Cuffed Tracheal Tubes Cuffed Tracheal Tubes in Childrenin Children
--Myths and FactsMyths and Facts
PD Dr. Markus Weiss PD Dr. Markus Weiss Department of Anaesthesia Department of Anaesthesia
University Children’s Hospital ZurichUniversity Children’s Hospital ZurichSwitzerlandSwitzerland
PD Dr. Markus Weiss PD Dr. Markus Weiss
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Cuffed Tracheal Tubes In Children Cuffed Tracheal Tubes In Children
PRO PRO
Reduced gas leak, low fresh gas flowReduced gas leak, low fresh gas flowDecreased atmospheric pollutionDecreased atmospheric pollutionConstant controlled ventilationConstant controlled ventilationImproved efficiency of ventilationImproved efficiency of ventilationReliable monitoring of endtidal coReliable monitoring of endtidal co2 and and anaesthetic gasesanaesthetic gasesImproved accuracy of tidal volume and Improved accuracy of tidal volume and lung compliance monitoringlung compliance monitoring
PD Dr. Markus Weiss PD Dr. Markus Weiss
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Child
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tracheastracheasCompensation for different shaped Compensation for different shaped tracheastracheasReduction in the requirement to change Reduction in the requirement to change the tubethe tubeDecreased risk of pulmonary aspirationDecreased risk of pulmonary aspirationDecreased use of too large uncuffed Decreased use of too large uncuffed tubestubesDecreased pressure exerted on the Decreased pressure exerted on the cricoid
Cuffed Tracheal Tubes In Children Cuffed Tracheal Tubes In Children
PRO PRO
cricoid
PD Dr. Markus Weiss PD Dr. Markus Weiss
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Cuffed Tracheal Tubes In Children Cuffed Tracheal Tubes In Children
PRO PRO
Tracheal TubeTracheal Tube cuffedcuffed uncuffeduncuffed
PostPost--operative Croupoperative Croup 2.4 %2.4 % 2.9 %2.9 %Tube ExchangeTube Exchange 1 %1 %
23 %23 %FGF > 2 FGF > 2 literliter/min/min 1 %1 % 11 11 %%N2O > 10 N2O > 10 ppmppm 0 % 37 %0 % 37 %
Khine HK - Anesthesiology 1997
PD Dr. Markus Weiss PD Dr. Markus Weiss
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Cuffed Tracheal Tubes In Children Cuffed Tracheal Tubes In Children
CON CON
No Cuff Required In Children < 8 No Cuff Required In Children < 8 yearsyearsLaryngoLaryngo--tracheal injuriestracheal injuriesInadvertent Cuff OverInadvertent Cuff Over--InflationInflationInadequate Designed Paediatric Tube Inadequate Designed Paediatric Tube CuffsCuffsSmaller Internal Tube Diameter Smaller Internal Tube Diameter Increased Costs Increased Costs Not The (G)old Standard !Not The (G)old Standard !
PD Dr. Markus Weiss PD Dr. Markus Weiss
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Cuffed Tracheal Tubes In Children Cuffed Tracheal Tubes In Children
Yes or No ?Yes or No ?
Democratic Medicine (APA 2002)Democratic Medicine (APA 2002)2/3 Con2/3 Con1/3 Pro1/3 ProHatch 2002: It Is Not Forbidden To Use Hatch 2002: It Is Not Forbidden To Use Cuffed Endotracheal Tubes in Children ...Cuffed Endotracheal Tubes in Children ...
Not EvidenceNot Evidence--Based Medicine !!!Based Medicine !!!
PD Dr. Markus Weiss PD Dr. Markus Weiss
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Cuffed Tracheal Tubes In Children Cuffed Tracheal Tubes In Children
Myths Myths
Cuffed Tubes Are Not Needed Cuffed Tubes Are Not Needed in Children Because in Children Because
The Circular Cricoid SealsThe Circular Cricoid SealsThe Tracheal TubeThe Tracheal Tube
PD Dr. Markus Weiss PD Dr. Markus Weiss
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Cuffed Tracheal Tubes In Children Cuffed Tracheal Tubes In Children
Myths and FactsMyths and Facts
Adult LarynxAdult Larynx
PD Dr. Markus Weiss PD Dr. Markus Weiss
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Cuffed Tracheal Tubes In Children Cuffed Tracheal Tubes In Children
Myths and FactsMyths and Facts
Infantile LarynxInfantile Larynx
Eckenhoff JE - Anesthesiology 1954
PD Dr. Markus Weiss PD Dr. Markus Weiss
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Cuffed Tracheal Tubes In Children Cuffed Tracheal Tubes In Children
Myths Myths
Cuffed Tracheal Tubes Cuffed Tracheal Tubes In Children Are In Children Are A Major Reason A Major Reason
For Airway For Airway InjurysInjurys
PD Dr. Markus Weiss PD Dr. Markus Weiss
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Cuffed Tracheal Tubes In Children Cuffed Tracheal Tubes In Children
FactsFacts
Reasons for Airway Injury in ChildrenReasons for Airway Injury in Children
Too Large Endotracheal TubeToo Large Endotracheal TubeTraumatic Intubation Traumatic Intubation Repeated Intubation AttemptsRepeated Intubation AttemptsRepeated Tracheal Tube Repeated Tracheal Tube ExchangeExchange
PD Dr. Markus Weiss PD Dr. Markus Weiss
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Cuffed Tracheal Tubes In Children Cuffed Tracheal Tubes In Children
FactsFacts
Reasons for Airway Injury in ChildrenReasons for Airway Injury in Children
Prolonged Intubation Prolonged Intubation Inadequate Tube Fixation Inadequate Tube Fixation (oral/nasal)(oral/nasal)Inadequate SedationInadequate SedationInsufficient Tissue Perfusion Insufficient Tissue Perfusion Local InfectionLocal Infection
PD Dr. Markus Weiss PD Dr. Markus Weiss
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Cuffed Tracheal Tubes In Children Cuffed Tracheal Tubes In Children
FactsFacts
Free Air Cuff HyperinflationFree Air Cuff Hyperinflation
Free air inflation results in variable cuff pressure with hyperinflation in 39% of
cases. Free inflation of the tracheal tube cuff, controlled only by the palpation of the
pilot balloon, is not reliable and results in extremely variable (and sometimes very high) initial cuff pressures in children.
