Paediatric Tracheal Tubes Research Articles

32 Lidocaine vs Mometasone Furoate Around Pediatric Tracheal Tube Cuff: A Prospective Randomized Study

32 Lidocaine vs Mometasone Furoate Around Pediatric Tracheal Tube Cuff: A Prospective Randomized Study

Insertion of cuff inflation line into pediatric tracheal tubes related to oral and nasal tracheal intubation depth.

In clinical practice, the cuff inflation line of cuffed pediatric tracheal tubes often interferes with securing tracheal tubes. The insertion site of the cuff inflation lines and the lengths of four different brands and nine sizes of commonly used cuffed pediatric tracheal tubes were measured and compared in vitro with oral and nasotracheal intubation depths as calculated by different formulas for pediatric patients aged from birth to 16years. Motoyama's recommendation was used for age-related size selection of cuffed pediatric tracheal tubes. The proportion of the distance from the tracheal tube tip to the insertion site of the cuff inflation line varied considerably between the tracheal tubes (Microcuff: 48.5-60.7%; Parker: 48.7-73.2%; Ruesch: 59.1-77.8%; and Shiley: 46.0-60.3%). Using different formulas for oral or nasotracheal intubation depth, the insertion site of the cuff inflation line was placed within the oral or nasal cavity or within an area 1cm beyond the teeth or the nostrils in almost all tracheal tubes tested. Positioning the insertion site 2cm from the proximal end of the tracheal tubes resulted in a cuff line-free tube area of ≥1cm in all orally and almost in all nasally inserted tracheal tubes, considering maximum recommended tracheal intubation depths. The cuff inflation line in almost all commonly used cuffed pediatric tracheal tubes interferes with securing the tracheal tube due to its insertion site into the tracheal tube. This potentially carries the risk of kinking, obstruction, or damage to the cuff inflation line with ensuing failure to deflate or inflate the cuff. The proposed position of the insertion of the cuff inflation line 2cm from the proximal end of the tracheal tube would ensure a 1-cm-wide cuff line-free circular area beyond the oral or nasal cavity in nearly all assessed tracheal tube sizes.

Cuffed endotracheal tubes in neonates and infants of less than 3kg body weight-A retrospective audit.

Large prospective clinical studies have shown that modern cuffed pediatric tracheal tubes can be used safely, even in children weighing ≥3kg. There is a growing interest in their use in children weighing <3kg so that they, too, can benefit from the potential advantages, particularly the high probability of these tubes fitting into and sealing the pediatric airway at the first intubation attempt. This study aimed to find a cut-off body weight for procedures requiring a cuffed tracheal tube to seal the airway in children weighing <3kg and to evaluate the frequency and predictive factors for the requirement to place a cuffed instead of an uncuffed tracheal tube. This study was a retrospective analysis of 269 children weighing 2000-2999g, primarily intubated by pediatric anesthetists. Frequency of intubation with uncuffed Sheridan tubes versus cuffed Microcuff® Pediatric Endotracheal Tube (PET) 3.0mm ID was studied. Predictive variables were assessed by means of logistic regression analysis. The ROC curve for weight at intubation time and Youden index was calculated. The 149 (55.4%) children were finally intubated with a cuffed tracheal tube. Logistic regression demonstrated that body weight at tracheal intubation and birth weight were the strongest predictors for the appropriateness of cuffed/uncuffed tracheal tubes. The threshold weight at tracheal intubation was 2700g for a probability >50% of using a cuffed tracheal tube. Half of the children weighing 2000-2999g received a Microcuff® PET 3.0mm ID, especially those with a body weight above 2700g. Because of the anatomical dimensions in patients with a body weight of 2000-2999g, cuffed tracheal tubes with smaller outer diameters may be required to better fit their airways.

