CORRESPONDENCE
Cuffed or uncuffed endotracheal tubes in pediatric anesthesia: a survey of current practice in the United Kingdom and The Netherlands SIR—The use of uncuffed (UETs) or cuffed (CETs) endotracheal tubes in children has been a subject of debate for years (1). The published evidence has shifted toward CETs, as no increased risk of airway injury (1– 3), a reduction in theater contamination with anesthetic gas, increased accuracy of capnography reading, fewer tube exchanges, lower risks of microaspiration, and respiratory adverse events (1,2) have been demonstrated with the use of CETs. From our clinical experience, we hypothesized that the shifting scientific evidence would only slowly change existing clinical practice. To evaluate and compare current practice in the use of CETs in pediatric anesthesia, an online survey was sent to 845 members of the Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI) and 235 members of the Section of Paediatric Anaesthesia in the Netherlands (SKA). The overall response rate was 34%. Usage of CETs was analyzed by examining the age at which anesthesiologists would first consider using CETs. CETs were first used in neonates by 33.5% of British anesthesiologists and 47.3% of Dutch anesthesiologists and more often with advancing age (Figure 1). The British figure compares well with that from a French survey in 1997, which found that 37% of French pediatric anesthesiologists rarely used CETs in children younger than 5 years (4). Ordinal regression showed that nation (in The Netherlands earlier, P < 0.001) and setting (in tertiary referral centers earlier, P = 0.01) influence the age at which anesthesiologists first consider using CETs. In all age groups, CETs are used more often by Dutch anesthesiologists than British anesthesiologists. This
survey suggests that current practice in The Netherlands has changed toward the use of CETs, quite dissimilar from that in the UK. This survey showed that British and Dutch anesthesiologists have continuing concerns about cuffed tubes, especially about tracheal injury. A recent study in previously intubated children showed no increased risk of tracheal injury with CETs and a higher incidence of subglottic cysts with UETs on laryngotracheoscopy (3). Although the risk of respiratory complications is reported to be significantly higher with UETs (2,3), 41% of British and 11% of Dutch respondents in our survey perceive no problems with UETs. A cuff pressure above 20 cm H2O was unacceptable to the majority of British and Dutch anesthesiologists. Of British anesthesiologists, 66.8% never measure cuff pressure. Most Dutch anesthesiologists measure cuff pressure once. High cuff pressures have been demonstrated to be the most important predictor of postoperative sore throat when CETs are used with incidences of 68% and 96% at cuff pressures of >30 cm H2O and >40 cm H2O, respectively (5). Several anesthesiologists mentioned to judge cuff pressure on the lowest cuff volume required for disappearance of an audible leak around the cuff. This practice may, however, result in unacceptably high cuff pressures of 40–60 cm H2O (6). Unavailability of equipment was a reason not to measure cuff pressure as well as a reason for British respondents not to use CETs. A simple handheld manometer with connection tubing could be made available at low costs and could obviate the above-mentioned issues around cuff pressure.
Figure 1 Percentage of anesthesiologists using cuffed. Solid line represents the UK, and dotted line represents The Netherlands. P < 0.001. © 2015 John Wiley & Sons Ltd Pediatric Anesthesia 25 (2015) 431–439
431
Correspondence
In conclusion, our survey showed that the use of CETs is lagging behind the current evidence in the literature. Dutch anesthesiologists use CETs more often than British anesthesiologists. The gap between the change of in opinion in literature and practice may be explained by ongoing concerns with the use of CETs and lack of simple equipment to measure cuff pressure. Acknowledgments The authors thank the Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI) and the Dutch Society of Pediatric Anesthesia (SKA) for sending out the survey to their members. The study was funded by departmental resources.