Felten ML - Anesth Analg 2003
PD Dr. Markus Weiss PD Dr. Markus Weiss
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Cuffed Tracheal Tubes In Children Cuffed Tracheal Tubes In Children
FactsFacts
Nitrous Oxide and Cuff HyperinflationNitrous Oxide and Cuff Hyperinflation
0
5
10
15
20
25
30
35
40
45
50
1 2 3 4 5gas removal (No)
time
(min
)
A/B A/BA/BA/BA/BC
Gas Removal for Cuff Pressure Release During Nitrous Oxide Exposure
(Set 20 cm H2O / Limit 25 cm H2O)
Dullenkopf A, Gerber AC, Weiss M - Canadian Journal of Anesthesia 2004
PD Dr. Markus Weiss PD Dr. Markus Weiss
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Cuffed Tracheal Tubes In Children Cuffed Tracheal Tubes In Children
Myths Myths
Cuffed Tracheal Tubes Cuffed Tracheal Tubes Are Are
Inadequately DesignedInadequately Designed
PD Dr. Markus Weiss PD Dr. Markus Weiss
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Cuffed Tracheal Tubes In Children Cuffed Tracheal Tubes In Children
FactsFacts
Inadequate Depth marks Inadequate Depth marks
Ho AMH, Aun CST, Karmakar MK. The margin of safety associated with the use of cuffed paediatric tracheal tubes. Anaesthesia 2002; 57: 169-182
Goel S, Lim SL. The intubation depth marker: the confusion of the black line.Paediatric Anaesthesia 2003; 13: 579-583
Wallace CJ, Bell Graham TB. Tracheal tube markings. Pediatric Anesthesia 2004; 14: 283-285
PD Dr. Markus Weiss PD Dr. Markus Weiss
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Cuffed Tracheal Tubes In Children Cuffed Tracheal Tubes In Children FactsFacts
Inadequate Design Inadequate Design ID Tracheal tube brand No Cuff 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0
Sheridan Tracheal Tube uncuffed Murphy 1 - 3.6 (3.6) 4.3 (4.2) 4.9 (4.9) 5.5 (5.5) 6.2 (6.2) 6.8 (6.8) 7.5 (7.5) 8.2 (8.2) 8.8 (8.8) 9.6 (9.6)
Sheridan Tracheal Tube cuffed Murphy 2 + NA 4.2 (4.2) 4.9 (4.9) 5.5 (5.5) 6.2 (6.2) 6.8 (6.8) 7.5 (7.5) 8.2 (8.2) 8.8 (8.8) 9.6 (9.6)
Sheridan Tracheal Tube cuffed Magill 3 + NA 4.3 (4.2) NA 5.5 (5.5) NA 6.9 (6.8) NA 8.1 (8.2) 8.9 (8.8) 9.4 (9.6)
Mallinckrodt TT Contour 4 - 3.7 (3.6) 4.4 (4.3) 5.0 (4.9) 5.7 (5.6) 6.2 (6.2) 6.9 (6.9) 7.6 (7.5) 8.1 (8.2) 8.8 (8.9) 9.6 (9.6)
Mallinckrodt TT High – Contour Murphy 5 + NA 4.4 (4.3) 4.9 (4.8) 5.7 (5.6) 6.3 (6.2) 7.0 (6.9) 7.6 (7.5) 8.2 (8.2) 8.9 (8.8) 9.5 (9.6)
Mallinckrodt TT High – Contour Murphy P-Serie 6 + NA 4.3 (4.3) 5.0 (4.9) 5.7 (5.6) 6.4 (6.2) 6.7 (6.9) 7.7 (7.5) 8.1 (8.2) 8.9 (8.8) 9.4 (9.6)
Mallinckrodt TT Lo – Contour Magill 7 + NA 4.5 (4.3) 4.9 (4.8) 5.7 (5.6) 6.2 (6.2) 6.9 (6.9) 7.5 (7.5) 8.3 (8.2) 9.0 (8.8) 9.8 (9.6)
Mallinckrodt TT Lo – Contour Murphy 8 + NA 4.4 (4.3) 5.0 (4.8) 5.6 (5.6) 6.2 (6.2) 7.0 (6.9) 7.5 (7.5) 8.2 (8.2) 8.8 (8.8) 9.4 (9.6)
Mallinckrodt TT Hi-Lo Murphy 9 + NA NA NA NA NA 6.9 (6.9) 7.5 (7.5) 8.1 (8.2) 8.8 (8.8) 9.4 (9.6)
Mallinckrodt TT Safety Flex 10 + NA 5.2 (5.0) 5.5 (5.2) 6.2 (6.2) 6.7 (6.7) 7.2 (6.9) 7.9 (7.5) 8.5 (8.2) 9.2 (8.8) 9.8 (9.6)
Portex TT - Blue Line, Magill, uncuffed 11 - 3.4 (3.5) 4.2 (4.2) 4.8 (4.8) 5.5 (5.5) 6.1 (6.2) 6.8 (6.9) 7.5 (7.6) 8.2 (8.2) 9.0 (8.9) 9.7 (9.6)
Portex TT - Profile Soft Seal Cuff, Murphy 12 + NA NA NA NA NA 7.0 (6.9) 7.6 (7.6) 8.3 (8.2) 8.8 (8.9) 9.6 (9.6)
Rüsch Ruschelit Safety Clear 13 - 3.4 (3.3) 4.0 (4.0) 4.8 (4.7) 5.3 (5.3) 6.0 (6.0) 6.7 (6.7)** 7.3 (7.3) 8.0 (8.0) 8.8 (8.9) 9.4 (9.3)
Rüsch Ruschelit Super Safety Clear Magill 14 + 4.0 (4.0) 5.1 (5.0) 5.3 (5.3) 5.9 (6.0) 6.2 (6.3) 6.7 (6.7)** 7.2 (7.3) 8.0 (8.0) 8.7 (8.7) 9.0 (9.0)
Ou
ter
diam
eter
(O
D)
(mm
)
Rüsch Ruschelit Super Safety Clear Murphy 15 + NA NA NA NA NA 6.7 (6.7) 7.3 (7.3) 8.0 (8.0) 8.8 (8.7) 9.2 (9.0)
ID (mm) 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0
Age related PCETT ID according to the formula of Khine4 PrematureNeonate
FulltermNeonate
1 year 3 years 5 year 7 years 9 years 11 years 13 years 15 years
Age related 95 % range of internal tracheal diameter (mm)20,21
Age related 95 % range of internal tracheal diameter (mm)20,22
3.6 - 7.8
3.5 – 8.2
4.1 – 8.3
3.9 – 8.8
5.2 – 9.5
4.7 – 9.9
6.3 – 10.6
5.5 – 11.1
7.4 – 11.7
6.3 – 12.2
8.5 – 12.8
7.1 – 13.3
9.6 – 13.9
7.9 – 14.5
10.8 – 15.0
8.7 – 15.6
11.9 – 16.3
9.5 – 16.7
Age related PCETT ID according to the formula of Motoyama19 PrematureNeonate
FulltermNeonate
