Cuffed or uncuffed tubes?

Cite this article as:
Tessa Davis. Cuffed or uncuffed tubes?, Don't Forget the Bubbles, 2018. Available at:

The debate over uncuffed versus cuffed endotracheal tubes (ETTs) is a long-standing one. In a paper published in Pediatric Anesthesia this week, one paediatric critical care unit has published the results of their experience of introducing cuffed ETTs.

Greaney D, Russell J, Dawkins I, Healy M, A retrospective observational study of acquired subglottic stenosis using low-pressure, high-volume cuffed endotracheal tubes. Pediatric Anesthesia, 2018, DOI: 10.1111/pan.13519


What’s the background?

Many intensive care units use uncuffed ETTs in neonates due to concerns of cuff-related trauma and subglottic stenosis. The estimated incidence of ETT-related subglottic stenosis (SGS) ranges from 0.3-11%.

The benefits of a cuffed tube are thought to be: accurate ETCO2 monitoring, protection from aspiration, fewer tube changes due to air leaks, and continuous lung recruitment.

The concerns about cuffed tubes are that they cause increased trauma and that this trauma can lead to erosion, infection, cricoid perichondritis, and ultimately sub-glottic stenosis.

The author introduced the use of Microcuff ETTs into their unit hypothesizing that it may lead to less ulceration, chondritis, and fibrosis in the subglottic space. Microcuffs are a specific type of ETT (low-pressure, high-volume), but the smallest type is 3.0mm internal diameter which is not recommended for neonates less than 3kg.


Who were the patients?

This was a retrospective analysis of all patients admitted to the Paediatric Critical Care Unit in Australia over a five year period.

Patients were included if they also had a microlaryngobronchoscopy (MLB) procedure.

Patients were excluded if they were >18 years old; had congenital SGS; had previous airway surgery, or had a previous SGS diagnosis.


What were the outcomes?

MLB reports were reviewed to look for findings consistent with clinically significant acquired endotracheal tube-related pathology (within six months of intubation).

Demographics were analyzed including age, sex, prematurity, comorbidities, duration of ventilation, number of intubations, duration of admission.


What did they find?

There were 5309 PCCU admissions over the five year period, and 61% required intubation.

297 patients had an MLB.

23 children (0.68% of all intubations) had a clinically significant ETT-related pathology: 8 had acquiredsub-glottic stenosis; the other 15 had other ETT-related pathology (granulomas, ulcers, or cysts).

5 of the 8 children with sub-glottic stenosis required tracheostomies.

All those who required surgical correction of the SGS were ex-prem neonates who had received invasive ventilation in a NICU with an uncuffed tube prior to admission to PCCU.


What conclusions did they draw?

They demonstrated a low incidence (but high morbidity) of acquired SGS.

There were a few issues around the conclusions drawn:

  • The authors state ‘there was no single case of de novo clinically significant acquired SGS with the use of cuffed ETTs‘. I’m not sure that this is a fair conclusion, as there were 8 cases of acquired SGS. Yes, these cases all had an uncuffed tube initially in NICU, but they also had a cuffed tube in PCCU.
  • It would be good to be able to compare the rates of SGS before the introduction of Microcuff ETTs with these rates after its introduction – this would help to see whether rates have increased. It would also be helpful to look at the neonatal group in particular as this study reports the overall percentage of SGS in all patients, and then draws conclusions about its safety in neonates.


However, in spite of concerns around the use of cuffed tubes that exist, no study has previously shown that cuffed ETTs lead to a higher incidence of SGS than uncuffed ETTs. This is an interesting paper to open the discussion around the use of cuffed ETTs in neonates.

If you want to learn more about tiny tubes then catch this talk from Shabs Rajapaksa from DFTB18.


Expert Opinion – Eric Levi, Consultant Paediatric Otolaryngologist

I would love to see other data to enhance this paper: comparison with rates of SGS prior to cuffed tubes and comparison of rates of SGS in other patients who did have an uncuffed tube but did not develop SGS. Surely in the 3000 or so intubations, there would have been others who were also tubed with uncuffed tube and yet not develop any tube related pathology.

Although this is not a perfect paper, I do think the authors are onto something, and that they are adding to the body of knowledge suggesting that in their cohort, cuffed tubes are not associated with SGS.

Crash course in tracheostomies

Cite this article as:
Tessa Davis. Crash course in tracheostomies, Don't Forget the Bubbles, 2017. Available at:

It’s 2am and the crash bleep goes off. You arrive at the bedside of 5-year-old Jerry who has suddenly dropped his sats to 80%. He looks like he has a tracheostomy tube in his neck. Can you keep your cool and handle it like a pro?