Conflicts of interest No conflicts of interest declared. Saskia L. Boerboom1, Sundar M. Muthukrishnan2, Jurgen C. de Graaff3 & Gersten Jonker3 1 Department of Anaesthesiology, University Medical Centre, Utrecht, The Netherlands 2 Department of Anaesthesiology, Hull and East Yorkshire NHS Trust, Hull, UK 3 Department of Anaesthesiology, Paediatric Anaesthesia Unit, Wilhelmina Children’s Hospital, University Medical Centre Utrecht, Utrecht, The Netherlands Email: [email protected] doi:10.1111/pan.12594
References 1 Litman RS, Maxwell LG. Cuffed versus uncuffed endotracheal tubes in pediatric anesthesia: the debate should finally end. Anesthesiology 2013; 118: 500–501. 2 von Ungern-Sternberg BS, Boda K, Chambers NA et al. Risk assessment for respiratory complications in paediatric anaesthesia: a prospective cohort study. Lancet 2010; 376: 773–783.
3 Weiss M, Dave M, Bailey M et al. Endoscopic airway findings in children with or without prior endotracheal intubation. Pediatr Anesth 2013; 23: 103–110. 4 Orliaguet GA, Renaud E, Lejay M et al. Postal survey of cuffed or uncuffed tracheal tubes used for paediatric tracheal intubation. Paediatr Anaesth 2001; 11: 277–281.
5 Calder A, Hegarty M, Erb TO et al. Predictors of postoperative sore throat in intubated children. Pediatr Anesth 2012; 22: 239–243. 6 Ong M, Chambers NA, Hullet B et al. Laryngeal mask airway and tracheal tube cuff pressures in children: are clinical endpoints valuable for guiding inflation? Anaesthesia 2008; 63: 738–744.
Risks of fixed-angle supraglottic airways in infants SIR—Supraglottic airways (SGAs) are considered safe and are used across all ages and for an increasing variety of procedures. In particular in pediatric anesthesia, SGAs require extra vigilance in regards to positioning and administration of positive pressure. Our patient had been diagnosed with a congenital lung malformation on fetal ultrasound and was scheduled for a chest CT with a scan sequence in inspiration at 4 months of age. She was 6.8 kg and asymptomatic. After inhalation induction with sevoflurane, an intravenous line was placed and following a dose of propofol, an air-QÒ1.5 (Cookgas LLCÒ, Saint Louis, MO, distributed by Mercury MedicalÒ, Clearwater, Florida, USA) was inserted as the air-QÒ1 was expected to not provide an adequate seal. A leak at 24 cm H2O was confirmed, indicating sufficient seal for positive pressure ventilation and inspiratory hold during the scan. The patient was repositioned for the scan with the anesthesia circuit pulled cranially across her forehead. Propofol was given to render her apneic, positive pressure of 15 cm H2O was held for the inspiratory scan sequence, and positive pressure ventilation was performed until return of 432
spontaneous ventilation. The patient was hemodynamically stable with unimpaired oxygenation and ventilation, the endtidal CO2 trace was unsuspicious. Gastric distention was noted, and a suction catheter was passed to empty air from the stomach before emergence. The SGA was removed and the patient recovered uneventfully. The family recalls no untoward experience following the anesthetic. The scans revealed massive distention of the esophagus, stomach, and small bowel with air (Figure 1a,b). The most cephalad images did not show the larynx, but the tip of the SGA can be seen posterior to the trachea in the esophagus at the level of the clavicles (1c), and the trachea is held in a pronounced anterior position with the SGA behind it in the neck before coursing posteriorly to its expected intrathoracic position (1d). The patient underwent uneventful resection of the lesion at 6 months with uncomplicated endotracheal intubation. Pediatric SGAs are used for patients with a large weight range: The air-QÒ1.5 is recommended for patients ‘from 7 to 17 kg.’ In patients ‘between sizes,’ either size may be disadvantageous. A leak test detects © 2015 John Wiley & Sons Ltd Pediatric Anesthesia 25 (2015) 431–439
