Cuffed Tracheal Tubes in Children - Myths and Facts. PD Dr. Markus Weiss Department of Anaesthesia University Children s Hospital Zurich Switzerland

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1 Cuffed Tracheal Tubes in Children - Myths and Department of Anaesthesia University Children s Hospital Zurich Switzerland

2 PRO Reduced gas leak, low fresh gas flow Decreased atmospheric pollution Constant controlled ventilation Improved efficiency of ventilation Reliable monitoring of endtidal co 2 and anaesthetic gases Improved accuracy of tidal volume and lung compliance monitoring

3 Cuffed Tracheal Tubes In Children PRO Compensation for different sized tracheas Compensation for different shaped tracheas Reduction in the requirement to change the tube Decreased risk of pulmonary aspiration Decreased use of too large uncuffed tubes Decreased pressure exerted on the cricoid

4 PRO Tracheal Tube cuffed uncuffed Post-operative operative Croup 2.4 % 2.9 % Tube Exchange 1 % 23 % FGF > 2 liter/min 1 % 11 % N2O > 10 ppm 0 % 37 % Khine HK - Anesthesiology 1997

5 CON No Cuff Required In Children < 8 years Laryngo-tracheal injuries Inadvertent Cuff Over-Inflation Inadequate Designed Paediatric Tube Cuffs Smaller Internal Tube Diameter Increased Costs Not The (G)old Standard!

6 Yes or No? Democratic Medicine (APA 2002) 2/3 Con 1/3 Pro Hatch 2002: It Is Not Forbidden To Use Cuffed Endotracheal Tubes in Children... Not Evidence-Based Medicine!!!

7 Myths Cuffed Tubes Are Not Needed in Children Because The Circular Cricoid Seals The Tracheal Tube

8 Myths and Adult Larynx

9 Myths and Infantile Larynx Eckenhoff JE - Anesthesiology 1954

10 Myths Cuffed Tracheal Tubes In Children Are A Major Reason For Airway Injurys

11 Reasons for Airway Injury in Children Too Large Endotracheal Tube Traumatic Intubation Repeated Intubation Attempts Repeated Tracheal Tube Exchange

12 Reasons for Airway Injury in Children Prolonged Intubation Inadequate Tube Fixation (oral/nasal) Inadequate Sedation Insufficient Tissue Perfusion Local Infection

13 Free 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

14 Nitrous Oxide and Cuff Hyperinflation time (min) A/B C Gas Removal for Cuff Pressure Release During Nitrous Oxide Exposure (Set 20 cm H 2 O / Limit 25 cm H 2 O) A/B A/B gas removal (No) A/B A/B Dullenkopf A, Gerber AC, Weiss M - Canadian Journal of Anesthesia 2004

15 Myths Cuffed Tracheal Tubes Are Inadequately Designed

16 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: Goel S, Lim SL. The intubation depth marker: the confusion of the black line. Paediatric Anaesthesia 2003; 13: Wallace CJ, Bell Graham TB. Tracheal tube markings. Pediatric Anesthesia 2004; 14:

17 Outer diameter (OD) Cuffed Tracheal Tubes In Children Inadequate Design ID Tracheal tube brand No Cuff (mm) Sheridan Tracheal Tube uncuffed Murphy (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 (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 (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 (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 (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) 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) Tracheal diameters and PCETT ID Age related PCETT ID according to the formula of Khine 4 Age related 95 % range of internal tracheal diameter (mm) 20,21 Age related 95 % range of internal tracheal diameter (mm) 20,22 Age related PCETT ID according to the formula of Motoyama 19 Age related 95 % range of internal tracheal diameter (mm) 20,21 Age related 95 % range of internal tracheal diameter (mm) 20,22 Premature Neonate Premature Neonate Fullterm Neonate Fullterm Neonate year 3 years 5 year 7 years 9 years 11 years 13 years 15 years year 2 year 4 year 6 years 8 years 10 years 12 years 14 years Weiss M - British Journal of Anaesthesia 2004