Thanks to the team at for their support in writing this post. Much of the content is a summary of all the wonderful learning resources on their website and also from their library of  videos. This post has been updated in Oct 2020 since it was originally written in 2017. Thanks also to Miran Pankhania (ENT Surgeon in Rotherham, UK) and Eric Levi (ENT Surgeon in Melbourne, Australia) for input. 

This update recognises the key differences between paediatric and adult tracheostomy emergency management.

-Paediatric bed signs showing the reasons for the tracheostomy and the type
-Tracheostomies in children are almost all surgical and have stay sutures and maturation sutures which help with emergency management
-In emergency management, have three attempts to change the tube before moving onto oral intubation
-On the third tube reinsertion attempt, use a suction catheter as a guide to insertion.

Do you know the difference between a tracheotomy, a tracheostomy, and a laryngectomy?

Tracheotomy – an incision in the trachea

Tracheostomy – a stoma in the trachea (i.e. an opening which has been created)

Laryngectomy – surgical removal of the larynx – tracheal remnants are stitched to the anterior tracheal wall and there is no connection from the mouth and nose to the rest of the airway. This is almost exclusively an adult procedure though.

Tracheotomy or tracheostomy patients potentially have two airways but a laryngectomy patient only has one.

Which does Jerry have?

It’s very hard to tell by looking at the patient which they have, and hospital inpatients will have a sheet above their bed making it clear which type they have, what pathology they have, and why they have the tracheostomy.

The key things you need to know are:

  • is there a connection between their mouth/nose and their lungs? (i.e. 1 or 2 airways)
  • are they known to have a difficult airway?
  • how old is the tracheostomy and what was the procedure to make it?

A surgical tracheostomy is made by making an incision in the neck and stitching it open – this type of approach will create an established tract. A percutaneous tracheostomy just stretches the skin back to make the stoma and so it more likely to close in 7-10 days if not kept patent.

Why do kids need tracheostomies?

  • Bilateral vocal cord palsy with decompensation
  • Subglottic or laryngeal stenosis​/atresia
  • Tracheoesophageal cleft/fistula
  • Respiratory toilet and airway protection
  • Long term ventilation
  • Covering for airway surgery – laryngotracheal reconstruction or as part of EXIT procedure
  • Covering for an extra-luminal mass

Do you know your anatomy? has fabulous eLearning resources that goes through the anatomy in more detail. But for now, we can recognise our major landmarks…

How is a tracheostomy created?

The trachea is entered by making a cut in the anterior tracheal wall at the level of the 2nd or 3rd tracheal cartilage.

Tracheostomies in children are usually open surgical procedures to minimise the risk of hypoxia from accidental decannulation. Whereas tracheostomies in adults are usually percutaneous procedures.

The child’s neck is fatty by comparison to an adult neck, so the subcutaneous fat is often removed to make the trachea as close to the skin as possible in the event of accidental decannulation.
Stay sutures are put in the tracheal wall (akin to parachute cords) to bring the tracheotomy to the skin and open it in case of decannulation.
Maturation sutures are from the tracheotomy to the skin to align all the holes made and minimise risk from decannulation and facilitate re-intubation of the stoma.


What could have gone wrong with Jerry’s tracheostomy?

Complications of tracheostomies are split into peri-operative, early postoperative, and late post-operative

Peri-operative: haemorrhage; misplaced tube; pneumothorax; tube occlusion; surgical emphysema

Early post-operative (<7 days): tube blockage; tube displacement; site infection; lung infection; tracheal ulceration; fistula; haemorrhage

Late post-operative (>7 days): granuloma; tracheal collapse; blocked tube; haemorrhage; tracheal stenosis

What are the different types of tubes?

Shiley do Neo and Ped trachy tubes are the main types. These are single lumen plus or minus a cuff (depending on the indication for insertion).

Paediatric tracheostomy tubes are usually uncuffed with no inner tube. This is because the trachea has a small diameter, and an inner tube would reduce that even further. Cuffed tubes can be used in cases where high pressures are needed or these is a risk of aspiration.

If a patient has an uncuffed tube, that patient has no airway protection from aspiration, but air can flow through the mouth and nose and down past the tube.

If a patient has a cuffed tube, that patient’s airway is protected from aspiration, but the tracheostomy is the only route for airflow (which is a problem if the tube becomes blocked). If you deflate the cuff, air can flow from the mouth and nose down the trachea.


