Comparison of Postoperative Respiratory Complications using Cuffed ETT vs Un-cuffed ETT in Pediatric Surgeries
Keywords:
Pediatric anesthesia, Cuffed endotracheal tube, Uncuffed endotracheal tube, Respiratory complications, Stridor, Oxygen desaturationAbstract
Background: Modern cuffed endotracheal tubes may improve airway sealing without increasing airway injury, but comparative evidence from pediatric surgical populations in Pakistan is limited. Objective: To compare postoperative respiratory complications between cuffed and uncuffed endotracheal tubes in children undergoing elective surgery. Methods: This prospective comparative observational study included 150 children aged 0–7 years undergoing elective surgery under general anesthesia at Mayo Hospital, Lahore, from January to April 2026. Participants were classified according to the endotracheal tube selected in routine care (75 cuffed and 75 uncuffed). Stridor, wheezing, dyspnea, oxygen desaturation and any respiratory complication were assessed during the first hour after extubation. Fisher’s exact test and risk ratios (RRs) with 95% confidence intervals (CIs) were used. Results: Any respiratory complication occurred in 24/75 (32.0%) children with cuffed tubes and 29/75 (38.7%) with uncuffed tubes (RR 0.83, 95% CI 0.54–1.28; p=0.495). Event rates were lower with cuffed tubes for stridor (6.7% vs 16.0%), wheezing (8.0% vs 20.0%), dyspnea (2.7% vs 9.3%) and desaturation (5.3% vs 14.7%). Only the unadjusted wheezing comparison excluded the null on the RR confidence interval (RR 0.40, 95% CI 0.16–0.98), while Fisher’s exact p=0.058. Conclusion: No statistically conclusive difference in the composite outcome was detected. The direction of the estimates favored cuffed tubes, but clinically important benefit or harm cannot be excluded
References
1. Habre W, Disma N, Virag K, Becke K, Hansen TG, Jöhr M, et al. Incidence of severe critical events in paediatric anaesthesia (APRICOT): a prospective multicentre observational study in 261 hospitals in Europe. Lancet Respir Med. 2017;5(5):412–25. doi:10.1016/S2213-2600(17)30116-9.
2. von Ungern-Sternberg BS, Boda K, Chambers NA, Rebmann C, Johnson C, Sly PD, et al. Risk assessment for respiratory complications in paediatric anaesthesia: a prospective cohort study. Lancet. 2010;376(9743):773–83. doi:10.1016/S0140-6736(10)61193-2.
3. von Ungern-Sternberg BS, Ramgolam A, Hall GL, Sly PD, Habre W. Peri-operative adverse respiratory events in children. Anaesthesia. 2015;70(4):440–4. doi:10.1111/anae.12946.
4. Drake-Brockman TFE, Ramgolam A, Zhang G, Hall GL, von Ungern-Sternberg BS. The effect of endotracheal tubes versus laryngeal mask airways on perioperative respiratory adverse events in infants: a randomised controlled trial. Lancet. 2017;389(10070):701–8. doi:10.1016/S0140-6736(16)31719-6.
5. Tobias JD. Pediatric airway anatomy may not be what we thought: implications for clinical practice and the use of cuffed endotracheal tubes. Paediatr Anaesth. 2015;25(1):9–19.
6. Klabusayová E, Klučka J, Kratochvíl M, Zazula R, Dostál P. Airway management in pediatric patients: cuff-solved problem? Children (Basel). 2022;9(10):1490. doi:10.3390/children9101490.
7. Bhardwaj N. Pediatric cuffed endotracheal tubes. J Anaesthesiol Clin Pharmacol. 2013;29(1):13–8. doi:10.4103/0970-9185.105786.
8. Park S, Shin SW, Kim HJ, Yoon JU, Byeon GJ, Kim EJ, et al. Choice of the correct size of endotracheal tube in pediatric patients. Anesth Pain Med. 2022;17(4):352–60.
9. Dullenkopf A, Schmitz A, Gerber AC, Weiss M. Tracheal sealing characteristics of pediatric cuffed tracheal tubes. Paediatr Anaesth. 2004;14(10):825–30.