Biochemical changes of Moringa‎ seeds extracts on Nile Tilapia breeding fish

The work of breathing through north- and south-facing Portex Polar 'Blue-Line' paediatric tracheal tubes of sizes 3.0-7.0 mm ID has been measured using sinusoidal flow at equivalent ventilatory rates of 10-50 breaths min-1 with tidal volumes of 10-500 ml. North-facing tubes are designed to sit with the connection on the forehead after intubation, whilst south-facing ones are designed so that the connection sits on the chin of the patient. It was found that the total work of breathing through north-facing tubes is approximately 8% higher than the total work of breathing through south-facing tubes of the same size, irrespective of tidal volume or respiration rate. The total work of breathing was dependent on total tube length but independent of tube design. The endotracheal connectors themselves were found to contribute a significant proportion of the total work of breathing but there was no significant difference between the inspiratory and expiratory performance of the tubes.

Derivation and validation of a formula for paediatric tracheal tube size using bootstrap resampling procedure.

Background and Aims:The accuracy of age-, length- and weight-based formulae to predict optimal size of uncuffed tracheal tubes (TTs) in children varies widely. We determined the accuracy of age, length and weight in predicting the size of TT in Indian children, and derived and validated a formula using the best predictor.Methods:In the derivation phase, 100 children aged 1-8 years undergoing general anaesthesia and tracheal intubation with an uncuffed tube were prospectively studied. The correct size of the TT used was confirmed using the leak test. A bootstrap resampling procedure was used to estimate the accuracy of the predictors (age, weight, or length alone; length and age; length and weight; and length, weight and age). The best predictor was used to derive a formula (Paediatric Tube Size Predictor, PTSP) to calculate the size of TT. The accuracy of PTSP was tested in 150 children of the same age group in the validation phase.Results:Length (L (in meters), R2 = 0.61) was the best single predictor of the size of TT and was used to derive the PTSP as internal diameter = 3L + 2.5. In the validation phase, the PTSP predicted the size of TT correctly in 75% of children. Re-intubation was associated with a higher incidence of respiratory morbidity than one-time tracheal intubation.Conclusion:Length of the child predicts the size of an uncuffed TT better than age and weight. The PTSP formula based on length correctly predicts the size of uncuffed TT in 75% of children.

Tube tip and cuff position using different strategies for placement of currently available paediatric tracheal tubes

BackgroundTracheal tube tip and cuff positions of different cuffed paediatric tracheal tube brands in the trachea can vary with design. MethodsData from three clinical studies with measured tracheal lengths were pooled in a database including 422 children aged from birth to 16 yr. Dimensional data of seven cuffed paediatric tracheal tube brands (ID 3.0–7.0 mm) were recorded. Positions of tracheal tube tip and upper cuff border were calculated for each of the 422 tracheas using depth mark based tracheal tube placement, placement of the tracheal tube tip at a calculated safety distance above the carina, and mid-tracheal tube placement. Percentage of accidental bronchial intubations and tracheal tube cuff positions in the subglottic or supraglottic region were calculated. ResultsDepth mark based tracheal tube placement resulted in accidental bronchial intubation of up to 18% of cases and tracheal tube cuffs being placed in the subglottic region in up to 91%. Tracheal tube tip placement at a calculated safety distance resulted in up to 54% of tube cuffs placed too high. Mid-tracheal tube placement led to 100% subglottic or supraglottic tracheal tube cuff positions. ConclusionsAll studied cuffed paediatric tracheal tubes have major design flaws potentially leading to airway complications. Tracheal tube manufacturers are urgently asked to improve the design of cuffed paediatric tracheal tubes. Alternative strategies for tracheal tube placement can allow safe tracheal tube placement of uncuffed but not of cuffed tracheal tubes.

Benefits of Using High-Volume–Low-Pressure Tracheal Tube in Children Undergoing Congenital Cardiac Surgery: Evidence From a Prospective Randomized Study