Tracheostomy tubes come with lots of different additions. Most of these are  Heat-Moisture Exchanges e.g. the Swedish nose. These help maintain humidity (like a real nose). During normal breathing, air is warmed, filtered and moistened by ciliated epithelial cells in the nose and upper airways. However, this does happen with a tracheostomy tube and so air inspired will be cold and dry. The HMEs conserve heat and moisture on expiration.

Now we have a good understanding of the anatomy and types of tracheostomies, how are we going to help Jerry?

Follow a step-by-step approach to managing tracheostomy emergencies.

1. Call for help (anaesthetics or ENT).

Establish how many airways we have to work with. Has Jerry had a laryngectomy (one airway) or a tracheostomy (two airways)? Look for a sign around his bed.


2. Look, listen, and feel at the mouth and the stoma.

Is the patient breathing? If not then consider airway positioning (depending on the age of the child).

In real life, many time where there are desaturations and difficulty ventilating, it is due to either clots or mucous plugging, or due to positioning (i.e. tracheostomy tube is too short and ends up hitting back wall of trachea, or too long and ends up in one bronchi). Extending the neck/shoulder roll and suctioning the tube vigorously may help resolve lots of common obstruction.

Jerry is breathing, but if he wasn’t we would check a pulse and follow the APLS algorithm. He has a tracheostomy with an uncuffed tube.

3. Apply high flow oxygen

Apply to the mouth and nose (if the patient has two airways, which we now know Jerry does) and to the tracheostomy.  This will require two oxygen sources.


Then think about some common tracheostomy problems:

  • Remove any attachments e.g. speaking valve or caps
  • Remove the inner cannula if there is one (although not common in younger children)

  • Assess patency by putting a suction catheter down (this is better than just bagging first because if the tube is dislodged you will cause surgical emphysema by bagging). If you can pass the catheter then you should suction and ventilate if they are not breathing.

You try to pass a suction catheter down Jerry’s tube, but you cannot pass it.

If you can’t pass the catheter then the problem is that the tracheostomy is blocked and it’s time to problem solve.

4. Do an emergency tracheostomy tube change

Jerry needs and emergency tube change. This is a key difference in children as Jerry will have maturation sutures – so this should be attempted before upper airway management. You need to cut and remove any tapes and aim for immediate reinsertion. If there are stay sutures then lift them up and out by hand.

Try to put one of the same size in again. No bougie, wire or catheter is recommended. An obturator can help guide insertion and protect the stoma. If it goes back in then check it is patent and assess again by look, listening, and feeling at the tracheostomy and mouth/nose (and reapply oxygen). Some gentle ventilation can be attempted if there are no spontaneous respiration efforts. Don’t attempt to ventilate if the suction catheter won’t pass – you do not want to cause subcutaneous emphysema if the tube is in a false passage.

5. Try a second emergency tracheostomy tube change

Try again with a tube a half-size smaller. Consider changing the position of the child to bring the trachea anteriorly.

Try oral airway manoeuvres by covering the stoma with gauze or your hand and: bag-valve-mask; oral or nasal airway adjuncts; or an LMA.

6. Try a third emergency tracheostomy tube change with a suction catheter

If this second attempt doesn’t work, then try a third attempt. This time use a soft suction catheter as a guide for your tube to go over (like the Seldinger technique). Also use a half size smaller than the original tube (same size as the second attempt).

You have removed the tracheostomy tube but Jerry is still not breathing (he has a pulse). You cannot replace the tube on your first three attempts.

7. Go for emergency oxygenation

Try oxygenation with the mouth (via bag-valve mask) or with a supraglottic airway. If this isn’t working then try via the stoma with a bag-valve mask over the stoma, or an LMA over the stoma.

If you aren’t able to ventilate Jerry with these basic maneouvres. It’s time for something more invasive.

8. Attempt oral intubation

Attempt oral intubation, but prepare for a difficult intubation and make sure your ETT passes the stoma.

9. Attempt intubation of the stoma

Attempt intubation of the stoma itself using a tracheal tube a half-size smaller than the previous tube. There is a risk of blindly intubating a stoma as you may create a false tract. If you have someone (or are someone) with more experience, you can put your finger into the trachea and guide the bougie, or use a fibre-optic technique.

10. This is a CICO situation

At this point you need to declare a CICO. Attempts should be made by more experienced staff, or emergency front of neck access will be required. Remember though that a tracheostomy is the quintessential FONA. If the tracheostomy tube fails, either a significant false passage, complete obstruction, or distal pathology at the level of the carina & bronchi has occurred. Definitive means to salvage this situation is tricky and may involve the urgent use of a flexible or rigid tracheobronchoscopic assessment to visualise the distal pathology.

