emergentmd

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What is the current recommendation for this?

Past EM teaching stated uncuffed for age less than 8 for concerns for airway injury.

I have had my ER uncuffed ETT changed out in the PICU to cuffed by PICU attending. I searched the literature and it looks like they are leaning towards cuffed for all kids.

Are most EM docs going towards cuffed or are you still sticking with uncuffed?
 
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What is the current recommendation for this?

Past EM teaching stated uncuffed for age less than 8 for concerns for airway injury.

I have had my ER uncuffed ETT changed out in the PICU to cuffed by PICU attending. I searched the literature and it looks like they are leaning towards cuffed for all kids.

Are most EM docs going towards cuffed or are you still sticking with uncuffed?
Locally the pendulum has swung back to uncuffed because of tracheal ulcers, unless you foresee high airway pressures or aspiration concerns in which case they still use cuffed. Best to have ED leadership conference with the PICU leadership and reach a consensus.
 

BoardingDoc

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What is the current recommendation for this?

Past EM teaching stated uncuffed for age less than 8 for concerns for airway injury.

I have had my ER uncuffed ETT changed out in the PICU to cuffed by PICU attending. I searched the literature and it looks like they are leaning towards cuffed for all kids.

Are most EM docs going towards cuffed or are you still sticking with uncuffed?
Recently I've been seeing only cuffed ETTs in use for peds. This is both among my EM colleagues and with PICU attendings. I recently tubed a 6 month old and used a 3.5 cuffed.
 
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Another Second Opinion

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Cuffed for sure. I don't think an uncuffed tube adequately protects the airway.
 

Angry Birds

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Cuffed for sure. I don't think an uncuffed tube adequately protects the airway.
This being the case I feel cuffed is the way for us to go and they can switch it out if they disagree. Better to adequately protect airway for us than worry about an ulcer that won't form until (I assume) much later, once out of the ER.
 
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gro2001

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Over the short term, and an appropriately inflated cuff (whichever way you want to confirm that your cuff is not over inflated is probably fine), I don't think it should be a concern for most kids and so I would err on the side of cuffed tube. Even if I anticipate they will be intubated for a longer period of time, I would not hesitate to intubate them with a cuffed tube in the ER and have anesthesia or PICU exchange it later oncer the dust settles and they've been NPO for an appropriate amount of time.

Now if the kid is younger than three years old or so, I would strongly consider going uncuffed unless there was imminent airway threat (vomiting, bleeding, just ate).

If the kid is younger than one year old, I would only use an uncuffed tube.
 

WilcoWorld

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Just want to add that it's easy to over-inflate peds cuffs, but it's also easy to avoid over-inflating peds cuffs.

These cuffs are smaller than the cuffs you usually inflate (adults), so if you push a typical amount of air into the cuff you're going to get high pressure, and high pressure--> tracheal injury.

But all you have to do is squeeze the bladder to know if you over-inflated. No math needed. Just feel the bladder - is it tense? If so, remove some air. You should be able to tell that there is some air in there, but it should also have some give.
 

AdmiralChz

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But all you have to do is squeeze the bladder to know if you over-inflated. No math needed. Just feel the bladder - is it tense? If so, remove some air. You should be able to tell that there is some air in there, but it should also have some give.
Please, don't do this. Especially in kids, just use a manometer if you have any doubt (your RTs should have one around). I know it's quick and easy and tons of providers do it, but we've known for some time that finger palpation is highly inaccurate:

Endotracheal tube cuff pressure assessment: pitfalls of finger estimation and need for objective measurement. - PubMed - NCBI

Experienced emergency medicine physicians cannot safely inflate or estimate endotracheal tube cuff pressure using standard techniques - ScienceDirect

Most authorities recommend cuffed tubes to fully protect the airway for almost all pediatric patients. This has been evolving over the past couple of decades as we better understand the implications of prolonged intubation (and more of a push towards tracheostomy relatively sooner). There remains some debate about preemies and neonates/infants to 6 months, but performing controlled leak tests with pediatric intubations is a requirement and can help with accurate sizing of endotracheal tubes.
 
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WilcoWorld

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Please, don't do this. Especially in kids, just use a manometer if you have any doubt (your RTs should have one around). I know it's quick and easy and tons of providers do it, but we've known for some time that finger palpation is highly inaccurate:

Endotracheal tube cuff pressure assessment: pitfalls of finger estimation and need for objective measurement. - PubMed - NCBI

Experienced emergency medicine physicians cannot safely inflate or estimate endotracheal tube cuff pressure using standard techniques - ScienceDirect

Most authorities recommend cuffed tubes to fully protect the airway for almost all pediatric patients. This has been evolving over the past couple of decades as we better understand the implications of prolonged intubation (and more of a push towards tracheostomy relatively sooner). There remains some debate about preemies and neonates/infants to 6 months, but performing controlled leak tests with pediatric intubations is a requirement and can help with accurate sizing of endotracheal tubes.
I appreciate you're educating me on the limitations of palpation for determining ETT balloon pressure - really, I do. I was taught my approach by Peds EM trained people, so this is surprising news to me.

