Cuffed vs. uncuffed tracheal tubes in children: a randomised controlled trial comparing leak, tidal volume and complications

In this paper, the authors performed a prospective randomised controlled study looking at leakage around the tracheal tube. 104 children presenting for elective surgery aged 0 – 16 years weighing more than 5kg were included in the study and were randomly allocated to either cuffed or uncuffed intubation. The initial tube size and type was based on patient age. The final tube size was determined by the anaesthetist based on absence of resistance to insertion and presence of audible leak (with inflation pressures of 25cmH2O following initial cuff infflation). Ventilation measurements were recorded from the anaesthesia workstation twice before and three times after a standardised recruitment manoeuvre (10 slow manual breaths up to 35cmH2O followed by PEEP of 5cmH2O) in 2 modes of ventilation (initially volume-controlled at 6mL/kg and PEEP 5cmH2O; followed by pressure-controlled at 10cmH2O with PEEP 5cmH2O).

The tracheal tube leak was greater in the uncuffed group compared to the cuffed group. The leak volume in the uncuffed group increased with time, whereas the leak volume in the cuffed group remained relatively consistent over the 4 post-recruitment measurement points. Expiratory tidal volumes increased over time in the cuffed group but decreased over time in the uncuffed group.

Take home message

What this paper adds to our understanding is the role of cuffed endotracheal tubes in stabilising ventilatory parameters. Reductions in lung volume during ventilation with an uncuffed endotracheal tube may contribute to reduction in lung compliance and functional residual capacity. The resultant atelectasis may increase risk of ventilator induced lung injury due to increase in shearing forces. It can be overcome with intermittent recruitment, but the cycle of recruitment and derecruitment may not be without its risk, with evidence to suggest this may contribute to lung inflammation.  If you haven’t embraced the cuffed endotracheal tube for children, consider reading the accompanying editorial by Craig Bailey (1).

  1. Bailey CR. Time to stop using uncuffed tracheal tubes in children? Anaesthesia 2018; 73: 147-150

Reviewed by: Scott Ma