Copyright of Pediatric Anesthesia is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Cuffed or uncuffed endotracheal tubes in pediatric anesthesia: a survey of current practice in the United Kingdom and The Netherlands SIR—The use of uncuffed (UETs) or cuffed (CETs) endotracheal tubes in children has been a subject of debate for years (1). The published evidence has shifted toward CETs, as no increased risk of airway injury (1– 3), a reduction in theater contamination with anesthetic gas, increased accuracy of capnography reading, fewer tube exchanges, lower risks of microaspiration, and respiratory adverse events (1,2) have been demonstrated with the use of CETs. From our clinical experience, we hypothesized that the shifting scientific evidence would only slowly change existing clinical practice. To evaluate and compare current practice in the use of CETs in pediatric anesthesia, an online survey was sent to 845 members of the Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI) and 235 members of the Section of Paediatric Anaesthesia in the Netherlands (SKA). The overall response rate was 34%. Usage of CETs was analyzed by examining the age at which anesthesiologists would first consider using CETs. CETs were first used in neonates by 33.5% of British anesthesiologists and 47.3% of Dutch anesthesiologists and more often with advancing age (Figure 1). The British figure compares well with that from a French survey in 1997, which found that 37% of French pediatric anesthesiologists rarely used CETs in children younger than 5 years (4). Ordinal regression showed that nation (in The Netherlands earlier, P < 0.001) and setting (in tertiary referral centers earlier, P = 0.01) influence the age at which anesthesiologists first consider using CETs. In all age groups, CETs are used more often by Dutch anesthesiologists than British anesthesiologists. This
survey suggests that current practice in The Netherlands has changed toward the use of CETs, quite dissimilar from that in the UK. This survey showed that British and Dutch anesthesiologists have continuing concerns about cuffed tubes, especially about tracheal injury. A recent study in previously intubated children showed no increased risk of tracheal injury with CETs and a higher incidence of subglottic cysts with UETs on laryngotracheoscopy (3). Although the risk of respiratory complications is reported to be significantly higher with UETs (2,3), 41% of British and 11% of Dutch respondents in our survey perceive no problems with UETs. A cuff pressure above 20 cm H2O was unacceptable to the majority of British and Dutch anesthesiologists. Of British anesthesiologists, 66.8% never measure cuff pressure. Most Dutch anesthesiologists measure cuff pressure once. High cuff pressures have been demonstrated to be the most important predictor of postoperative sore throat when CETs are used with incidences of 68% and 96% at cuff pressures of >30 cm H2O and >40 cm H2O, respectively (5). Several anesthesiologists mentioned to judge cuff pressure on the lowest cuff volume required for disappearance of an audible leak around the cuff. This practice may, however, result in unacceptably high cuff pressures of 40–60 cm H2O (6). Unavailability of equipment was a reason not to measure cuff pressure as well as a reason for British respondents not to use CETs. A simple handheld manometer with connection tubing could be made available at low costs and could obviate the above-mentioned issues around cuff pressure.
Figure 1 Percentage of anesthesiologists using cuffed. Solid line represents the UK, and dotted line represents The Netherlands. P < 0.001. © 2015 John Wiley & Sons Ltd Pediatric Anesthesia 25 (2015) 431–439
431
Correspondence
In conclusion, our survey showed that the use of CETs is lagging behind the current evidence in the literature. Dutch anesthesiologists use CETs more often than British anesthesiologists. The gap between the change of in opinion in literature and practice may be explained by ongoing concerns with the use of CETs and lack of simple equipment to measure cuff pressure. Acknowledgments The authors thank the Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI) and the Dutch Society of Pediatric Anesthesia (SKA) for sending out the survey to their members. The study was funded by departmental resources.
