Table 4

 Do cuffed endotracheal tubes increase the risk of airway mucosal injury and post-extubation stridor in children?

CitationStudy groupStudy type (level of evidence)OutcomeKey resultsComments
Khine et al (1997)1Children aged from term newborns to 8 y who required tracheal intubation as a part of anaesthetic care. 251 children with odd medical record numbers were assigned to the cuffed tube group, and 237 children with even numbers were assigned to the uncuffed tube group. Children with a history or physical evidence of intrinsic or extrinsic airway obstruction or severe pulmonary disease or those who required nasotracheal intubation were excludedRCT (1b)1. Incidence of croup (post extubation stridor) 2. Number of intubations required to achieve an appropriately sized tube. 3. Concentration of nitrous oxide in operating room 4. The need to use more than 21min sup –1 fresh gas flow6 (2.4%) patients in the cuffed tube group and 7 (2.9%) patients in the uncuffed tube group had signs or symptoms of croup and 3 patients in each group were treated with racemic epinephrine. None of them required reintubation 3 (0.01%) patients in the cuffed tube group required a second tube while 54 (22.7%) patients required a second tube in the uncuffed group Nitrous oxide concentration at 24 inches from patients mouth were greater when uncuffed tracheal tubes were used (p<0.001)Not blinded. Mallinkrodt Io-pro or Sheridan low-pressure cuffed endotracheal tubes were used and duration of intubation was 60 minutes
Deakers et al (1994)2A total of 243 patients had 282 intubations in a paediatric intensive care unit setting. Of the 243 patients, 123 (49%) had cuffed endotracheal tubes. Analysis was performed for 188 (77%) of 243 patients Patients who died, or had a history of upper airway obstruction or surgery to the upper airway were excludedProspective Case control study (3b)1. Incidence of post-extubation stridor 2. Frequency of cuffed endotracheal tube use 3. Any increase risk of long-term post extubation complicationsIncidence of stridor: (a) cuffed endotracheal tube, 15.1%; (b) uncuffed endotracheal tube, 14.7% [RR 1.02, CI (0.5, 2.34)] 2 patients from the cuffed endotracheal group and 4 from the uncuffed group required reintubation for post extubation stridor There was no significant difference in rates of stridor when the subgroups under 1 y and aged 1–5 y were compared 33 (17%) of the 188 patients required readmission to the hospital during the next 18 months. None of these had problems with upper airwayNot randomised. Low pressure, high-volume cuffed endotracheal tubes were used
Newth et al (2004)3597 children <5 years of age, with 210 having cuffed tubes and 387 having uncuffed tubes were included. Setting was a paediatric intensive care unitProspective case control study (3b)Rate of post-extubation stridorRacemic epinephrine use in children with uncuffed tube: 6.1% in children <1 month old, 6.7% in children 1–2 years of age, and 9.4% in children 2–5 years of age Racemic epinephrine use in children with cuffed tube: 7.4% in children <1 month old; 9.5% in children 1–2 years of age, and 8.8% in children 2–5 years of ageNot randomised