• Paediatric anaesthesia · Sep 2018

    Work of breathing for cuffed and uncuffed pediatric endotracheal tubes in an in vitro lung model setting.

    Although cuffed paediatric endotracheal tubes increase work-of-breathing and inspiratory pressures, this is easily compensated for by pressure support ventilation with automatic tube compensation, and so has limited clinical significance.

    pearl
    • Jörg Thomas, Markus Weiss, Vincenzo Cannizzaro, Christian Peter Both, and Alexander Robert Schmidt.
    • Department of Anesthesia, University Children's Hospital of Zurich, Zurich, Switzerland.
    • Paediatr Anaesth. 2018 Sep 1; 28 (9): 780-787.

    BackgroundOver the last decade, cuffed endotracheal tubes are increasingly used in pediatric anesthesia and also in pediatric intensive care. However, the smaller inner diameter of cuffed endotracheal tubes and, implicitly, the increased endotracheal tube resistance is still a matter of debate.AimsThis in vitro study investigated work of breathing and inspiratory airway pressures in cuffed and uncuffed endotracheal tubes and the impact of pressure support ventilation and automatic tube compensation.MethodsIn 5 simulated neonatal and pediatric lung models, the Active Servo Lung 5000 and an intensive care ventilator were used to quantify the differences in work of breathing under spontaneous breathing (with and without pressure support ventilation and automatic tube compensation) between cuffed and uncuffed endotracheal tubes. Additionally, differences in inspiratory airway pressures, measured either proximal or distal of the endotracheal tube, between cuffed and uncuffed endotracheal tubes under mechanical ventilation were investigated.ResultsWork of breathing was overall 10.27% [95% confidence interval 9.01-11.94] higher with cuffed than with uncuffed endotracheal tubes and was dramatically reduced by 34.19% [95% confidence interval 31.61-35.25] with the application of pressure support. Automatic tube compensation almost diminished work of breathing differences between the 2 endotracheal tube types in nearly all pediatric lung models. Peak inspiratory and mean airway pressures measured at the proximal endotracheal tube end revealed significantly higher values in cuffed than in uncuffed endotracheal tubes. However, these differences measured at the distal end of the endotracheal tube became minimal.ConclusionThis in vitro study confirmed significant differences in work of breathing and inspiratory pressures between cuffed and uncuffed endotracheal tubes. Work of breathing, however, is almost neutralized by pressure support ventilation with automatic tube compensation and distal inspiratory airway pressures that, from a clinical perspective, are not significantly increased.© 2018 John Wiley & Sons Ltd.

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    This article appears in the collection: Use of cuffed endotracheal tubes in pediatric anesthesia.

    Notes

    pearl
    1

    Although cuffed paediatric endotracheal tubes increase work-of-breathing and inspiratory pressures, this is easily compensated for by pressure support ventilation with automatic tube compensation, and so has limited clinical significance.

    Daniel Jolley  Daniel Jolley
    comment
    1

    What is automatic tube compensation? Glad you asked!

    "Automatic tube compensation (ATC) is a new option to compensate for the non-linearly flow-dependent pressure drop across an endotracheal or tracheostomy tube (ETT) during inspiration and expiration. ATC is based on a closed-loop working principle. ATC is not a true ventilatory mode but rather a new option which can be combined with all conventional ventilatory modes."

    Guttmann 2002

    Daniel Jolley  Daniel Jolley
     
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