1 year 2 year 4 year 6 years 8 years 10 years 12 years 14 years
Trac
hea
l dia
met
ers
and
PC
ETT
ID
Age related 95 % range of internal tracheal diameter (mm) 20,21
Age related 95 % range of internal tracheal diameter (mm) 20,22
3.6 – 7.8
3.5 – 8.2
4.1 – 8.3
3.9 – 8.8
4.7 – 8.9
4.3 – 4.9
5.8 – 9.8
5.1 – 10.5
6.9 – 11.1
5.9 – 11.6
8.0 – 12.2
6.7 – 12.8
9.1 – 13.3
7.5 – 13.9
10.2 – 14.4
8.3 – 15.0
11.3 – 15.5
9.1 –16.2
Weiss M - British Journal of Anaesthesia 2004
PD Dr. Markus Weiss PD Dr. Markus Weiss
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Cuffed Tracheal Tubes In Children Cuffed Tracheal Tubes In Children
FactsFacts
Inadequate Design Inadequate Design ID Tracheal tube brand No Cuff 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0
Sheridan Tracheal Tube uncuffed Murphy 1 -/-/21 -/-/22 -/-/24 -/-/27 -/-/29 -/-/31 -/-/31 -/-/35 -/-/37 -/-/41
Sheridan Tracheal Tube cuffed Murphy 2 + NA 12/25/- 13/32/- 13/32/- 15/35/- 20/42/- 20/46/- 21/48/- 23/55/- 25/60/-
Sheridan Tracheal Tube cuffed Magill 3 + NA 10/23/- NA 10/27/- NA 12/35/- NA 14/40/- 14/47/- 16/50/-
Mallinckrodt TT Contour 4 -/-/30 -/-/30 -/-/30 -/-/30 -/-/30 -/-/29 -/-/30 -/-/29 -/-/31 -/-/31
Mallinckrodt TT High – Contour Murphy 5 + NA 14/26/- 13/26/- 16/30/- 19/37/- 20/40/- 20/44/- 21/51/- 21/49/- 26/54/-
Mallinckrodt TT High – Contour Murphy P-Serie 6 + NA 13/24/42 16/29/50 17/30/49 22/39/57 20/37/59 22/43/62 18/40/60 24/49/67 19/46/67
Mallinckrodt TT Lo – Contour Magill 7 + NA 11/21/- 11/23/- 12/27/- 12/29/- 12/43/- 17/50/- 17/50/- 17/50/- 19/60/-
Mallinckrodt TT Lo – Contour Murphy 8 + NA 14/24/- 16/27/- 15/29/- 18/36/- 19/49/- 21/53/- 21/54/- 24/57/- 26/66/-
Mallinckrodt TT Hi-Lo Murphy 9 + NA NA NA NA NA 19/46/- 19/47/- 18/48/- 19/51/- 20/53/-
Mallinckrodt TT Safety Flex 10 + NA 10/21/42 11/26/44 11/26/47 12/30/53 17/45/68 15/50/70 18/50/70 18/52/72 18/56/80
Portex TT - Blue Line, Magill, uncuffed 11 - -/19/22 -/21/27 -/21/32 -/22/37 -/21/42 -/22/47 -/21/52 -/22/59 -/-/- -/-/-
Portex TT - Profile Soft Seal Cuff, Murphy 12 + NA NA NA NA NA 20/42/76 21/45/79 23/53/84 22/51/85 24/58/92
Rüsch Rüschelit Safety Clear 13 - -/-/20 -/-/20 -/-/21 -/-/30 -/-/30 -/-/40 -/-/39 -/-/40 -/-/41 -/-/-
Rüsch Rüschelit Super Safety Clear Magill 14 + 9/21/36 12/28/40 11/30/44 14/33/47 13/32/48 17/42/70 16/42/70 16/48/79 18/52/80 18/54/84
Dis
tan
ces
A/C
/D (
mm
)
Rüsch Rüschelit Super Safety Clear Murphy 15 + NA NA NA NA NA 21/47/76 20/47/76 22/55/82 23/57/84 25/63/88
ID (mm) 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0
Age related PCETT ID according to the formula of Khine4 PrematureNeonate
FulltermNeonate
1 year 3 year 5 year 7 years 9 years 11 years 12 years 15 years
Age-related 95 % range of tracheal length (mm) 20,21
Tracheal length (mm) 23
39.4-60.5
40
43.0 – 65.8
45
50.2 – 76.4
53
57.4 – 87.1
56
64.6 – 97.7
59
71.8 – 108.3
61
78.9 - 119 86.1 – 129.6 93.3 – 140.2
Age related PCETT ID according to the formula of Motoyama19 PrematureNeonate
FulltermNeonate
1 year 2 year 4 year 6 years 8 years 10 years 12 years 14 years
Trac
hea
l dia
met
ers
and
PC
ETT
ID
Age-related 95 % range of tracheal length (mm) 20,21
Tracheal length (mm) 23
39.4-60.5
40
43.0 – 65.8
45
46.6 – 71.1
50
53.8 – 81.8
54
61.0 – 92.4
57
68.2 – 103.0
60
75.4 – 113.7
63
82.5 – 124.5 89.7 – 134.9
PD Dr. Markus Weiss PD Dr. Markus Weiss
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Unive
rsity
Child
ren‘s
Hos
pita
l Zu
rich
Cuffed Tracheal Tubes In Children Cuffed Tracheal Tubes In Children
FactsFacts
Inadequate Design Inadequate Design ID Tracheal Tube Brand No Cuff 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0
Sheridan Tracheal Tube cuffed Murphy 2 + NA 7.0 (7.3) 8.8 (8.9) 8.8 (8.9) 11 (11) 13 (13) 16 (16) 16 (16) 19 (19) 19 (19)
Sheridan Tracheal Tube cuffed Magill 3 + NA 7.1 (7.3) NA 8.5 (8.9) NA 13 (13) NA 16 (16) 18 (19) 18 (19)
Mallinckrodt TT High – Contour Murphy 5 + NA 6 (6) 7 (7) 8 (8) 11 (11) 20 (18) 21 (21) 23 (22) 24 (23) 28 (25)
Mallinckrodt TT High – Contour Murphy P-Serie 6 + NA 6.5 (6) 7 (7) 8 (8) 12 (12) 20 (18) 22 (21) 23 (22) 24 (23) 28 (25)
Mallinckrodt TT Lo – Contour Magill 7 + NA 6 (6) 7 (7) 8 (8) 11 (11) 17 (17) 19 (19) 21 (21) 22 (22) 24 (24)
Mallinckrodt TT Lo – Contour Murphy 8 + NA 6 (6) 7 (7) 8 (8) 11 (11) 17 (17) 19 (19) 21 (21) 22 (22) 24 (24)
