To the editors:
“When I disagree with a rational man, I let reality be our final arbiter; if I am right, he will learn; if I am wrong, I will…but both will profit.” Ayn Rand
“To disagree, one doesn't have to be disagreeable.” Barry Goldwater
“Everyone's entitled to my own opinion.” Anonymous
Spirited but respectful disagreement is a powerful teacher. Drs. Lindsay and Swanson, both respected and capable leaders and clinicians, differed widely but professionally in their opinions on whether the best pediatric airway is an uncuffed or a cuffed endotracheal tube (ETTs) (“Letters to the Editors,” May/June 2005) as they commented on Tung's review of pediatric airway management.1 I offer further comments in the spirit of the quotations that preface this letter.
As a clinician involved in both pediatric intensive care and also in air medical transport, I encourage prehospital providers to place cuffed ETTs in infants and children routinely, unless the receiving pediatric intensivists have asked them not to (and if that is the case, they will soon be changing their minds, vide infra!).
The practice in this country has shifted dramatically in the past few years. I believe most pediatric ICUs now rely largely if not exclusively on the cuffed ETT. Drs. Lindsay and Swanson and many others agree on the advantages these tubes offer: they minimize the risk of aspiration, permit the use of high PEEP and peak inspiratory pressure when necessary, and provide the ability to measure static pressures and volumes. Further, the cuff is there. If one chooses not to use it, it remains in place, ready for inflation when some subsequent provider deems it necessary.
Although the Dillier reference2 is an interesting case report, it is just that—one case. The specifics are instructive: the child required not only a cuffed ETT but, significantly, that cuffed tube replaced an uncuffed tube placed moments earlier. The original uncuffed tube, as is often the case, did not provide secure ventilation because of an excessive volume leak. Further, the infant had been intubated at least three times earlier for diagnostic and surgical procedures.
The title of Dillier's report might just as accurately have been “Laryngeal damage due to poor planning requiring placement of a proper cuffed ETT after a rough intubation with an improperly selected, poorly sized uncuffed ETT in an infant with unrecognized prior glottic damage from multiple intubations”! The point is clear.
Cuffed tubes (because they can be selected to be of a slightly smaller diameter) do present greater resistance to spontaneous ventilation, but your receiving intensivist will deal with that efficiently and easily by providing controlled or facilitated ventilation, just as you do en route with a self-inflating bag or ventilator. No less importantly, my observation has been that the smaller diameter of the tip of the cuffed tube is easier for the occasional pediatric airway manager to place easily on the first attempt and may be associated with less glottic and subglottic trauma.
The use of cuffed tubes is supported not only by the recent Newth study cited by Lindsay but also by a similar study in PICU patients published in 1994,3 by a similar study dealing with surgical patients from 1997,4 by a very recent article from a respected pediatric airway center,5 and even by European research.6
Arguments favoring the perceived greater safety of the uncuffed tubes ignore or minimize strong evidence supporting the cuffed tube. The studies that have looked at the complication rates for the two devices ordinarily have excluded patients who have had to be switched from an uncuffed to a cuffed tube. It is exactly this significant subpopulation that is at greatest risk: they get the cumulative trauma and complications inherent in two intubations and both types of tubes.
Today's pediatric critical care techniques will mandate that a majority of the pediatric patients transported with uncuffed tubes will require repeat laryngoscopy to change the tube. When well intentioned prehospital caregivers place uncuffed tubes, they may not reasonably think that they have provided the safer alternative. On the contrary, they have burdened that patient with a possible need for repeat laryngoscopy and reintubation. Any fair analysis of this situation makes it clear that the original airway manager has created this problem and the risk associated with it.
Finally, although it is clear that Dr. Swanson is correct that the transport environment makes it difficult to assess the degree of inflation of a cuffed tube, I assert that a gentle squeeze of the pilot tube between thumb and forefinger allows a reasonably experienced caregiver to assess whether the inflation is way too tight or probably OK, and I believe that is quite sufficient for most transports. Cases of subglottic stenosis, rare as they are, typically are like the Dillier case; they follow many days of intubation, not an hour or two in an aircraft. Purists can ask their respiratory therapy colleagues for a compact 4-ounce device that measures cuff pressures and simply pack it along or merely keep the cuff deflated if that makes them feel better.
A bumper sticker popular on construction and rescue vehicles where I live provides sound advice: please place the definitive airway the first time and “Git 'er done!”
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