice and Safety Across International PICUs: A Report From National Emergency Airway Registry for Children. Pediatr Crit Care Med. 2019 Jan;20(1):1-8.
  2. Holzki J, Brown KA, Carroll RG, Cote CJ. The anatomy of the pediatric airway: Has our knowledge changed in 120 years? A review of historic and recent investigations of the anatomy of the pediatric larynx. Paediatr Anaesth. 2018;28(1):13-2
  3. De Orange FA, Andrade RG, Lemos A, Borges PS, Figueiroa JN, Kovatsis PG. Cuffed versus uncuffed endotracheal tubes for general anaesthesia in children aged eight years and under. Cochrane Database Syst Rev. 2017;11:CD011954.
  4. Thomas R, Rao S, Minutillo C. Cuffed endotracheal tubes for neonates and young infants: a comprehensive review. Arch Dis Child Fetal Neonatal Ed. 2016;101(2):F168-7
  5. Newth CJ, Rachman B, Patel N, Hammer J. The use of cuffed versus uncuffed endotracheal tubes in pediatric intensive care. J Pediatr. 2004; 144(3):333-7.l
  6. Khemani RG, Hotz J, Morzov R, Flink R, Kamerkar A, Ross PA, Newth CJ. Evaluating Risk Factors for Pediatric Post-extubation Upper Airway Obstruction Using a Physiology-based Tool. Am J Respir Crit Care Med. 2016 Jan 15;193(2):198-209.

Related Articles

cuffed tubes, endotracheal, pediatric, PICU, intubation, newborns, reintubation, leakage airway obstruction

Date of Printing: 30.06.2022
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Date of Printing: 30.06.2022
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