Are you recommending using an uncuffed ET tube if my ED does not have an ETT manometer? (there are a lot of things that "should" be in the ED, but aren't)
 
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AdmiralChz

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Are you recommending using an uncuffed ET tube if my ED does not have an ETT manometer? (there are a lot of things that "should" be in the ED, but aren't)
Definitely not... but you need to be use only the minimum amount of air required to create an adequate seal. That seal should be to a leak somewhere between 20-30 cm H20 of sustained pressure depending on which text you consult (meaning above these pressures you should have a small leak, which is fine in pediatrics). If you place a cuffed tube and have no leak above 30 before placing any air then you have too big of a tube in.

You would be surprised about how little air you need, since the narrowest portion of the airway is at the cricoid for small kids. In the OR we use the ventilator circuit and in the PICU they/we use a Jackson-Reese/Mapelson circuit to assess this (only for kids < 2 years old). I am not sure of what equipment is readily available in the typical Peds ED. An Ambu/BVM with CPAP attachment could work as well I suppose.

Once they get above the age of about 6-8 you have more safety since the narrowest part of the airway progressed to the glottic opening as in adults. Didn't mean to be condescending (and I apologize if it came off that way), just trying to promote safe practices.

This article goes into this a little bit more (isn't directly applicable as nitrous oxide is used as an anesthetic, but the principles are the same). It also addressed the changes in practice over the years from uncuffed to cuffed tubes in the discussion section:

Laryngeal mask airway and tracheal tube cuff pressures in children: are clinical endpoints valuable for guiding inflation?
 

WilcoWorld

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Definitely not... but you need to be use only the minimum amount of air required to create an adequate seal. That seal should be to a leak somewhere between 20-30 cm H20 of sustained pressure depending on which text you consult (meaning above these pressures you should have a small leak, which is fine in pediatrics). If you place a cuffed tube and have no leak above 30 before placing any air then you have too big of a tube in.

You would be surprised about how little air you need, since the narrowest portion of the airway is at the cricoid for small kids. In the OR we use the ventilator circuit and in the PICU they/we use a Jackson-Reese/Mapelson circuit to assess this (only for kids < 2 years old). I am not sure of what equipment is readily available in the typical Peds ED. An Ambu/BVM with CPAP attachment could work as well I suppose.

Once they get above the age of about 6-8 you have more safety since the narrowest part of the airway progressed to the glottic opening as in adults. Didn't mean to be condescending (and I apologize if it came off that way), just trying to promote safe practices.

This article goes into this a little bit more (isn't directly applicable as nitrous oxide is used as an anesthetic, but the principles are the same). It also addressed the changes in practice over the years from uncuffed to cuffed tubes in the discussion section:

Laryngeal mask airway and tracheal tube cuff pressures in children: are clinical endpoints valuable for guiding inflation?
Thanks. That's a helpful response, and I will try to apply it next time I've got an intubated child in the ED. That said, I still think "squeeze the bulb and take some air out if it feels tight" is sound advice to follow while I'm trying to address whatever emergency led to my having to intubate someone under 6. Once that's settled, this seems like a good thing to do for the patient.
 

BigRedBeta

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PICU attending here - please use cuffed tubes unless your PICU tells you otherwise. And if there's a question (and there's time), call us - I think 99% of us feel a duty to be a resource for y'all. If there is help we can provide, we want to do that.

We end up in one of two situations when a kid comes in with an uncuffed tube - either the leak is there, kid is stable enough and we limp through but with suboptimal ventilation - we can do it but life is easier cuffed. Or the kid is totally not stable, we can't ventilate/can't oxygenate, and we're left having to change out an established airway that's not working in a high risk patient (as y'all know since you knew kid needed the tube in the first place). Both situations are less than ideal.

The ONLY time I use an uncuffed ETT is if I can't place a cuffed due to airway swelling - eg croup. But even then I'll start with a cuffed tube, downsize to the smaller sized cuff tube that is still appropriate for size, then if that's still not working, will go uncuffed.

Talk with your local PICU's and get their preference, call if questions. We're here to help.
 

Apollyon

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Definitely not... but you need to be use only the minimum amount of air required to create an adequate seal. That seal should be to a leak somewhere between 20-30 cm H20 of sustained pressure depending on which text you consult (meaning above these pressures you should have a small leak, which is fine in pediatrics). If you place a cuffed tube and have no leak above 30 before placing any air then you have too big of a tube in.
Here in the non Ped ED, honest question - how do I determine the bolded? Most of us in the ED are not in places that have a PICU. When I get such a patient, I call Children's in Pittsburgh for transfer. Having to tube a kid raises the pucker factor to, if not 10, a hard 9.

