Pediatr Emerg Med J.  2023 Jul;10(3):77-86. 10.22470/pemj.2023.00675.

Pediatric application of cuffed endotracheal tube: a secondary publication translated into Korean

• Kim JH
• Ahn JH
• Chae YJ

• KMID: 2543574
• DOI: http://doi.org/10.22470/pemj.2023.00675

Abstract

A young child’s larynx was formerly believed to be narrowest at the cricoid level, circular in section, and funnel shaped. This supported the routine use of uncuffed endotracheal tubes in young children despite the benefits of cuffed tubes, such as lower risk for air leakage and aspiration. In the late 1990s, evidence supporting the pediatric use of cuffed tubes emerged largely from anesthesiology studies, while some technical flaws of the tubes remained a concern. Since the 2000s, imaging-based studies have clarified laryngeal anatomy, revealing that it is narrowest at the glottis, elliptical in section, and cylindrical in shape. The update was contemporaneous with technical advances in the design, size, and material of cuffed tubes. The American Heart Association currently recommends the pediatric use of cuffed tubes. In this review, we present the rationale for using cuffed tubes in young children based on our updated knowledge of pediatric anatomy and technical advances.

Keyword

Airway Management; Cricoid Cartilage; Infant; Intubation; Larynx

Figure

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  Fig. 1. Schematic representation of shifts from uncuffed (A and C) to cuffed (B and D) endotracheal tubes, and from cricoid-circular-funnel (A and B) to glottis-elliptical-cylinder (C and D) laryngeal configuration. In addition, this schema depicts the myths 1 (A) and 2 (B) and recently discovered features (C and D). Each inset shows a transverse section with a tube shaft inserted at each level (marked in black). The cricoid cartilage is drawn as a blue-gray ring (insets in A and B) or V-shaped lamina (insets in C and D [upper]). B exemplifies an erroneously high cuff location caused by a Murphy eye (asterisks). C illustrates the posterolateral compression by the tube shaft. The compression is considered stronger than previously expected, given the shift in laryngeal configuration. C also shows that the tip of movable, uncuffed tube can injure the tracheal wall, which can be minimized by the added stability provided by a cuff. D depicts a high volume-low pressure cuff without a Murphy eye placed at an appropriate location, which results in stabilization of the tip by the cuff, less leak through the cuff, less pressure on the subglottis by the tube shaft (upper inset) and on the trachea by the cuff (lower inset). Airway injury may be further prevented by the posterior trachea, which distends when intracuff pressure increases. Numbers in millimeters indicate the inner diameters of the tubes.

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  Fig. 2. A laryngeal configuration based on the computed tomography-measured transverse diameters on AP view (A) and AP (i.e., sagittal) diameters on lateral view (B)18). It is narrowest in the transverse diameter at the glottis (A). Looking down the larynx at 45° from above, elliptical section is noted at the glottis (C). The ellipticity means a potential for uncuffed tube-induced posterolateral compression (Fig. 1C). AP: anteroposterior. Modified from Kim et al.20) (Children [Basel] 2022;9:1532) according to the Creative Commons License.

Reference

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