In the past 2 decades, usage of high-volume-low-pressure microcuffed tracheal tubes in smaller children has increased. However, there is paucity of evidence of its usage in smaller children undergoing congenital cardiac surgery. The aim of this study was to assess if microcuff endotracheal tubes in neonates and younger children undergoing congenital cardiac surgery is associated with better outcomes than uncuffed tubes. We carried out this single-center, prospective, randomized study between June and November 2016. Eighty patients were randomized into those receiving microcuff tracheal tubes and conventional uncuffed tubes. Primary outcome was stridor postextubation. Secondary outcomes measured included number of tube changes, volume of anesthetic gases required, and cost incurred. The 2 groups were comparable in terms of baseline characteristics and duration of intubation. Incidence of stridor was significantly higher in conventional uncuffed tubes (12 [30%] vs 4 [10%]; P = .04) and so was the number of tube changes required (17/40 [42.5%] vs 2/40 [5%]; P ≤ .001). Tube change was associated with more than 3-fold risk of stridor (odds ratio = 3.92; 95% confidence interval = 1.23-12.43). Isoflurane (29.14 ± 7.01 mL vs19.2 ± 4.81 mL; P < .0001) and oxygen flow requirement ( P < .0001) and the resultant cost (7.46 ± 1.4 vs 5.77 ± 1.2 US$; P < .0001) were all significantly higher in the conventional uncuffed group. Microcuff pediatric tracheal tube is associated with significantly lower incidence of stridor, tube changes, and anesthetic gas requirement. This leads to significant cost reduction that offsets the higher costs associated with usage of a microcuff tracheal tube.

A successful case of pediatric tracheal tube exchange utilizing gum-elastic bougie and videolaryngoscope.

Here we report on our experiences with successful pediatric tracheal tube exchange utilizing the gum-elastic bougie (GEB; SmithMedical, USA) and videolaryngoscope (Pentax-AWS Airwayscope®; Hoya, Japan) with an infant-size Intlock in a ventilated child, whose condition was complicated by pneumonia and dilated cardiomyopathy. A 2-year-old female (height 77 cm; weight 8.8 kg) was transferred to our emergency department due to severe dyspnea and vital sign collapse. She was diagnosed with cardiac failure due to dilated cardiomyopathy associated with pneumonia. We performed emergent tracheal intubation with a tracheal tube with an internal diameter (ID) of 3.5 mm, and sedated her with midazolam and dexmedetomidine. Intensive care was continued with antibiotics and mechanical ventilation, and catecholamine support with dobutamine was added. Demands for secretion management and ventilator weaning dictated tracheal tube exchange with a larger size tube. To avoid cardiopulmonary collapse associated with tube exchange or prolonged hypoxia, we decided to perform tracheal tube exchange with

Safety and reliability of the sealing cuff pressure of the Microcuff pediatric tracheal tube for prevention of post-extubation morbidity in children: A comparative study.

Objectives:The objective of this study is to evaluate the efficacy and safety of sealing pressure as an inflation technique of the Microcuff pediatric tracheal cuffed tube.Materials and Methods:A total of 60 children were enrolled in this study. After induction of anesthesia and intubation with Microcuff pediatric tracheal tube, patients were randomly assigned, to one of the three groups. Control group (n = 20) the cuff was inflated to a cuff pressure of 20 cm H2O; sealing group (n = 20) the cuff was inflated to prevent the air leak at peak airway pressure of 20 cm H2O and the finger group (n = 20) the cuff was inflated to a suitable pressure using the finger estimation. Tracheal leak, incidence and severity of post-extubation cough, stridor, sore throat and hoarseness were recorded.Results:The cuff pressure as well as the volume of air to fill the cuff was significantly low in the sealing group when compared with the control group (P < 0.001); however, their values were significantly high in the finger group compared with both the control and the sealing group (P < 0.001). The incidence and severity of sore throat were significantly high in the finger group compared with both the control and the sealing group (P = 0.0009 and P = 0.0026). Three patients in the control group developed air leak around the endotracheal tube cuff. The incidence and severity of other complications were similar in the three groups.Conclusion:In pediatric N2O, free general anesthesia using Microcuff pediatric tracheal tub, sealing cuff pressure is safer than finger palpation technique regarding post-extubation morbidities and more reliable than recommended safe pressure in prevention of the air leak.