Not antagonising - just a dumb EM doc, who is not up to the level of the anesthesia answer.
 
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The White Coat Investor

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WTH? How often are you guys intubating kids? Unless you're in a children's hospital, big trauma center, or the only ivory tower for hundreds of miles (with no children's hospital in that area) you're probably not doing one a year. It's almost like we're debating the proper equipment for a perimortem C-section here. Sick kids are rare and getting rarer all the time. And the ones that are out there are heavily concentrated.

Assuming you have them, why not put in a cuffed tube? If the person you transfer the patient to doesn't like it, they can just deflate the cuff. Voila- uncuffed tube! If they do like it, the child gets to avoid a procedure to change the tube out. And a manometer? Seriously. I don't think I've seen a manometer used in an ED to check the cuff pressure in my entire career, including residency. If the tube pressure matters that much, I'm sure it can be checked and adjusted when the child arrives at the receiving facility PICU without any significant risk of harm.
 

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If the tube pressure matters that much, I'm sure it can be checked and adjusted when the child arrives at the receiving facility PICU without any significant risk of harm.
Nope. I'm wrong. It says here: Laryngeal mask airway and tracheal tube cuff pressures in children: are clinical endpoints valuable for guiding inflation?

In adults, an intracuff pressure > 30 cmH2O for 15 min is sufficient to induce histological evidence of tracheal mucosal lesions and impair mucosal blood flow [24–26]. Total occlusion of mucosal blood flow occurs at a pressure of 50 cmH2O [25].

So you've got to get it right in the ED. I think what i've learned from this discussion and subsequent research is put less air in kid's cuffs and see if I can find a manometer in the hospital.
 

gro2001

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Here in the non Ped ED, honest question - how do I determine the bolded? Most of us in the ED are not in places that have a PICU. When I get such a patient, I call Children's in Pittsburgh for transfer. Having to tube a kid raises the pucker factor to, if not 10, a hard 9.

Not antagonising - just a dumb EM doc, who is not up to the level of the anesthesia answer.
I don't think there is a super convenient way to do this on most ventilators you are likely to encounter in the ER. Unlike the anesthesia circuits, they do not allow us to deliver sustained pressure for an arbitrary amount of time while we listen (or look at the ventilator) for a leak.

As I see it, you have the following options (roughly in order of how I would recommend them):

1) Sigh breath. Most ventilators will have an option for a sigh breath, which is an extra large breath (used to be defined as 150% normal tidal volume). On some newer ventilators that setting is part of either the Pressure Control Mode or Bilevel Ventilation Mode where you can have it periodically deliver breaths at a pressure of 20-40 cm H2O. You should not see any evidence of a leak during normal breaths but should see it during sigh breaths.

2) Minimally occlusive volume. After intubating but before inflating the cuff, look for a leak. Add air 1 cc at a time until the leak disappears.

3) Ambu with a PEEP valve. After intubating but before inflating the cuff, look for a leak. Add air 1 cc at a time until the leak disappears. Then dial up the PEEP valve till 20 cm H20 and listen for a leak. If you don't hear a leak, take a little out until you do. Check that the leak is still absent without the PEEP valve.

4) Hope that RT has a manometer.
 
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ranvier

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When we drop off in the picu/icu, I always deflate the cuff to less than needed during the case as the ventilatory conditions and aspiration risk are obviously different now that surgery is completed. The reverse is also true when picking up. The peds cuffed ett are much better now....and RT will eventually check with a manometer.

Interesting discussion.
 

anbuitachi

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Agree with above. we use cuffed ET tubes for pretty much all our pediatric patients. But obviously get a leak at ~20cm h20
 

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How about this? Intubate with a cuffed tube but if no manometer available then don't inflate the cuff. Communicate to the PICU attending rationale behind not wanting to over-inflate. They can then adjust accordingly without having to re-intubate while in the PICU with RT.
 

BigRedBeta

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How about this? Intubate with a cuffed tube but if no manometer available then don't inflate the cuff. Communicate to the PICU attending rationale behind not wanting to over-inflate. They can then adjust accordingly without having to re-intubate while in the PICU with RT.
That's a reasonable starting point. The pediatric transport RT's will have manometers with them (or at least should based on the fact that going to altitude results in changes in cuff pressure Pediatric Endotracheal Tube Cuff Pressures During Aeromedical Transport. - PubMed - NCBI), and so can inflate cuff per their protocols.

Certainly if you're having to tube the kid that walked in the door eating Flaming Hot Cheetos, aspiration risk might be a consideration to inflate the cuff in the ED
 
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