Andreas C. Gerber

Prospective randomized controlled multi-centre trial of cuffed or uncuffed endotracheal tubes in small children

BACKGROUND The use of cuffed tracheal tubes (TTs) in small children is still controversial. The aim of this study was to compare post-extubation morbidity and TT exchange rates when using cuffed vs uncuffed tubes in small children. METHODS Patients aged from birth to 5 yr requiring general anaesthesia with TT intubation were included in 24 European paediatric anaesthesia centres. Patients were prospectively randomized into a cuffed TT group (Microcuff PET) and an uncuffed TT group (Mallinckrodt, Portex, Rüsch, Sheridan). Endpoints were incidence of post-extubation stridor and the number of TT exchanges to find an appropriate-sized tube. For cuffed TTs, minimal cuff pressure required to seal the airway was noted; maximal cuff pressure was limited at 20 cm H(2)O with a pressure release valve. Data are mean (SD). RESULTS A total of 2246 children were studied (1119/1127 cuffed/uncuffed). The age was 1.93 (1.48) yr in the cuffed and 1.87 (1.45) yr in the uncuffed groups. Post-extubation stridor was noted in 4.4% of patients with cuffed and in 4.7% with uncuffed TTs (P=0.543). TT exchange rate was 2.1% in the cuffed and 30.8% in the uncuffed groups (P<0.0001). Minimal cuff pressure required to seal the trachea was 10.6 (4.3) cm H(2)O. CONCLUSIONS The use of cuffed TTs in small children provides a reliably sealed airway at cuff pressures of <or=20 cm H(2)O, reduces the need for TT exchanges, and does not increase the risk for post-extubation stridor compared with uncuffed TTs.

Predictors of Airway and Respiratory Adverse Events With Ketamine Sedation in the Emergency Department: An Individual-Patient Data Meta-analysis of 8,282 Children

STUDY OBJECTIVE Although ketamine is one of the most commonly used sedatives to facilitate painful procedures for children in the emergency department (ED), existing studies have not been large enough to identify clinical factors that are predictive of uncommon airway and respiratory adverse events. METHODS We pooled individual-patient data from 32 ED studies and performed multiple logistic regressions to determine which clinical variables would predict airway and respiratory adverse events. RESULTS In 8,282 pediatric ketamine sedations, the overall incidence of airway and respiratory adverse events was 3.9%, with the following significant independent predictors: younger than 2 years (odds ratio [OR] 2.00; 95% confidence interval [CI] 1.47 to 2.72), aged 13 years or older (OR 2.72; 95% CI 1.97 to 3.75), high intravenous dosing (initial dose > or =2.5 mg/kg or total dose > or =5.0 mg/kg; OR 2.18; 95% CI 1.59 to 2.99), coadministered anticholinergic (OR 1.82; 95% CI 1.36 to 2.42), and coadministered benzodiazepine (OR 1.39; 95% CI 1.08 to 1.78). Variables without independent association included oropharyngeal procedures, underlying physical illness (American Society of Anesthesiologists class >or = 3), and the choice of intravenous versus intramuscular route. CONCLUSION Risk factors that predict ketamine-associated airway and respiratory adverse events are high intravenous doses, administration to children younger than 2 years or aged 13 years or older, and the use of coadministered anticholinergics or benzodiazepines.

Fit and seal characteristics of a new paediatric tracheal tube with high volume–low pressure polyurethane cuff

Background:  To evaluate a new paediatric tracheal tube (Microcuff, Weinheim, Germany) with an ultrathin high volume–low pressure polyurethane cuff.

Predictors of Emesis and Recovery Agitation With Emergency Department Ketamine Sedation: An Individual-Patient Data Meta-Analysis of 8,282 Children

STUDY OBJECTIVE Ketamine is widely used in emergency departments (EDs) to facilitate painful procedures; however, existing descriptors of predictors of emesis and recovery agitation are derived from relatively small studies. METHODS We pooled individual-patient data from 32 ED studies and performed multiple logistic regression to determine which clinical variables would predict emesis and recovery agitation. The first phase of this study similarly identified predictors of airway and respiratory adverse events. RESULTS In 8,282 pediatric ketamine sedations, the overall incidence of emesis, any recovery agitation, and clinically important recovery agitation was 8.4%, 7.6%, and 1.4%, respectively. The most important independent predictors of emesis are unusually high intravenous (IV) dose (initial dose of > or =2.5 mg/kg or a total dose of > or =5.0 mg/kg), intramuscular (IM) route, and increasing age (peak at 12 years). Similar risk factors for any recovery agitation are low IM dose (<3.0 mg/kg) and unusually high IV dose, with no such important risk factors for clinically important recovery agitation. CONCLUSION Early adolescence is the peak age for ketamine-associated emesis, and its rate is higher with IM administration and with unusually high IV doses. Recovery agitation is not age related to a clinically important degree. When we interpreted it in conjunction with the separate airway adverse event phase of this analysis, we found no apparent clinically important benefit or harm from coadministered anticholinergics and benzodiazepines and no increase in adverse events with either oropharyngeal procedures or the presence of substantial underlying illness. These and other results herein challenge many widely held views about ED ketamine administration.

Measurement of cerebral oxygenation state in anaesthetized children using the INVOS 5100 cerebral oximeter

Background: Near‐infrared spectroscopy is a developing technique for monitoring cerebral oxygenation during anaesthesia. The aim of this study was to evaluate absolute values of cerebral oxygenation during stable anaesthesia conditions in otherwise healthy children using the recently introduced INVOS 5100 cerebral oximeter with a paediatric and adult sensor and to compare them with values obtained from the NIRO 300 oximeter.