Conflicts of interest No conflicts of interest declared. Saskia L. Boerboom1, Sundar M. Muthukrishnan2, Jurgen C. de Graaff3 & Gersten Jonker3 1 Department of Anaesthesiology, University Medical Centre, Utrecht, The Netherlands 2 Department of Anaesthesiology, Hull and East Yorkshire NHS Trust, Hull, UK 3 Department of Anaesthesiology, Paediatric Anaesthesia Unit, Wilhelmina Children’s Hospital, University Medical Centre Utrecht, Utrecht, The Netherlands Email: [email protected] doi:10.1111/pan.12594
References 1 Litman RS, Maxwell LG. Cuffed versus uncuffed endotracheal tubes in pediatric anesthesia: the debate should finally end. Anesthesiology 2013; 118: 500–501. 2 von Ungern-Sternberg BS, Boda K, Chambers NA et al. Risk assessment for respiratory complications in paediatric anaesthesia: a prospective cohort study. Lancet 2010; 376: 773–783.
3 Weiss M, Dave M, Bailey M et al. Endoscopic airway findings in children with or without prior endotracheal intubation. Pediatr Anesth 2013; 23: 103–110. 4 Orliaguet GA, Renaud E, Lejay M et al. Postal survey of cuffed or uncuffed tracheal tubes used for paediatric tracheal intubation. Paediatr Anaesth 2001; 11: 277–281.
5 Calder A, Hegarty M, Erb TO et al. Predictors of postoperative sore throat in intubated children. Pediatr Anesth 2012; 22: 239–243. 6 Ong M, Chambers NA, Hullet B et al. Laryngeal mask airway and tracheal tube cuff pressures in children: are clinical endpoints valuable for guiding inflation? Anaesthesia 2008; 63: 738–744.
Risks of fixed-angle supraglottic airways in infants SIR—Supraglottic airways (SGAs) are considered safe and are used across all ages and for an increasing variety of procedures. In particular in pediatric anesthesia, SGAs require extra vigilance in regards to positioning and administration of positive pressure. Our patient had been diagnosed with a congenital lung malformation on fetal ultrasound and was scheduled for a chest CT with a scan sequence in inspiration at 4 months of age. She was 6.8 kg and asymptomatic. After inhalation induction with sevoflurane, an intravenous line was placed and following a dose of propofol, an air-QÒ1.5 (Cookgas LLCÒ, Saint Louis, MO, distributed by Mercury MedicalÒ, Clearwater, Florida, USA) was inserted as the air-QÒ1 was expected to not provide an adequate seal. A leak at 24 cm H2O was confirmed, indicating sufficient seal for positive pressure ventilation and inspiratory hold during the scan. The patient was repositioned for the scan with the anesthesia circuit pulled cranially across her forehead. Propofol was given to render her apneic, positive pressure of 15 cm H2O was held for the inspiratory scan sequence, and positive pressure ventilation was performed until return of 432
spontaneous ventilation. The patient was hemodynamically stable with unimpaired oxygenation and ventilation, the endtidal CO2 trace was unsuspicious. Gastric distention was noted, and a suction catheter was passed to empty air from the stomach before emergence. The SGA was removed and the patient recovered uneventfully. The family recalls no untoward experience following the anesthetic. The scans revealed massive distention of the esophagus, stomach, and small bowel with air (Figure 1a,b). The most cephalad images did not show the larynx, but the tip of the SGA can be seen posterior to the trachea in the esophagus at the level of the clavicles (1c), and the trachea is held in a pronounced anterior position with the SGA behind it in the neck before coursing posteriorly to its expected intrathoracic position (1d). The patient underwent uneventful resection of the lesion at 6 months with uncomplicated endotracheal intubation. Pediatric SGAs are used for patients with a large weight range: The air-QÒ1.5 is recommended for patients ‘from 7 to 17 kg.’ In patients ‘between sizes,’ either size may be disadvantageous. A leak test detects © 2015 John Wiley & Sons Ltd Pediatric Anesthesia 25 (2015) 431–439
Copyright of Pediatric Anesthesia is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
