What type of endotracheal (ET) tube should be used for pediatric intubation?

Endotracheal Tube Selection for Pediatric Intubation

Both cuffed and uncuffed endotracheal tubes are acceptable for pediatric intubation, but cuffed tubes are generally preferred due to lower reintubation rates and no increased risk of complications when properly used. 1

General Recommendations

• The American Heart Association guidelines (Class IIa, LOE C) support the use of both cuffed and uncuffed endotracheal tubes in pediatric patients 1
• Cuffed endotracheal tubes are associated with higher likelihood of correct tube size selection on first attempt, achieving lower reintubation rates with no increased risk of perioperative complications 1, 2
• In intensive care settings, the risk of complications in infants and children is no greater with cuffed tubes than with uncuffed tubes 1
• When using cuffed tubes, cuff inflation pressure must be monitored and limited according to manufacturer's instructions (usually less than 20-25 cm H2O) to prevent tracheal mucosal damage 1

Clinical Scenarios Favoring Cuffed Tubes

Cuffed endotracheal tubes are particularly beneficial (Class IIa, LOE B) in:

• Poor lung compliance 1
• High airway resistance 1
• Large glottic air leak 1
• Risk of aspiration 1
• Situations requiring low fresh gas flow 3
• Reducing operating room contamination with anesthetic gases 3

Tube Size Selection Guidelines

For Uncuffed Tubes:

• Infants up to 1 year: 3.5 mm ID 1, 4
• Children 1-2 years: 4.0 mm ID 1
• Children >2 years: 4 + (age/4) mm ID 1, 5

For Cuffed Tubes:

• Infants <1 year: 3.0 mm ID 1, 4
• Children 1-2 years: 3.5 mm ID 1
• Children >2 years: 3.5 + (age/4) mm ID 1, 3

Practical Considerations

• Always have tubes 0.5 mm smaller and 0.5 mm larger than the estimated size available during intubation 1, 4
• Length-based resuscitation tapes provide more accurate tube size estimates than age-based formulas for children up to 35 kg 1, 4
• If resistance is met during intubation, use a tube 0.5 mm smaller 1
• If a large glottic air leak interferes with oxygenation or ventilation after intubation with an uncuffed tube, consider replacing with a tube 0.5 mm larger or switching to a cuffed tube of the same size 1, 4
• For infants under 1 year, depth of insertion (cm at lip) = weight in kg + 6 cm 4
• Alternatively, depth can be estimated as 3 times the internal diameter of the tube 4

Verification of Tube Placement

Proper verification of tube placement is essential regardless of tube type, using multiple methods (Class I, LOE B):

• Bilateral chest movement 1, 4
• Equal breath sounds over both lung fields, especially over the axillae 4
• Absence of gastric insufflation sounds 1, 4
• Exhaled CO2 monitoring 1, 4
• In hospital settings, chest x-ray to verify proper position in the midtrachea 4

Common Pitfalls and Considerations

• Remember the "DOPE" mnemonic if a patient's condition deteriorates after intubation: Displacement, Obstruction, Pneumothorax, Equipment failure 4
• Maintain the patient's head in neutral position after securing the tube; neck flexion may push the tube further into the airway, while extension may pull it out 4
• Replacement of a functional endotracheal tube carries risks and should be performed in an appropriate setting by experienced personnel 1, 4
• Age-based formulas may not always be accurate for all populations, with studies showing they apply to only about 53.5% of Japanese children 5
• For infants under 1 year, a straight blade (typically Miller size 1) is generally preferred as it provides better visualization by lifting the epiglottis directly 4