Mallinckrodt TT Hi-Lo Murphy 9 + NA NA NA NA NA 20.5 (20) 21 (21) 23 (23) 25 (25) 28 (28)
Mallinckrodt TT Safety Flex 10 + NA 7 (6) 8 (7) 9 (8) 11 (11) 17 (17) 19 (19) 21 (21) 22 (22) 24 (24)
Portex TT - Profile Soft Seal Cuff, Murphy 12 + NA NA NA NA NA 16 (17) 17 (17) 23 (23) 23 (23) 30 (30)
Rüsch Rüschelit Super Safety Clear Magill 14 + 8 (8) 8 (8) 8 (8) 10 (10) 10 (11) 12 (13) 14.5 (16.5) 16.5 (18.5) 18.5 (20.5) 24 (24)Cuf
f di
amet
er (
mm
)at
20
H2O
cuf
fpr
essu
re
Rüsch Rüschelit Super Safety Clear Murphy 15 + NA NA NA NA NA 11 (13) 16.5 (16.5) 16 (18.5) 20.5 (20.5) 23 (24)
Sheridan Tracheal Tube cuffed Murphy 2 + NA 42 62 62 95 133 201 201 283 283
Sheridan Tracheal Tube cuffed Magill 3 + NA 42 NA 62 NA 133 NA 201 283 283
Mallinckrodt TT High – Contour Murphy 5 + NA 28 38 50 95 254 346 380 415 491
Mallinckrodt TT High – Contour Murphy P-Serie 6 + NA 28 38 50 113 254 346 380 415 491
Mallinckrodt TT Lo – Contour Magill 7 + NA 28 38 50 95 227 283 346 380 452
Mallinckrodt TT Lo – Contour Murphy 8 + NA 28 38 50 95 227 283 346 380 452
Mallinckrodt TT Hi-Lo Murphy 9 + NA NA NA NA NA 314 346 415 490 615
Mallinckrodt TT Safety Flex 10 + NA 28 38 50 95 227 283 346 380 452
Portex TT - Profile Soft Seal Cuff, Murphy 12 + NA NA NA NA NA 201 227 415 415 707
Rüsch Rüschelit Super Safety Clear Magill 14 + 8 (50) 50 50 79 95 133 214 269 330 452
Cro
ss-s
ecti
onal
cuf
far
ea (
mm
2)a
t 2
0 c
mH
2O c
uff
pres
sure
Rüsch Rüschelit Super Safety Clear Murphy 15 + NA NA NA NA NA 133 214 269 330 452
ID ( mm) 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0Age related PCETT ID according to the formula of Khine4 Premature
NeonateNeonate to1st birthday
1 to3rd birthday
3 to5th birthday
5 to7th birthday
7 to9th birthday
9 to11th birthday
11 to13th birthday
13 to15th birthday
15 to16th birthday
Maximal (95%) age-related internal tracheal diameter (mm) 20,21 8.3 9.5 10.6 11.7 12.8 13.9 15.0 16.3 17.3
Maximal (95%) age-related cross-sectional tracheal area (mm2)20,22
47.1 63.6 81.7 102.0 124.6 149.5 176.6 206.0 234.9
Age related PCETT ID according to the formula of Motoyama19 PrematureNeonate
Neonate to1st birthday
1 to2nd birthday
2 to4th birthday
4 to6th birthday
6 to8th birthday
8 to10th birthday
10 to12th birthday
12 to14th birthday
14 to16th birthday
Maximal (95%) age-related internal tracheal diameter (mm) 20,21 8.3 8.9 10 11.1 12.2 13.3 14.4 15.7 17.3
Trac
hea
l dia
met
ers
and
PC
ETT
ID
Maximal (95%) age-related cross-sectional tracheal area (mm2)20,22
47.1 55.4 72.3 91.6 113.0 136.8 162.8 191.0 234.9
PD Dr. Markus Weiss PD Dr. Markus Weiss
Dep
artm
ent
of A
naes
thes
ia -
Unive
rsity
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ren‘s
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pita
l Zu
rich
Dep
artm
ent
of A
naes
thes
ia
Dep
artm
ent
of A
naes
thes
ia --
Unive
rsity
Child
ren‘s
Hos
pita
l Zu
rich
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rsity
Child
ren‘s
Hos
pita
l Zu
rich
Cuffed Tracheal Tubes In Children Cuffed Tracheal Tubes In Children
FactsFacts
Injury Due To Wrong Tube Cuff Design Injury Due To Wrong Tube Cuff Design
11 months old boy11 months old boyCardiac surgical procedure with Cardiac surgical procedure with cpbcpbTracheal intubation: Tracheal intubation: rueschruesch tttt id 4.0 cufflessid 4.0 cufflessUnacceptable high air leak around the tubeUnacceptable high air leak around the tubeTracheal intubation: Tracheal intubation: rueschruesch tttt id 4.0 with cuffid 4.0 with cuffTight fit Tight fit -- small leak with active deflated cuffsmall leak with active deflated cuff
PD Dr. Markus Weiss PD Dr. Markus Weiss
Dep
artm
ent
of A
naes
thes
ia -
Unive
rsity
Child
ren‘s
Hos
pita
l Zu
rich
Dep
artm
ent
of A
naes
thes
ia
Dep
artm
ent
of A
naes
thes
ia --
Unive
rsity
Child
ren‘s
Hos
pita
l Zu
rich
Unive
rsity
Child
ren‘s
Hos
pita
l Zu
rich
Cuffed Tracheal Tubes In Children Cuffed Tracheal Tubes In Children
FactsFacts
Injury Due To Wrong Tube Cuff Design Injury Due To Wrong Tube Cuff Design
CicuCicu: ventilation with active deflated cuff : ventilation with active deflated cuff (2 (2 days) days)
Transfer to Transfer to picupicu uchuchCuff pressure set to ambient pressureCuff pressure set to ambient pressureExtubation 3Extubation 3rdrd postoperative daypostoperative dayPostextubationPostextubation stridorstridorIncreasing oxygen requirementsIncreasing oxygen requirements