Impaction of suction catheter during paediatric anaesthesia

We read with interest articles describing impaction of a gum-elastic bougie in a tracheal tube (TT) and the effects of different types of lubrication on the force needed to retract a stylet from a TT 1, 2. We report a case of catheter impaction during tracheal suction under general anaesthesia. A 6-year-old weighing 16 kg was scheduled for right nephrectomy under general anaesthesia. All routine investigations were within normal limits and physical examination including airway assessment was unremarkable. Laryngoscopy revealed a Cormack and Lehane grade-3 view and the trachea was intubated with a 5-mm cuffed TT after external laryngeal manipulation. The child was positioned in the left lateral decubitus position. Approximately 40 min after intubation, audible crepitations were heard from the TT. A 10-FG PVC suction catheter was introduced into the TT to clear presumed secretions. Insertion was easy but whilst being withdrawn, the suction catheter appeared to become lodged within the TT's lumen. Attempts to remove the catheter proved futile despite gentle traction and rotation of the catheter. Before desaturation occurred, the TT cuff was deflated and the TT was removed with the suction catheter in situ. The lungs were ventilated via a facemask but several attempts at re-intubation failed because obtaining a view of the vocal cords was impossible. Finally the airway was secured with a size-2 LMA. Thereafter, maintenance of and recovery from anaesthesia proceeded uneventfully. No visible abnormality was identified in the TT or suction catheter. Similar impaction has been attributed to an increase in surface tension due to small amounts of condensed vapour between the outer surface of the suction catheter and the inner aspect of the TT's anterior wall 3. Interestingly, use of water as a lubricant to aid easier passage of a suction catheter through the TT has also been advocated. We believe that paediatric TTs, with a smaller lumen and sharper curve, exaggerates the friction between the two and may more readily lead to impaction of the catheter. Selection of an appropriately sized catheter for suctioning is important. The French gauge of the suction catheter should be no more than one and half times the size of the TT's internal diameter in mm. We also believe that the suction catheter should be lubricated, or another option is to use a siliconised suction catheter.

Unrecognized bronchial intubation associated with the uncuffed pediatric tracheal tube with bilateral Murphy eyes

Unreliability of breath sounds auscultation after intubation is reportedly mainly related to the presence of the Murphy eye. This study was performed to ascertain whether an uncuffed pediatric tracheal tube with bilateral Murphy eyes increases the risk of unrecognized bronchial intubation, compared to an uncuffed tube without eyes. Following induction of anesthesia in 50 toddlers, either an uncuffed tube without eyes or an uncuffed tube with bilateral eyes was inserted into the trachea. The tube was then slowly advanced while breath sounds were auscultated using a stethoscope. In study 1, when breath sounds changed and disappeared, the distance from the carina to the tube tip was measured using a fiberoptic bronchoscope. In study 2, when breath sounds changed, the tracheal tube was withdrawn 5, 10, 15 and 20 mm while using a fiberoptic bronchoscope to ascertain whether bronchial intubation had occurred. When breath sounds changed and disappeared, the tip of the tube with bilateral eyes was positioned more deeply below the carina than that of the tube without eyes. When the tube was withdrawn 10 mm from the point at which breath sounds changed, frequencies of bronchial intubation were 13% and 80% in the no eyes and double eyes groups, respectively. An uncuffed pediatric tracheal tube with bilateral Murphy eyes reduces the ability of breath sounds auscultation to detect bronchial intubation and may increase the risk of unrecognized bronchial intubation compared to an uncuffed tube without eyes.

It is time to establish an international manufacturing standard for paediatric tracheal tubes?

It is time to establish an international manufacturing standard for paediatric tracheal tubes?

Equipment and monitoring - what is in the future to improve safety?

There have been a number of recent developments in the practice of anesthesia and intensive care aimed at improving outcome in terms of reducing both morbidity and mortality, as well as other less-defined factors, such as quality of service provision. Significant advances have been made in airway devices such as pediatric tracheal tube designs, Microcuff(®) tracheal tubes, and new laryngoscopes. Noninvasive monitoring devices, including continuous hemoglobin analysis and near infrared spectrometry, are being increasingly used in pediatric anesthesia. Other, 'scaled-down' versions from adult anesthesia care, however, have not universally been shown to result in improved safety and outcomes in pediatric anesthesia.

