For more than 50 yr, uncuffed tracheal tubes have been the gold standard for intubation in children under the age of 8 yr. This recommendation derived from descriptions of anatomical differences between the adult and child larynx , which supported a view that the presence of a tracheal tube cuff was not only unnecessary but also a potential source of airway morbidity.
However, the last decade has witnessed a growing body of evidence in support of high-volume low-pressure (HVLP) cuffed tracheal tubes in paediatric airway management. Studies have highlighted the benefits of such tubes  with their superior airway sealing properties compared with uncuffed ones as well as evidence that suggests that they present no increased risk of airway morbidity [3,4]. In the UK, the recent availability of cuffed tracheal tubes incorporating ultrathin HVLP cuffs combined with improved tube design  has brought the debate to the fore again.
This study aimed to discover the current pattern of cuffed tube use in children in specialist paediatric centres in the UK, as we believe that any widespread change in practice is likely to follow the lead of such specialist institutions. Our target populations within these centres were the paediatric anaesthetic and paediatric intensive care unit (PICU) clinical leads, acting as spokespeople for their respective departments.
After identifying the 30 specialist paediatric centres (those with level 3 PICUs) in the UK, the PICU and anaesthetic clinical lead physicians in each were sent a confidential questionnaire via e-mail with instructions to return the completed questionnaire as an attachment by return e-mail. A follow-up e-mail was sent to non-respondents after 2 weeks, and were reminded again 2 weeks later.
Questions centred on the frequency of routine use of cuffed tubes in specific paediatric age groups, as well as whether the respondents believed such use was appropriate or not. Reasons for the non-use of cuffed tubes by age group were identified, in addition to what specific indications were believed to warrant a cuffed tube and whether the intracuff pressure was routinely monitored. Finally, respondents were questioned on their personal experience of specific complications which could be attributed to tracheal tube use, and if they believed such morbidity was more commonly encountered with cuffs or not.
Where appropriate, statistical analysis was performed using Fisher's exact test using the statistical package InStat v.3.0a, (GraphPad Software Inc., San Diego, CA, USA). Significance was set at P < 0.05.
Replies were received from 20 of the 30 PICU questionnaires (67% response rate), and 15 of the 30 anaesthetic questionnaires (50% response rate).
In all, 60% of the PICU consultants (12/20) described themselves as frequent or routine users of cuffed tubes in children overall, compared with 27% (4/15) of the anaesthetic consultants (P = 0.0866) (Table 1).
The age-specific pattern of routine cuffed tube use was similar between the two groups, with only 5% of PICU respondents and 7% of anaesthetic respondents using a cuffed tube in infants (P = 1.000), and the same proportions doing so in children aged 1–8 yr (P = 1.000). Of note, 40% of the PICU clinical leads and 27% of their anaesthetic counterparts did not routinely use a cuffed tube in the 8–10 yr age group (Fig. 1). There was a significant difference between the PICU and anaesthetic respondents in their views of appropriateness of using a cuffed tube in children of 1–8 yr age, with 60% of the former and only 20% of the latter considering the practice appropriate (P = 0.0369).
The commonest reason for not routinely using a cuffed tube in children under 8 yr amongst PICU clinical leads was that there was no/minimal benefit over an uncuffed tube (32% of those not using cuffed tubes in infants and 26% in 1–8 yr), followed by the belief that the potential risks of using a cuffed tube outweighed any possible benefit. In the anaesthetic group, the commonest reason quoted was that a cuffed tube had no/minimal benefit over an uncuffed tube (36% of those not using cuffed tube in infants and 50% in 1–8 yr), with the lack of a suitably designed tube being the second most stated reason (Table 2).
Both groups of respondents reported that reduced lung compliance was the commonest indication for using a cuffed tube (60% PICU and 60% anaesthetic consultant leads). The control of end-tidal carbon dioxide was also an important factor (45% of PICU and 27% anaesthetic respondents); however, only 5% of the PICU consultants and 7% of anaesthetic consultants thought that a cuffed tube was a useful tool when confronted with a difficult airway/intubation scenario.
In all, 45% of PICU respondents did not routinely monitor the intracuff pressure. Those who did measure it used a pressure limit of 15–20 cmH2O most commonly (45%), and a monitoring interval of 4–6 h (range of 1–2 h to >12 h). None of the anaesthetic respondents routinely measured the cuff pressure irrespective of whether they were using nitrous oxide or not as part of their maintenance anaesthesia.