PD Dr. Markus Weiss PD Dr. Markus Weiss
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ia -
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rsity
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ren‘s
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Dep
artm
ent
of A
naes
thes
ia
Dep
artm
ent
of A
naes
thes
ia --
Unive
rsity
Child
ren‘s
Hos
pita
l Zu
rich
Unive
rsity
Child
ren‘s
Hos
pita
l Zu
rich
CuffCuff--Free Subglottic Tube Shaft Free Subglottic Tube Shaft No Murphy Eye No Murphy Eye Short High Volume Short High Volume -- Low Pressure Cuff (HVLP)Low Pressure Cuff (HVLP)Adequately Positioned Depth MarkingAdequately Positioned Depth Marking
Minimal Thickness of The CuffMinimal Thickness of The Cuff--Membrane Membrane Automatic Cuff Pressure Release ValveAutomatic Cuff Pressure Release ValveRecommendations for AgeRecommendations for Age--Related UseRelated Use
Cuffed Tracheal Tubes In Children Cuffed Tracheal Tubes In Children
FactsFacts
Ideal Design of Cuffed Pediatric Tubes Ideal Design of Cuffed Pediatric Tubes
PD Dr. Markus Weiss PD Dr. Markus Weiss
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ren‘s
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Dep
artm
ent
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naes
thes
ia
Dep
artm
ent
of A
naes
thes
ia --
Unive
rsity
Child
ren‘s
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pita
l Zu
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rsity
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ren‘s
Hos
pita
l Zu
rich
Cuffed Tracheal Tubes In Children Cuffed Tracheal Tubes In Children
FactsFacts
Ideal Design of Cuffed Pediatric Tubes Ideal Design of Cuffed Pediatric Tubes
Inte
rnal
tub
e di
amet
er
(ID; m
m)
Age
grou
p (y
ears
)
Sm
alle
st tra
chea
l dia
met
er o
f
age
gro
up (
mm
)
Out
er tub
e di
amet
er (
OD; m
m)
Cuf
f di
amet
er (
mm
) at
20
cm H
2O
cuf
f pr
essu
re
Cro
ss-s
ectio
nal c
uff ar
ea (
mm
2 )
Lar
gest
inte
rnal
tra
chea
l are
a
cro
ss-s
ectio
nal o
f ag
e gr
oup
(mm
2 )
Rat
io o
f cu
ff-t
o-la
rges
t tr
ache
a lc
ross
-sec
tiona
l are
a (%
)
3.0 Full term neonates to 1st birthday year 3.6 4.1 10 78.5 35.3 222.4
3.5 1 year to 2nd birthday 4.1 4.8 12 113.0 46.8 241.5
4.0 2 years to 4th birthday 4.7 5.4 12 113.0 70 161.5
4.5 4 years to 6th birthday 5.8 6.1 14 153.9 93.1 165.3
5.0 6 years to 8th birthday 6.9 6.7 16 201.0 116.2 172.9
5.5 8 years to 10th birthday 8 7.3 16 201.0 139.4 144.2
6.0 10 years to 12th birthday 9.1 8.0 18 254.3 162.5 156.5
6.5 12 years to 14th birthday 10.2 8.7 20 314.0 185.7 169.1
7.0 14 years to 16th birthday 11.3 9.3 22 379.9 234.9 161.7
Weiss M, Dullenkopf, Gerber AC - Anaesthesist 2004
PD Dr. Markus Weiss PD Dr. Markus Weiss
Dep
artm
ent
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naes
thes
ia -
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rsity
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ren‘s
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pita
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Dep
artm
ent
of A
naes
thes
ia
Dep
artm
ent
of A
naes
thes
ia --
Unive
rsity
Child
ren‘s
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pita
l Zu
rich
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rsity
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ren‘s
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pita
l Zu
rich
Cuffed Tracheal Tubes In Children Cuffed Tracheal Tubes In Children
FactsFacts
Microcuff Pediatric Tracheal Tube Microcuff Pediatric Tracheal Tube Mean Mean Mean Mean Mean Mean Mean Mean Mean
ID Age Height Weight Leak P Seal P Lips Tip-Carina D Trachea L % Trachea Tubeyrs cm kg cmH2O cmH2O cm dm cm %
3 0.4 60.9 6.7 12.4 9.9 10.0 2.3 4.7 51.33.5 1.4 78.8 10.5 12.5 9.8 11.6 2.8 5.5 50.14 2.9 93.9 13.9 8.6 10.0 12.9 3.1 6.1 49.8
4.5 4.9 107.9 17.6 8.6 9.7 13.7 3.3 6.7 51.95 6.9 120.8 23.6 8.0 9.6 14.9 3.3 7.1 54.4
5.5 8.9 131.3 27.6 8.8 9.7 15.7 3.6 8.1 55.86 11.0 144.5 39.0 7.2 9.6 16.4 3.9 8.9 56.7
6.5 13.0 153.8 44.7 7.8 9.5 17.4 4.3 9.7 56.57 15.0 165.3 56.9 6.1 9.6 18.4 5.1 10.9 53.9
Dullenkopf A, Gerber AC, Weiss M - European Journal of Anaesthesiology 2004; in press
PD Dr. Markus Weiss PD Dr. Markus Weiss
Dep
artm
ent
of A
naes
thes
ia -
Unive
rsity
