Oropharynx, Larynx, Epiglottis, true vocal cords, false cords 

Intubating with a Cuffed ETT

• Before intubation, check to make sure the cuff inflates properly!

• Make sure the patient is adequately sedated to avoid airway damage during the intubation. 

• Pass the ETT through the vocal cords (with the cuff down). 

• Slowly inflate the cuff (5-10cc of air).

• Secure the cuffed-ETT as you normally would. 

Measuring Intracuff Pressures 

• The respiratory therapist will measure cuff pressure following placement of a new ETT and then at least every 4 hours.

•  The minimal amount of air needed to seal the airway and ensure adequate tidal volumes.

• Cuff pressure should generally be maintained: greater than 20 cm H2O and less than 30 cm H2O. 

Management of High Cuff Pressures (>30cmH20) 

• Decrease the cuff pressure to 30 cm H2O by withdrawing a small amount of air from the balloon with a 10 mL syringe. 

• Listen for the presence of an air leak around the cuff during a positive pressure breath. 

• If an air leak is present, add just enough air to seal the airway and measure cuff pressure again. 

• If pressure remains > 30 cm H2O, 

  • Evaluate position of tube in the airway and reposition if needed. 

  • Consider other possible causes. 

  • Consider changing to a larger tube. 

Management of the Cuffed ETT

• If the depth of the tube needs to be readjusted: 

  1. Suction any secretions that may have collected above the cuff.

  2. Remove all the air from the cuff

  3. Reposition the tube to the desired depth

  4. Re-inflate the cuff

• Suctioning with a cuffed endotracheal tube:

  • Is the same as suctioning with an uncuffed ETT!

Patient’s should be suctioned every two hours and as needed!

How to Extubate with a Cuffed ETT?

1. Always suction pooled secretions above the cuff.

   • This reduces the incidence of aspiration and Ventilator Associated Pneumonia (VAP)

2. Take the cuff down by removing the air from the cuff.

3. Check for a leak

   • If there is no leak, the patient may need a dose of steroids to decrease airway edema.    

4. Pull the endotracheal tube as you would a cuffed tube!

   • If possible, have steroids and racemic epinephrine available for post-extubation stridor.  

Complications of Using Cuffed ETTs

• Prolonged over-inflation of the cuff can cause pressure necrosis of the tracheal mucosa.

• This mucosal injury can lead to failed extubation. 

• Post-extubation stridor, subglottic stenosis

• This is why we take extra care to make sure:

  • the cuff is inflated with the minimal amount of pressure needed to seal the airway  

  • and never exceeding 30 cmH20.

Take Home Points

• Cuffed ETTs are better for the pediatric patient!

  • They are better for optimizing pulmonary mechanics by creating a seal that avoids leaks and facilitates mechanical ventilation

  • This decreases the number of ETT exchanges.

  • Overall decreased rate of post extubation stridor and long-term  airway damage.

References for Further Reading

• Christopher J l CJ Newth, Bonnie B Rachman, Neal N Patel and Jürg J Hammer J. The use of cuffed versus uncuffed endotracheal tubes in pediatric intensive care. Pediatr 144(3):333-7 (2004) PMID 15001938

• Robert L Sheridan. Uncuffed endotracheal tubes should not be used in seriously burned children. Pediatr Crit Care Med 7(3):258-9 (2006) PMID 16575345

• R S RS Clements, A G AG Steel, A T AT Bates and R R Mackenzie. Cuffed endotracheal tube use in paediatric prehospital intubation: challenging the doctrine? Emerg Med J. 24(1):57-8 1 Jan 2007 PMID 17183050

• M Weiss, A Dullenkopf, J E Fischer, C Keller and A C Gerber. Prospective randomized controlled multi-centre trial of cuffed or uncuffed endotracheal tubes in small childrenBr J Anaesth 103(6):867-873 (2009) PMID 19887533

• BestBetsDo cuffed endotracheal tubes increase the risk of airway mucosal injury and post-extubation stridor in children? Report By: C S Ashtekar and A Wardhaugh – Specialist Registrars in Paediatrics