18 Distances A/C/D (mm) Tracheal diameters and PCETT ID Inadequate Design ID Tracheal tube brand No Cuff 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 /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 /-/20 -/-/20 -/-/21 -/-/30 -/-/30 -/-/40 -/-/39 -/-/40 -/-/41 -/-/- Rüsch Rüschelit Super Safety Clear Magill /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 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) Age related PCETT ID according to the formula of Khine 4 Age-related 95 % range of tracheal length (mm) 20,21 Tracheal length (mm) 23 Age related PCETT ID according to the formula of Motoyama 19 Age-related 95 % range of tracheal length (mm) 20,21 Tracheal length (mm) 23 Premature Neonate Premature Neonate Fullterm Neonate Fullterm Neonate year 3 year 5 year 7 years 9 years 11 years 12 years 15 years year 2 year 4 year 6 years 8 years 10 years 12 years 14 years

19 Inadequate Design ID Tracheal Tube Brand No Cuff Cuff diameter (mm) at 20 H 2 O cuff pressure Cross-sectional cuff area (mm 2 )at 20 cm H 2 O cuff pressure Tracheal diameters and PCETT ID 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 (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) 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 Sheridan Tracheal Tube cuffed Magill 3 + NA 42 NA 62 NA 133 NA Mallinckrodt TT High Contour Murphy 5 + NA Mallinckrodt TT High Contour Murphy P-Serie 6 + NA Mallinckrodt TT Lo Contour Magill 7 + NA Mallinckrodt TT Lo Contour Murphy 8 + NA Mallinckrodt TT Hi-Lo Murphy 9 + NA NA NA NA NA Mallinckrodt TT Safety Flex 10 + NA Portex TT - Profile Soft Seal Cuff, Murphy 12 + NA NA NA NA NA Rüsch Rüschelit Super Safety Clear Magill (50) Rüsch Rüschelit Super Safety Clear Murphy 15 + NA NA NA NA NA ID ( mm) Age related PCETT ID according to the formula of Khine 4 Premature Neonate Neonate to 1 st birthday 1 to 3 rd birthday 3 to 5 th birthday 5 to 7 th birthday 7 to 9 th birthday 9 to 11 th birthday 11 to 13 th birthday 13 to 15 th birthday Maximal (95%) age-related internal tracheal diameter (mm) 20, Maximal (95%) age-related cross-sectional tracheal area (mm 2 ) 20,22 Age related PCETT ID according to the formula of Motoyama 19 Premature Neonate 15 to 16 th birthday Neonate to 1 st birthday 1 to 2 nd birthday 2 to 4 th birthday 4 to 6 th birthday 6 to 8 th birthday 8 to 10 th birthday 10 to 12 th birthday 12 to 14 th birthday Maximal (95%) age-related internal tracheal diameter (mm) 20, Maximal (95%) age-related cross-sectional tracheal area (mm 2 ) 20,22 14 to 16 th birthday

20 Injury Due To Wrong Tube Cuff Design 11 months old boy Cardiac surgical procedure with cpb Tracheal intubation: ruesch tt id 4.0 cuffless Unacceptable high air leak around the tube Tracheal intubation: ruesch tt id 4.0 with cuff Tight fit - small leak with active deflated cuff

21 Injury Due To Wrong Tube Cuff Design Cicu: : ventilation with active deflated cuff (2 days) Transfer to picu uch Cuff pressure set to ambient pressure Extubation 3 rd postoperative day Postextubation stridor Increasing oxygen requirements

22 Ideal Design of Cuffed Pediatric Tubes Cuff-Free Subglottic Tube Shaft No Murphy Eye Short High Volume - Low Pressure Cuff (HVLP) Adequately Positioned Depth Marking Minimal Thickness of The Cuff-Membrane Automatic Cuff Pressure Release Valve Recommendations for Age-Related Use