Child
ren‘s
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pita
l Zu
rich
Dep
artm
ent
of A
naes
thes
ia
Dep
artm
ent
of A
naes
thes
ia --
Unive
rsity
Child
ren‘s
Hos
pita
l Zu
rich
Unive
rsity
Child
ren‘s
Hos
pita
l Zu
rich
Cuffed Tracheal Tubes In Children Cuffed Tracheal Tubes In Children
FactsFacts
Microcuff Pediatric Tracheal Tube Microcuff Pediatric Tracheal Tube
0
5
10
15
20
25
30
35
40
45
50
Patie
nts
(%)
< 5 < 10 < 15 < 20 > 20 > 25 > 35
Leak Pressure Groups (cm H2O)
Frequency Distribution of Leak Pressures
All (%)
Boys (%)
Girls (%)
Dullenkopf A, Gerber AC, Weiss M - Anesthesiology; submitted
PD Dr. Markus Weiss PD Dr. Markus Weiss
Dep
artm
ent
of A
naes
thes
ia -
Unive
rsity
Child
ren‘s
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pita
l Zu
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Dep
artm
ent
of A
naes
thes
ia
Dep
artm
ent
of A
naes
thes
ia --
Unive
rsity
Child
ren‘s
Hos
pita
l Zu
rich
Unive
rsity
Child
ren‘s
Hos
pita
l Zu
rich
Cuffed Tracheal Tubes In Children Cuffed Tracheal Tubes In Children
FactsFacts
Microcuff Pediatric Tracheal Tube Microcuff Pediatric Tracheal Tube
0
5
10
15
20
25
30
35
40
n Pa
tient
s (%
)
0 2 4 6 8 10 12 14 16 18 20Sealing Pressures (cm H2O)
Frequency D istribution of Sealing Pressures
All (% )
Boys (% )
Girls (% )
Dullenkopf A, Gerber AC, Weiss M - Anesthesiology; submitted
PD Dr. Markus Weiss PD Dr. Markus Weiss
Dep
artm
ent
of A
naes
thes
ia -
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rsity
Child
ren‘s
Hos
pita
l Zu
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Dep
artm
ent
of A
naes
thes
ia
Dep
artm
ent
of A
naes
thes
ia --
Unive
rsity
Child
ren‘s
Hos
pita
l Zu
rich
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rsity
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ren‘s
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pita
l Zu
rich
Cuffed Tracheal Tubes In Children Cuffed Tracheal Tubes In Children
FactsFacts
Microcuff Pediatric Tracheal Tube Microcuff Pediatric Tracheal Tube
Tracheal Tube Insertion based on Intubation Depth Marks(Children 0-16 years)
-2
0
2
4
6
8
0 2 4 6 8 10 12 14 16 18
Age (years)
Dis
tan
ce T
ube
Tip
to
Car
ina
(cm
)
Dullenkopf A, Gerber AC, Weiss M - British Journal of Anaesthesia; submitted
PD Dr. Markus Weiss PD Dr. Markus Weiss
Dep
artm
ent
of A
naes
thes
ia -
Unive
rsity
Child
ren‘s
Hos
pita
l Zu
rich
Dep
artm
ent
of A
naes
thes
ia
Dep
artm
ent
of A
naes
thes
ia --
Unive
rsity
Child
ren‘s
Hos
pita
l Zu
rich
Unive
rsity
Child
ren‘s
Hos
pita
l Zu
rich
Cuffed Tracheal Tubes In Children Cuffed Tracheal Tubes In Children
FactsFacts
Microcuff Pediatric Tracheal Tube Microcuff Pediatric Tracheal Tube
Oral Tube Insertion Depth Correction to cm = 12 + (Age/2)(Children > 2 years)
-2
0
2
4
6
8
0 2 4 6 8 10 12 14 16 18
Age (years)
Tube
Tip
Cor
rect
ion
/
Dis
tan
ce T
ube
Tip
to
Car
ina
(cm
)
Dullenkopf A, Gerber AC, Weiss M - British Journal of Anaesthesia; submitted
PD Dr. Markus Weiss PD Dr. Markus Weiss
Dep
artm
ent
of A
naes
thes
ia -
Unive
rsity
Child
ren‘s
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pita
l Zu
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Dep
artm
ent
of A
naes
thes
ia
Dep
artm
ent
of A
naes
thes
ia --
Unive
rsity
Child
ren‘s
Hos
pita
l Zu
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Unive
rsity
Child
ren‘s
Hos
pita
l Zu
rich
Cuffed Tracheal Tubes In Children Cuffed Tracheal Tubes In Children
FactsFacts
Microcuff Pediatric Tracheal Tube Microcuff Pediatric Tracheal Tube
Mic
r oc u
f fI D
4.0
mm
Ma l
li nc k
r odt
I D 4
.0 m
m
R üe s
chI D
4.0
mm
Sher
idan
I D 4
.0 m
m
Picture:Comparison of 4 tracheal cuffed pediatric tubes
Dullenkopf A, Gerber AC, Weiss M - Pediatric Anesthesia 2004
PD Dr. Markus Weiss PD Dr. Markus Weiss
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artm
ent
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naes
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rsity
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ren‘s
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Dep
artm
ent
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naes
thes
ia
Dep
artm
ent
of A
naes
thes
ia --
Unive
rsity
Child
ren‘s
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pita
l Zu
rich
Unive
rsity
Child
ren‘s
Hos
pita
l Zu
rich