Complications attributed to the use of a cuffed tube had been observed amongst a greater proportion of the PICU group compared with the anaesthetic group (65% vs. 7%, respectively, P = 0.0006) (Fig. 2), however the majority in both groups thought that such complications were no more common than when using an uncuffed tube (60% vs. 53%, respectively, P = 0.7412).
Our target populations for this survey were the lead anaesthetists and intensivists within specialist paediatric centres (those with level 3 PICUs), chosen because we believed they would provide a good indication of current specialist practice nationally.
This survey provides a snapshot of current UK specialist centre paediatric tracheal intubation practice with regard to the use of cuffed tracheal tubes. In both the PICU and anaesthetic environments, the results suggest that a cuffed tube is seldom used in children under the age of 8 yr, with less than 10% of respondents using one routinely. This mirrors similar findings in other studies outside the UK . The majority of PICU consultants who did not routinely use a cuffed tube believed that they do not present any significant advantage over an uncuffed tube and could increase the risk of airway morbidity. Some respondents commented that many PICU patients are intubated by the referring hospital prior to transfer, and unless specifically indicated the tracheal tube is not changed; so their practice is influenced to a degree by external factors. The majority of anaesthetists not using cuffed tubes in younger children also believe they provide little advantage; however, for a significant number, the lack of a suitably designed tube is an important factor.
The benefits of a cuffed tracheal tube in adult practice are well established and include reduced pollution from anaesthetic volatile agents, ability to use lower fresh-gas flows, improved protection against aspiration, more effective control of ventilation and reduced reintubation rates . The reluctance to use cuffed tubes in young children reflects the influence of several case reports in the literature that describe complications arising from cuffed tubes . Studies have highlighted the shortcomings in the design of many cuffed tubes available until now , which may account for these cases of airway morbidity . Specifically designed cuffed tubes for children have been available for some time but their use has not been widely adopted.
It is not surprising that complications attributed to the use of a cuffed tube were reported by more intensivists (65%) than anaesthetists (7%). Their patient population is frequently more physiologically compromised, with unpredictable tracheal mucosal capillary perfusion pressures and extended periods of intubation and ventilation. However, it is interesting that the majority of respondents from both groups in our survey felt that the incidence of such complications was comparable with cuffed and uncuffed tubes. Whether this observation will remain true if cuffed tubes begin to be used more routinely in younger children remains to be seen.
Airway injury attributed to uncuffed tubes can result from repeated tube exchanges, tracheal mucosal trauma caused by the tube tip, and up-and-down movement of the tube within the larynx during ventilation. Recent studies of the anatomy of the paediatric larynx have revealed the cricoid area to be ellipsoid and not, as previously thought, circular in shape. An uncuffed tracheal tube tends to lie against the lateroposterior cricoid wall potentially impairing mucosal blood flow [10,11], even in the presence of a positive leak test. The stability provided by a cuff minimizes tube movement, may tend to lift the tube tip away from the tracheal wall and allows the tube to attain a more central position within the cricoid area, thereby potentially reducing the risk of airway trauma . The adjustable airway seal allowed by the cuff also reduces the incidence of tube exchange .
Finally, numerous studies have emphasized the necessity for monitoring intracuff pressures particularly in the paediatric population . The lower mucosal perfusion pressures in children compared with adults coupled with the risk of inadvertent cuff over-inflation has led to the suggestion that measurement of intracuff pressure should be considered mandatory. This may have been a contributory factor in accounts of airway trauma from cuffed tube use. In this setting, it is of some concern to find that 45% of our PICU and 100% of our anaesthetic responders do not routinely measure the intracuff pressure. Similar observations have been made in other countries , and the PICU result is consistent with findings from adult intensive care units .
In conclusion, this survey has demonstrated that the use of cuffed tracheal tubes for intubation in children, particularly those under the age of 8 yr, is still not widely practiced within specialist paediatric centres in the UK. It reveals that many clinicians have yet to be convinced that using a cuffed tube in children provides significant benefits. In addition, concerns persist over the possibility of an increased incidence in airway morbidity if cuffed tracheal tube usage becomes routine paediatric practice, despite the majority agreeing that, at present, this has not been shown.
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