23 Ideal Design of Cuffed Pediatric Tubes Internal tube diameter (ID; mm) Age group (years) Smallest tracheal diameter of age group (mm) Outer tube diameter (OD; mm) Cuff diameter (mm) at 20 cm H2O cuff pressure Cross-sectional cuff area (mm 2 ) Largest internal tracheal area cross-sectional of age group (mm 2 ) Ratio of cuff-to-largest trachea lcross-sectional area (%) 3.0 Full term neonates to 1 st birthday year year to 2 nd birthday years to 4 th birthday years to 6 th birthday years to 8 th birthday years to 10 th birthday years to 12 th birthday years to 14 th birthday years to 16 th birthday Weiss M, Dullenkopf, Gerber AC - Anaesthesist 2004

24 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 Tube yrs cm kg cmh2o cmh2o cm dm cm % Dullenkopf A, Gerber AC, Weiss M - European Journal of Anaesthesiology 2004; in press

25 Microcuff Pediatric Tracheal Tube Patients (%) Frequency Distribution of Leak Pressures < 5 < 10 < 15 < 20 > 20 > 25 > 35 Leak Pressure Groups (cm H 2 O) All (%) Boys (%) Girls (%) Dullenkopf A, Gerber AC, Weiss M - Anesthesiology; submitted

26 Microcuff Pediatric Tracheal Tube Frequency Distribution of Sealing Pressures All (% ) Boys (%) Girls (%) n Patients (%) Sealing Pressures (cm H 2 O) Dullenkopf A, Gerber AC, Weiss M - Anesthesiology; submitted

27 Microcuff Pediatric Tracheal Tube Tracheal Tube Insertion based on Intubation Depth Marks (Children 0-16 years) Age (years) Distance Tube Tip to Carina (cm) Dullenkopf A, Gerber AC, Weiss M - British Journal of Anaesthesia; submitted

28 Microcuff Pediatric Tracheal Tube Oral Tube Insertion Depth Correction to cm = 12 + (Age/2) (Children > 2 years) Age (years) PD Dr. Markus Dullenkopf Weiss A, Gerber AC, Weiss M - British Journal of Anaesthesia; submitted Tube Tip Correction / Distance Tube Tip to Carina (cm)

29 Microcuff Pediatric Tracheal Tube Microcuff ID 4.0 mm Mallinckrodt ID 4.0 mm Rüesch ID 4.0 mm Sheridan ID 4.0 mm Picture: Comparison of 4 tracheal cuffed pediatric tubes Dullenkopf A, Gerber AC, Weiss M - Pediatric Anesthesia 2004

30 Microcuff Pediatric Tracheal Tube High Volume - Low Pressure Cuff Sealing Characteristics

31 Myths Smaller Diameters in Cuffed Tracheal Tubes Increase Work of Breathing and Cause Difficulties With Tracheal Suctioning

32 Smaller Diameters Not A Problem During IPPV or Pressure Support Rare Suctioning During Anaesthesia Problems In The ICU Problems In Tubes Sizes ID 3.0 and 3.5 mm

33 Myths Cuffed Tracheal Tubes Cause Increased Costs

34 Increased Costs 2-44 Times More Expensive Than Uncuffed Tubes Reduced Overall Costs by: Less Tube Exchange ( up to 28 % ) Less Fresh Gas Flow Consumption Less Volatile Anaesthetic Consumption No Enviromental Pollution (Health!) Other Advantages (ETCO2 Monitoring, Oxygenation, Loss of Time by Tube Exchange,... )

35 Myths There Is Limited Experience With Cuffed Tracheal Tubes In Small Children

36 Experience Large Experience from Single Centers Paris Zurich Lund Pittsburgh Limited Multi-Centre Experience Limited Randomised Prospective Studies

37 Myths Uncuffed Tracheal Tubes Are The GOLD Standard For Children Below 8 Years Of Age

38 Uncuffed Tracheal Tubes Becomes The OLD Standard For Children Below 8 Years Of Age

39 Conclusions Cuffed Tracheal Tubes Can Be Safely Used in Children: Air Leak Control (<20 cm H 2 0) Cuff Pressure Control (<20 cm H 2 0) Adequate Designed Cuffed Tubes