Cuffed Tracheal Tubes In Children Cuffed Tracheal Tubes In Children
FactsFacts
Microcuff Pediatric Tracheal Tube Microcuff Pediatric Tracheal Tube
High Volume - Low Pressure Cuff Sealing Characteristics
PD Dr. Markus Weiss PD Dr. Markus Weiss
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ren‘s
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Dep
artm
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naes
thes
ia
Dep
artm
ent
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naes
thes
ia --
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rsity
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ren‘s
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rsity
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ren‘s
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Cuffed Tracheal Tubes In Children Cuffed Tracheal Tubes In Children
Myths Myths
Smaller Diameters inSmaller Diameters inCuffed Tracheal TubesCuffed Tracheal Tubes
Increase Work of Breathing Increase Work of Breathing and Cause Difficulties With and Cause Difficulties With
Tracheal SuctioningTracheal Suctioning
PD Dr. Markus Weiss PD Dr. Markus Weiss
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ren‘s
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artm
ent
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naes
thes
ia
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artm
ent
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naes
thes
ia --
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rsity
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ren‘s
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pita
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rsity
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ren‘s
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pita
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Cuffed Tracheal Tubes In Children Cuffed Tracheal Tubes In Children
FactsFacts
Smaller Diameters Smaller Diameters
Not A Problem During IPPV or Pressure Not A Problem During IPPV or Pressure SupportSupportRare Suctioning During AnaesthesiaRare Suctioning During AnaesthesiaProblems In The ICUProblems In The ICUProblems In Tubes Sizes ID 3.0 and 3.5 Problems In Tubes Sizes ID 3.0 and 3.5 mm mm
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artm
ent
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naes
thes
ia
Dep
artm
ent
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naes
thes
ia --
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rsity
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ren‘s
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pita
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rsity
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ren‘s
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pita
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Cuffed Tracheal Tubes In Children Cuffed Tracheal Tubes In Children
Myths Myths
Cuffed Tracheal Tubes Cuffed Tracheal Tubes Cause Cause
Increased CostsIncreased Costs
PD Dr. Markus Weiss PD Dr. Markus Weiss
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artm
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naes
thes
ia -
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rsity
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ren‘s
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Dep
artm
ent
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naes
thes
ia
Dep
artm
ent
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naes
thes
ia --
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rsity
Child
ren‘s
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pita
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rsity
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ren‘s
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pita
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Cuffed Tracheal Tubes In Children Cuffed Tracheal Tubes In Children
FactsFacts
Increased Costs Increased Costs 22--4 Times More Expensive Than Uncuffed 4 Times More Expensive Than Uncuffed Tubes Tubes Reduced Overall Costs by:Reduced Overall Costs by:
Less Tube Exchange ( up to 28 % )Less Tube Exchange ( up to 28 % )Less Fresh Gas Flow ConsumptionLess Fresh Gas Flow ConsumptionLess Volatile Anaesthetic ConsumptionLess Volatile Anaesthetic ConsumptionNo No EnviromentalEnviromental Pollution (Health !)Pollution (Health !)Other Advantages (ETCO2 Monitoring, Other Advantages (ETCO2 Monitoring, Oxygenation, Loss of Time by Tube Exchange, ... )Oxygenation, Loss of Time by Tube Exchange, ... )
PD Dr. Markus Weiss PD Dr. Markus Weiss
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thes
ia -
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ren‘s
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Dep
artm
ent
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naes
thes
ia
Dep
artm
ent
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naes
thes
ia --
Unive
rsity
Child
ren‘s
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pita
l Zu
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rsity
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ren‘s
Hos
pita
l Zu
rich
Cuffed Tracheal Tubes In Children Cuffed Tracheal Tubes In Children
Myths Myths
There Is LimitedThere Is LimitedExperience With Experience With
Cuffed Tracheal TubesCuffed Tracheal TubesIn Small ChildrenIn Small Children
PD Dr. Markus Weiss PD Dr. Markus Weiss
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artm
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ia -
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rsity
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ren‘s
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Dep
artm
ent
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naes
thes
ia
Dep
artm
ent
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naes
thes
ia --
Unive
rsity
Child
ren‘s
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pita
l Zu
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rsity
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ren‘s
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pita
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Cuffed Tracheal Tubes In Children Cuffed Tracheal Tubes In Children
FactsFacts
Experience Experience
Large Experience from Single Large Experience from Single CentersCentersParisParisZurichZurichLund Lund PittsburghPittsburgh
Limited MultiLimited Multi--Centre ExperienceCentre ExperienceLimited Randomised Prospective StudiesLimited Randomised Prospective Studies
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Dep
artm
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naes
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ia
Dep
artm
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naes
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ia --
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rsity
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ren‘s
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rsity
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ren‘s
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Cuffed Tracheal Tubes In Children Cuffed Tracheal Tubes In Children
Myths Myths
Uncuffed Tracheal TubesUncuffed Tracheal TubesAre The GOLD Standard Are The GOLD Standard
For Children Below For Children Below 8 Years Of Age8 Years Of Age
PD Dr. Markus Weiss PD Dr. Markus Weiss
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artm
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Dep
artm
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ia --
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rsity
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ren‘s
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rsity
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Cuffed Tracheal Tubes In Children Cuffed Tracheal Tubes In Children
Facts Facts
Uncuffed Tracheal TubesUncuffed Tracheal TubesBecomes The OLD Standard Becomes The OLD Standard
For Children Below For Children Below 8 Years Of Age8 Years Of Age
PD Dr. Markus Weiss PD Dr. Markus Weiss
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Cuffed Tracheal Tubes In Children Cuffed Tracheal Tubes In Children
ConclusionsConclusions
Cuffed Tracheal Tubes Can Cuffed Tracheal Tubes Can Be Safely Used in Children:Be Safely Used in Children:
Air Leak Control (<20 cm HAir Leak Control (<20 cm H220)0)Cuff Pressure Control (<20 cm HCuff Pressure Control (<20 cm H220)0)Adequate Designed Cuffed TubesAdequate Designed Cuffed Tubes