31-Impact of Cuffed Endotracheal Tube Size on Post-Extubation Upper Airway Obstruction in Infants
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Pediatrics, Pulmonary, 2021
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The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Deirdre Lewis


Introduction/Hypothesis: Infants comprise a relatively large proportion of PICU admissions. There are no standardized guidelines for selection of cuffed endotracheal tube (ETT) size in this age group, though the modified Cole formula is frequently used. Upper airway obstruction (UAO) after extubation is a common problem. The purpose of this study was to assess the relationship of ETT size to post-extubation UAO in infants in the PICU.

Methods: This was a single-center retrospective chart review of patients <1 year corrected gestational age (CGA) admitted to the PICU at a pediatric tertiary care center between 2013-2020. Patients were included if their first intubation during a hospital admission was with a cuffed ETT. The outcome of interest was UAO, defined as the need for racemic epinephrine (RE) within 12 hours post-extubation. Only the first intubation per admission was considered. Univariate and multivariate analyses were performed.

Results: 356 charts met inclusion criteria. 22 (6.2%) patients received a 3.0 cuffed ETT, 275 (77.2%) received a 3.5 cuffed ETT, and 77 (21.6%) received a 4.0 cuffed ETT. Patients with CGA 181-365 days were more likely to be intubated with a 4.0 than 3.5 ETT compared to patients with CGA 0-180 days (51.0% vs. 11.4%, p<0.001). 88 (24.7%) patients in the whole cohort required RE post-extubation. Patients intubated with a 4.0 cuffed ETT compared to 3.5 cuffed ETT were more likely to require RE, with an OR of 2.27 [1.31-3.94] (p=0.035) for the whole cohort, an OR of 2.19 [0.95-5.02] (p=0.065) for CGA ≤180 days, and an OR of 6.19 [1.91-20.04] (p=0.002) for CGA 180-365 days. There was no difference in RE use in 3.0 vs. 3.5 cuffed ETT in either whole group (OR=0.90 p=0.85) or subgroup analysis. A multivariate logistic regression model was constructed using variables with p<0.20 in the univariate analysis; cuffed ETT size remained significant after controlling for intubation indication and pre-extubation steroid use.

Conclusions: Older infants were more likely to have 4.0 than 3.5 cuffed ETTs placed, but subgroup and whole cohort analysis showed that 4.0 cuffed ETTs were consistently associated with higher rates of RE use post-extubation. As infants comprise a large proportion of PICU admissions, these results are important for assisting pediatric intensivists in cuffed ETT size selection.


Meta Tag
Content Type Presentation
Knowledge Area Pediatrics
Knowledge Area Pulmonary
Knowledge Level Intermediate
Knowledge Level Advanced
Membership Level Select
Tag Extubation
Tag Airway Management
Year 2021
cuffed endotracheal tube size
post-extubation stridor
retrospective chart review study
pediatric ICUs


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