​​​​​​​Cuffed Endotracheal Tubes Presentation




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