Evaluation of a new recommendation for improved cuffed tracheal tube size selection in infants and small children

Background:  The purpose of this study was to evaluate a new recommendation for tracheal tube size selection using second‐generation Microcuff paediatric endotracheal tubes (PETs) with optimized outer diameter (OD) of the distal tube.

Cuffed tracheal tubes in children - things have changed.

Whether cuffed tubes should be routinely used in infants and small children has been extensively discussed in the past. However, opinions and recommendations were not based on scientific evidence but rather on empiricism. The basic function of a tracheal tube is to provide a reliable connection between the patient’s lung and the bag or ventilator. Ideally, this connection should be leak-proof without causing undue pressure to laryngeal or tracheal structures. If this connection is not reasonably tight or sealed, constant minute ventilation, precise respiratory monitoring and capnography, low fresh gas flow and prevention of pulmonary aspiration are not possible. In an emergency situation and in patients with severe lung disease good sealing becomes even more important. Traditional teaching for the last 50 years was that in children under 8‐10 years of age, this sealing should be obtained with an uncuffed tracheal tube that would slip easily through the cricoid and leave some space for an air leak at 25 cm H2O airway pressure. Without any real evidence, cuffed tubes were not considered appropriate for children, in contrast with adults. This teaching was based on the idea that the

Anesthesia and periinterventional morbidity of rigid bronchoscopy for tracheobronchial foreign body diagnosis and removal

Background : Undiagnosed tracheobronchial foreign body aspiration (FBA) or delayed extraction can lead to serious morbidity. The aim of this study was to evaluate anesthetic and periinterventional morbidity of a straightforward regime using rigid bronchoscopy to rule out or remove a tracheobronchial foreign body in children with suspicion of FBA.

Teaching and supervising tracheal intubation in paediatric patients using videolaryngoscopy

In 85 patients (mean age 4.6 ± 3.1 years, range 0–10 years), a prototype of a new videolaryngoscope was used to provide a display of the intubation procedure in a paediatric anaesthesia teaching unit. The device provided important information to the teacher about the trainee’s problems related to direct laryngoscopy, difficulties with tube insertion into the larynx as well as the need and extent for anterior laryngeal pressure. Because the videolaryngoscope did not impair the normal intubation procedure, it seems to be a safe and a benefical tool for teaching and supervising tracheal intubation in children. In addition, it provides a potentially useful aid during difficult laryngoscopy, since the monitor view of the vocal cords was significantly better compared with a direct laryngoscopic view (P < 0.001).

Laryngeal damage due to an unexpectedly large and inappropriately designed cuffed pediatric tracheal tube in a 13-month-old child.

PurposeTo present a case of laryngeal damage in an infant caused by a too large and inappropriately designed cuffed tracheal tube.Clinical featuresA 13-month-old child undergoing cardiac surgery was intubated with an uncuffed endotracheal tube with an internal diameter (ID) of 4.0 mm. Because of an important air leak around the tracheal tube during mechanical ventilation, a cuffed endotracheal tube lD 4.0 mm was inserted. The air leak with the tube cuff not inflated was acceptable at 25 cm H2O airway pressure. After extubation on the third postoperative day the patient showed increasing stridor and respiratory deterioration. Fibreoptic laryngoscopy of the spontaneously breathing patient showed a large intra-laryngeal web. After surgical removal of the web, the child rapidly recovered and was discharged from the hospital on the 12th postoperative day.Inspection of the 4.0 mm (ID) cuffed tracheal tube revealed a cuff positioned inappropriately high and an increase of 0.7 mm in outer tube diameter compared to the 4.0 mm (lD) uncuffed tracheal tube from the same manufacturer. The tube cuff is likely to be situated within the larynx when placed in accordance to insertion depth formulas or radiological criteria, as used for uncuffed tracheal tubes in children.ConclusionThe larger than expected tracheal tube with its intralaryngeal cuff position in a 13-month-old child likely caused mucosal damage and an inflammatory reaction within the larynx resulting in granulation tissue formation and fibrous healing around the tracheal tube.RésuméObjectifPrésenter un cas de lésion laryngée causée, chez un enfant, par un tube trachéal à ballonnet, trop grand et mal conçu. Élémentscliniques : Un enfant de 13 mois devant subir une intervention cardiaque a été intubé avec un tube endotrachéal sans ballonnet d’un diamètre interne (Dl) de 4,0 mm. Étant donné l’importante fuite d’air autour du tube trachéal pendant la ventilation mécanique, un tube endotrachéal à ballonnet de 4,0 mm de Dl a été inséré. La fuite d’air notée autour du ballonnet non gonflé était acceptable pour une pression des voies aériennes de 25 cm H2O. Après l’extubation, au troisième jour postopératoire, le patient a présenté un stridor croissant et une détérioration respiratoire. La fibroscopie du larynx pendant la respiration spontanée a montré une grande membrane intralaryngée. Après le retrait chirurgical de la membrane, l’enfant s’est rapidement rétabli et a quitté l’hôpital le 12e jour.Lexamen du tube à ballonnet de 4,0 mm a révélé un ballonnet placé trop haut et une augmentation de 0,7 mm du diamètre extérieur du tube, comparé au tube sans ballonnet de 4,0 mm réalisé par le même fabricant. Le ballonnet se situe à l’intérieur du larynx quand on place le tube selon les formules d’insertion ou les critères radiologiques, comme on le fait avec les tubes trachéaux sans ballonnets chez les enfants.ConclusionLe tube trachéal, plus gros que prévu, placé dans le larynx dans la position indiquée pour un tube à ballonnet chez un enfant de 13 mois, a causé une lésion de la muqueuse et une réaction inflammatoire dans le larynx, ce qui a entraîné la formation de tissu de granulation et une cicatrisation fibreuse autour du tube trachéal.