Appropriate Placement Of Endotracheal Tubes In Pediatric Cardiac Patients

AIM To evaluate the appropriateness of intubation depth marks on the pediatric tracheal tube as a method of achieving midtracheal tube placement.To review other methods used for correct depth placement of endotracheal tube (ETT). METHODS This is a prospective study carried out at Innova childrens heart hospital Hyderabad India between June 1st to September 30th 2010. One hundred patients with body weight of 10kg and below who had elective cardiac surgeries under general anesthesia were included in the study. Demographic data were obtained from patientscase file. Data concerning type of operation done, ETT (uncuffed polyvinyl chloride tube) size, position, adjustment, type of endotracheal intubation and level of carina were observed. The tube was placed with the recommended centimeter marking aligned with the vocal cords. Radiological examination was carried out in the surgical intensive care unit immediate post operation and after 24hrs with the head in neutral, flexed and extended positions. RESULT The patients were between the ages of 23 days and 4years. They were 58 males and 42 females. The mean body weight of patients was 6.2 ± 2.0kg and height 68.2 ± 10.6cm. The sizes of ETT used were 4.0 (n=37), 4.5 (n=44), and 5.0 (n=9). In 76% of cases the ETT was located at first thoracic vertebra (T1) and in 6% of patients ETT was adjusted to T1. No case of endobronchial intubation or accidental extubation was recorded. CONCLUSION Midtrachea ETT placement was achieved by using intubation depth marks on the pediatric tracheal tube.

The safety of cuffed paediatric tracheal tubes during palatoplasty

The safety of cuffed paediatric tracheal tubes during palatoplasty

The design of pediatric tracheal tubes

Differences in the anatomy and physiology of the young child necessitate specialist equipment and anesthetic equipment is constantly evolving. We will review the factors influencing the design of pediatric tubes and highlight those areas of special interest. There have been pleas for more standardization of tube markings, as this would help with positioning of tubes, especially in small babies, and there are recent advances in this area. Anesthetists need to be aware that there are important differences between tubes so that they take this into account when choosing an appropriate tube. In addition, developments in the design of cuffed tubes are increasingly being used both for routine care and specialist surgery.

Paediatric tracheal tube for the exchange of tracheostomy tubes

Paediatric tracheal tube for the exchange of tracheostomy tubes

Scanning electron‐microscopic evaluation of cuff shoulders in pediatric tracheal tubes

Technical and conceptual shortcomings of cuffed pediatric tracheal tubes have been pointed out in the past, all representing a potential risk for mucosal damage of the pediatric airway. In this study, cuffed pediatric tracheal tubes from different manufacturers were investigated with regard to the cuff shoulder design using scanning electron microscopy (SEM). Cuffed pediatric tracheal tubes with the smallest internal diameter available were ordered from five manufacturers. SEM scans were performed from the tube shaft - cuff shoulder - tube cuff assembly and from the cuff shoulder alone. Each investigation was repeated in four samples of each tube brand. In addition, thickness of cuff membrane was measured. Major differences were found among the cuff shoulders investigated ranging from smooth transitions, softened borders to very sharp steps. There was also considerable difference in the thickness among the cuff membranes between the different tube brands ranging from 18 microm in polyurethane cuffs up to 90 microm in polyvinylchloride cuffs. Because the gap between the outer tracheal tube and the internal mucosal layer of the pediatric airway is often very narrow, some of the observed irregularities have the potential to injure the airway mucosa in pediatric patients, particularly during long-term use and firm fit of the tracheal tube in the airway. As cuffed tubes are increasingly used in small children, the observed irregularities in some tracheal tube brands may need to be improved and their safety should be proved by the manufacturers.

The depth markings on Portex blue‐line pediatric tracheal tubes need to be re‐organized for enhanced safety

The depth markings on Portex blue‐line pediatric tracheal tubes need to be re‐organized for enhanced safety

Cuffed tracheal tubes in children: past, present and future

This article reviews recent developments and core topics in the use and design of pediatric cuffed tracheal tubes. A concept for an appropriate pediatric cuffed tracheal tube is introduced. The main points in this concept are evidence-based tracheal tube size recommendation, continuous cuff pressure monitoring and a pediatric tracheal tube with an anatomically-based intubation depth mark and a short distally placed high-volume–low pressure cuff made from an ultra-thin polyurethane membrane with markedly improved tracheal sealing performance. The main points in proper handling of cuffed tracheal tubes in children are highlighted. Finally, an outlook on future developments in the design of pediatric cuffed tracheal tubes and an overview of tasks to be performed in evaluating them is given.