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Cuffed ETT is not associated with increase in use of post-extubation racemic epinephrine


  • In critically-ill young children requiring intubation does the use of a cuffed ETT lead to increased post-extubation morbidity?

Clinical Bottom Lines

  1. 1. The use of a cuffed endotracheal tube in children under 8 has not been shown to result in increased incidence of post-extubation stridor, as indicated by use of racemic epinephrine.1 Whether stridor is a good measure for airway injury is speculative. (In children under 8 in this study, 6.7% (28) in uncuffed group vs 7.5% (19) in the cuffed group required racemic epinephrine.1
    2. Long-term sequelae, as indicated by need for tracheostomy, were not well documented or presented, but there was no demonstrated difference in rate of tracheostomy.1

Summary of Key Evidence

1. This was an observational prospective cohort study that followed patients requiring intubation in a Pediatric Intensive Care Unit and Pediatric Cardiothoracic Intensive Care Unit. Ages ranged from 1 day old to 30 years. No patients were excluded.
2. Decision with regards to tube type was made by attending physician based on clinical presentation. No data was presented regarding clinical indication for tube type choice.
3. Tube size was determined by a modified Cole formula: tube size = age in yr/4 +4 with use of a ½ size less for cuffed tube.
4. Outcome measures for morbidity were use of racemic epinephrine, as measure of rate of stridor, and need for tracheostomy. Data of tracheostomy outcome were not clearly presented nor discussed.
5. Decision to use racemic epinephrine was made by attending physician. No data was presented regarding clinical indication.
6. Based on these outcome measures there was no significant difference in use of racemic epinephrine or tracheostomy following the use of cuffed tubes in young children.1
7. Limitations of this study include: lack of long-term follow up; lack of documentation of reason behind choice of type of tube; lack of documentation of clinical indication for use of racemic epinephrine; use of racemic epinephrine as a surrogate marker for airway damage, which is speculative; lack of documention of clinical indication for cuffed ETT.

Additional Comments

  • Historically, the use of ETT led to complications such as subglottic damage. The argument against the use of cuffed tubes was that the presence of an air leak ensured that pressure was not being placed against the delicate tracheal structures, particularly the cricoid. However, high-compliance, low-pressure cuffed ETT were introduced in the 1970s and are now widely available, changing the nature of the debate. This aim of this study was to show that these tubes can be used safely in the pediatric population.1
    • The AHA 2005 PALS Guidelines were revised to state that cuffed tube was as a safe as uncuffed tube when in used in the in-hospital setting. They also advise that they may be indicated for certain situations including high airway pressure, poor lung compliance or large airleak.2
    • There is on-going debate with regards to use of cuffed tubes in the pre-hospital setting.5
    • This study used a modified Cole formula as above. The AHA recommends the Khine formula for tube size = age in yr/4 +3.2,4 However, a recent study found that the Khine formula underestimated tube size chosen at discretion of anesthesiologists.3
    • AHA recommends a cuff pressure of 20mmH20.2 This study used the goal almost no audible leak or 25mmH20.1
    • Given these recommendations, it would be useful to have study looking at the risks and benefits of cuffed ETT in the specific situations for which they are indicated, those in which it is difficult to adequately ventilate using an uncuffed tube.
    • There is a lack of evidence regarding long-term sequelae of cuffed ETT use. Much of the literature the use of cuffed ETT is in the Anesthesia literature, which is not as directly applicable to a critically-ill children requiring long-term ventilation.


1. Newth CJL et al. The use of cuffed versus uncuffed endotracheal tubes in Pediatric Intensive Care Unit. J of Pediatr. 2004;144:333-7.
2. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emercency Cardiovascular Care of Pediatric and Neonatal Patients: Pediatric Advanced Life Support. American Heart Association. Pediatrics. 2006;117:e1005-1028.
3. Duracher et al. Evaluation of cuffed tracheal tube size predicted using the Khine formula in children. Paediatr Anaesth. 2008 Feb;18(2):113-8.
4. Khine HH et al. Comparison of cuffed and uncuffed endotracheal tubes in young children during general anesthesia. Anesthesiology. 1997 Mar;86(3):627-31.
5. Clements RS et al. Cuffed endotracheal tube use in paediatric prehospital intubation: challenging the doctrine? Emerg Med J. 2007 Jan;24(1):57-8.

CAT Author: Emily Whitfield, MD

CAT Appraisers: Emily Whitfield, MD

Date appraised: November 5th, 2008

Last updated June 15, 2009
Department of Pediatrics and Communicable Diseases
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