Thankfully using a face mask over the stoma works and Jerry picks up just as the Anaesthetic Consultant arrives.

If you want a nice summary with Sheila rather than Jerry – then watch this fabulous video of the emergency tracheostomy algorithm.

Selected references:

The Association of Anaesthetists of Great Britain & Ireland grants readers the right to reproduce the algorithms included in this article (Figs 1 and 2) for non-commercial purposes (including in scholarly journals, books and non-commercial websites), without the need to request permission. Each reproduction of any algorithm must be accompanied by the following text: Reproduced from McGrath BA, Bates L, Atkinson D, Moore JA. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. Anaesthesia. 2012 Jun 26. doi: 10.1111/j.1365-2044.2012.07217, with permission from the Association of Anaesthetists of Great Britain & Ireland/Blackwell Publishing Ltd.

Check out for more resources on this topic and read the paediatric tracheostomy emergencies guideline here:

Ears looking at you, kid

Cite this article as:
Andrew Tagg. Ears looking at you, kid, Don't Forget the Bubbles, 2016. Available at:

Earache is a leading cause of grumpiness in children.  A recent paper in the New England Journal of Medicine has suggested that a 10 day course of antibiotics is more effective than a 5 day course in treating acute otitis media and, as such, should be considered in infants under 2 years with otitis media. But is this right?

Can’t intubate, Can’t Oxygenate

Cite this article as:
Andrew Tagg. Can’t intubate, Can’t Oxygenate, Don't Forget the Bubbles, 2016. Available at:

Paediatric critical procedures are rare in the emergency department. Data from one Victorian network showed that 83% of emergency physicians had not performed one in a twelve month period. We also know from audit data that we seem to have a lower first pass success rate (around 78%) when it comes to paediatric intubation. We can put in a lot of strategies to increase the chance of first pass success but what happens if you get into a ‘Can’t Intubate, Can’t Oxygenate” (CICO) scenario?

ENT Part 3: a frog in your throat?

Cite this article as:
Tessa Davis. ENT Part 3: a frog in your throat?, Don't Forget the Bubbles, 2016. Available at:

Here is the third part in our three part ENT series looking at recognition and management of common paediatric ENT conditions. This series is based on a presentation by Rahul Santram, adapted by Tessa Davis, and checked by our resident ENT surgeon, Sinéad Davis.

Part 1 was on – the ear. Part 2 was on – the nose. Today, we look at the throat.

ENT Part 2: who nose?

Cite this article as:
Tessa Davis. ENT Part 2: who nose?, Don't Forget the Bubbles, 2016. Available at:

Here is the second part in our three part ENT series looking at recognition and management of common paediatric ENT conditions.This series is based on a presentation by Rahul Santram, adapted by Tessa Davis, and checked by our resident ENT surgeon, Sinéad Davis.

Part 1 was on – the ear. Today, we look at the nose. Part 3 is on – the throat.

ENT Part 1: a word in your ear

Cite this article as:
Tessa Davis. ENT Part 1: a word in your ear, Don't Forget the Bubbles, 2016. Available at:

Here is the first part in our three part ENT series looking at recognition and management of common paediatric ENT conditions.This series is based on a presentation by Rahul Santram , adapted by Tessa Davis, and checked by our resident ENT surgeon, Sinéad Davis.

Today, we start with the ear. Part 2 is on – the nose. Part 3 is on – the throat.

Otitis externa

This can be acute or chronic and is otherwise known as swimmer’s ear. It occurs commonly in hot humid climates or in the summer of temperate areas.

Risk factors for developing otitis externa include – water exposure, local trauma, lack of cerumen (acidic protection), obstruction of the canal, and allergy.


There is often a history of aural fullness. Patients can have pain, which can be severe and worse on mastication. Otorrhoea may be present. 10% of cases are fungal and here there is a more insidious onset, with mild wall inflammation and thick otorrhoea.

Exam findings

On examination, you can see oedema and erythema of canal. There may be serous or purulent discharge. The tragus is often tender to manipulation (helps differentiate from otitis media). Sometimes there is occlusion of canal and periauricular oedema with increasing severity. There can be lymphadenopathy. Furunculosis (localised otitis externa) can occur anywhere in the outer third of the ear canal where the hair-bearing skin is located.


Most commonly pseudomonas and staph aureus. Staph is usually causative in furunculosis.

In otomycosis, the culprits usually are aspergillus and candida.

Consider aerobic, anaerobic and fungal cultures in cases resistant to conventional treatment, or if disease is extensive.


