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Show full transcript for Cuffed and Uncuffed ET Tubes video

In this lesson, you will be learning when to use cuffed ET tubes vs. uncuffed ET tubes along with some things to be aware of when making your decision. We'll also provide you with some information on cuffed ET tube benefits, verifying tube placement, and cuff pressures. At the end of the lesson, you'll find out why key changes were made in the PALS recommendations and what those changes are.

Selecting appropriate equipment and medications for infant and child intubation is vital. Many providers have historically preferred the use of uncuffed ET tubes for infants and children because the normal pediatric airway narrows below the vocal cords.

This creates an anatomical seal around the distal end of the tube. In settings such as pre-hospital or when the patient is moved around, uncuffed ET tubes may need to be changed to cuffed tubes to maintain a patent airway.

Cuffed ET Tube Benefits

The benefits of using cuffed ET tubes at the beginning of a resuscitation attempt for pediatric patients are:

  • The improvement in the accuracy of capnography
  • Better tidal volume delivery
  • Reductions in the need for a potential tube change

Warning: Reintubation is a high-risk procedure. It should be avoided whenever possible.

Using a cuffed tube can decrease the risk of airway trauma by decreasing the need for tube changes. Cuffed ET tubes may also decrease the risk of aspiration.

Beware of High Cuff Pressure

However, cuffed tubes can cause airway damage when too high of pressure is used in the cuff. Careful attention must be made when selecting the correct tube size, position, and cuff inflation.

Pro Tip #1: Cuff inflation pressure should normally be less than 20-25 cm of H2O. However, it's important to consider that ET tube cuff pressures could change during transport, altitude changes, and with increasing airway edema.

Verifying Tube Placement

After placing an ET tube, it is important to verify proper tube placement. Oscillations of breath sounds missed in the tube or chest rise may be good indicators of proper placement.

Pro Tip #2: For patients with a pulse, oscillations of breath sounds and chest rise are not the most reliable signs. Either a colorimetric detector or capnography should be used to access initial tube placement.

Another point to be aware of when managing an infant's or child's airway is that cricoid pressure during bag-mask ventilation and intubation is not recommended.

Even though it has historically been used to minimize the risk of gastric contents refluxing into the airway, it may reduce the effectiveness of bag-mask ventilation and significantly reduce the success of intubation.

A Word About Key Changes in the PALS Recommendations

More than 20 000 infants and children have a cardiac arrest each year in the United States. Despite increases in survival and comparatively good rates of good neurologic outcome after pediatric IHCA, survival rates from pediatric OHCA remain poor, particularly in infants.

Recommendations for pediatric basic life support (PBLS) and CPR in infants, children, and adolescents have been combined with recommendations for pediatric advanced life support (PALS) in a single document in the 2020 Guidelines.

The causes of cardiac arrest in infants and children differ from cardiac arrest in adults, and a growing body of pediatric-specific evidence supports these recommendations. Key issues, major changes, and enhancements in the 2020 Guidelines include the following:

  1. Algorithms and visual aids were revised to incorporate the best science and improve clarity for PBLS and PALS resuscitation providers.
  2. Based on newly available data from pediatric resuscitations, the recommended assisted ventilation rate has been increased to 1 breath every 2 to 3 seconds (20-30 breaths per minute) for all pediatric resuscitation scenarios.
  3. Cuffed ETTs are suggested to reduce air leaks and the need for tube exchanges for patients of any age who require intubation.
  4. The routine use of cricoid pressure during intubation is no longer recommended.
  5. To maximize the chance of good resuscitation outcomes, epinephrine should be administered as early as possible, ideally within 5 minutes of the start of cardiac arrest from a non-shockable rhythm (asystole and pulseless electrical activity).
  6. For patients with arterial lines in place, using feedback from continuous measurement of arterial blood pressure may improve CPR quality.
  7. After ROSC, patients should be evaluated for seizures; status epilepticus and any convulsive seizures should be treated.
  8. Because recovery from cardiac arrest continues long after the initial hospitalization, patients should have formal assessment and support for their physical, cognitive, and psychosocial needs.
  9. A titrated approach to fluid management, with epinephrine norepinephrine infusions if vasopressors are needed, is appropriate in resuscitation from septic shock.
  10. On the basis largely of extrapolation from adult data, balanced blood component resuscitation is reasonable for infants and children with hemorrhagic shock.
  11. Opioid overdose management includes CPR and the timely administration of naloxone by either lay rescuers or trained rescuers.
  12. Children with acute myocarditis who have arrhythmias, heart block, ST-segment changes, or low cardiac output are at high risk of cardiac arrest. Early transfer to an intensive care unit is important, and some patients may require mechanical circulatory support or extracorporeal life support (ECLS).
  13. Infants and children with congenital heart disease and single ventricle physiology who are in the process of staged reconstruction require special considerations in PALS management.
  14. Management of pulmonary hypertension may include the use of inhaled nitric oxide, prostacyclin, analgesia, sedation, neuromuscular blockade, the induction of alkalosis, or rescue therapy with ECLS.