10. Hockey CA, van Zundert AAJ, Paratz JD. Does objective measurement of tracheal tube cuff pressures minimise adverse effects and maintain accurate cuff pressures? A systematic review and meta-analysis. Anaesth Intensive Care. 2016;44(5):560–70.
11. Moon KM, Donaworth S, Hagele MS, Kim SS, Willer BL, Tobias JD. Endotracheal tube cuff pressures in the operating room of a pediatric hospital: a quality improvement initiative. Pediatr Qual Saf. 2022;7(6):e619.
12. Weiss M, Dullenkopf A, Fischer JE, Keller C, Gerber AC; European Paediatric Endotracheal Intubation Study Group. Prospective randomized controlled multi-centre trial of cuffed or uncuffed endotracheal tubes in small children. Br J Anaesth. 2009;103(6):867–73. doi:10.1093/bja/aep290.
13. Khine HH, Corddry DH, Kettrick RG, Martin TM, McCloskey JJ, Rose JB, et al. Comparison of cuffed and uncuffed endotracheal tubes in young children during general anesthesia. Anesthesiology. 1997;86(3):627–31.
14. Shi F, Xiao Y, Xiong W, Zhou Q, Huang X. Cuffed versus uncuffed endotracheal tubes in children: a meta-analysis. J Anesth. 2016;30(1):3–11.
15. De Orange FA, Andrade RG, Lemos A, Borges PS, Figueiroa JN, Kovatsis PG. Cuffed versus uncuffed endotracheal tubes for general anaesthesia in children aged eight years and under. Cochrane Database Syst Rev. 2017;11(11):CD011954. doi:10.1002/14651858.CD011954.pub2.
16. Chambers NA, Ramgolam A, Sommerfield D, Zhang G, Ledowski T, Thurm M, et al. Cuffed vs. uncuffed tracheal tubes in children: a randomised controlled trial comparing leak, tidal volume and complications. Anaesthesia. 2018;73(2):160–8.
17. Dariya V, Moresco L, Bruschettini M, Brion LP. Cuffed versus uncuffed endotracheal tubes for neonates. Cochrane Database Syst Rev. 2022;1(1):CD013736. doi:10.1002/14651858.CD013736.
18. Sripadungkul D, Tanasoontornsut N, Wittayapairoch P, Ruenhunsa T, Sangsungnern P, Kasemsiri C, et al. The evaluation of endotracheal tube cuff pressure in pediatric patients by subjective inflation techniques: a prospective observational study. BMC Anesthesiol. 2024;24:398. doi:10.1186/s12871-024-02780-7.
19. Tobias JD, Schwartz L, Rice J, Jatana K, Kang DR. Cuffed endotracheal tubes in infants and children: should we routinely measure the cuff pressure? Int J Pediatr Otorhinolaryngol. 2012;76(1):61–3.
20. Krishna SG, Hakim M, Sebastian R, Dellinger HL, Tumin D, Tobias JD. Cuffed endotracheal tubes in children: the effect of the size of the cuffed endotracheal tube on intracuff pressure. Paediatr Anaesth. 2017;27(5):494–500.
21. Wettstein RW, Gardner DD, Wiatrek S, Ramirez KE, Restrepo RD. Endotracheal cuff pressures in the PICU: incidence of underinflation and overinflation. Can J Respir Ther. 2020;56:1–4.
22. Ferenczy ED, Stoner MJ, Spencer SP, Gee SW, Scherzer DJ, Tobias JD. Elevated endotracheal tube cuff pressure in the pediatric emergency department. Int J Pediatr Otorhinolaryngol. 2018;113:289–91.
23. Güneş K, Sever F, Özmert S. Determining optimal cuff volume for cuffed endotracheal tubes commonly used in pediatric patients: a prospective observational study. Saudi Med J. 2024;45(2):147–53.
24. Calder A, Hegarty M, Erb TO, von Ungern-Sternberg BS. Predictors of postoperative sore throat in intubated children. Paediatr Anaesth. 2012;22(3):239–43.
25. Stepanovic B, Regli-von Ungern-Sternberg BS. Preoperative preparation of children with upper respiratory tract infection: a focussed narrative review. Br J Anaesth. 2024. doi:10.1016/j.bja.2024.07.035.
26. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP; STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007;370(9596):1453–7. doi:10.1016/S0140-6736(07)61602-X.