  • Aural toilet
  • Avoid water
  • Ciproxin HC drops
  • Ear wick (to allow for drop delivery if the canal is too narrow to allow the drops to flow into the canal naturally)

Furunculosis requires treatment with local heat application plus flucloxacillin or cephalexin. It may need incision and drainage.

Otomycosis requires ear toilet plus anti-fungal drops. It needs treatment for considerably longer than bacterial infections – often up to 6 weeks.


These include:

  • Mastoiditis
  • Meningitis
  • Lymphadenitis
  • Parotid/TMJ/BOS may get infected

Chronic OE may indicate dermatitis as an underlying disorder

Acute otitis media

This is an acute infection of the middle ear space, which is usually preceded by an URTI.

Diagnosis is not straight forward and it is frequently overdiagnosed in the paediatric population.

It is caused by both viruses and bacteria.

Antibiotic use is debated and indiscriminate use has led to resistant strains of bacteria.

It most commonly occurs from 6 months to 3 years of age.

Risk factors include: attending daycare; bottle-fed; cigarette smoking family; families with a history of otitis media.


Infants and young children present with less specific signs and symptoms including ear pulling, irritability, fever, vomiting and diarrhoea, and loss of appetite.

In older kids you can ascertain if there is loss of hearing.

Examination findings

On otoscopy you find a red and bulging tympanic membrane, pus in the middles ear, and loss of light reflex.

A bulging TM is the most specific finding, as the build up of pus in the middle ear space is the main condition that causes a bulging TM. Decreased mobility of the tympanic membrane on pneumatic otoscopy (due to fluid in the middle ear) is also evident, but will be seen in the presence of glue ear also. Unless you are skilled at performing pneumatic otoscopy, a child in pain is not likely to tolerate this procedure and it is unlikely to help in your diagnosis.



Viruses are the most common cause.

Bacteria causing otitis media include: strep pneumoniae, moraxella, haemophilus, mycoplasma (bullous myringitis), Group A strep


Amoxycillin is the first line treatment in a bacterial infection. Many will be viral aetiology and will not require antibiotics. There should be no treatment in the absence of pus. Even in bacterial infections, without complications, antibiotics are not required unless the infection fails to improve over 48-72 hours.

A macrolide can be used if the patient has a penicillin allergy. Follow-up should be by the GP in 48 hours


These include:

  • Hearing loss
  • Recurrent otitis media – if otitis media occurs in the first year of life, there is increased risk of recurrence
  • Perforation of the tympanic membrane and otorrhoea
  • Labrynthitis
  • Mastoiditis
  • Facial palsy – if the facial nerve is exposed in the middle ear, as is found in 5 – 10% of patients
  • Meningitis
  • Cerebral abscess
  • Venous sinus thrombosis

Middle ear effusion occurs in many cases of otitis media, with spontaneous gradual resolution within three months in 90% of cases.

Persistent effusion (over 3 months) requires a tympanogram (to look for flattening) and an ENT review.

Chronically discharging ear

This occurs in the presence of a perforation of the tympanic membrane, which has usually arisen when a perforation due to AOM fails to heal. Ongoing discharge, which fails to settle spontaneously within 72 hours and is not treated with antibiotics, might be one reason why this condition develops. In Australia, Aboriginal and Pacific Island kids are at greater risk.

It also can occur as a complication of a tympanostomy tube (2% short-term and up to 15% long-term grommets leave a permanent perforation after the grommet extrudes).

Examination findings

The discharge will be mucoid in consistency, as it arises from the middle ear mucosa.

A secondary OE might also be evident.


Swabs grow pseuodomonas and staph aureus.


Treatment is ear toilet and ciproxin HC drops for the ear canal infection, and also systemic antibiotics for the middle ear mucosal infection.

Differential diagnosis should include cholesteatoma. This is particularly the case in developing nations.


Cholesteatoma is defined as an abnormal collection of skin within the middle ear cleft (middle ear space, antrum and mastoid).


Symptoms include a foul-smelling scanty discharge and a reduction in hearing. It is most often painless.

Examination findings

There is usually a small amount of whitish discharge or skin-like tissue overlying the tympanic membrane; especially superiorly and posteriorly.



Refer to ENT OPD, unless a complication is suspected; in which case the patient should be seen acutely.


  • Complications include:
  • Loss of hearing – maybe complete
  • Vertigo/nystagmus
  • Facial palsy
  • Meningitis
  • Temporal lobe abscess
  • Sigmoid sinus thrombosis


This is a serious complication of otitis media.

It is infection of the mastoid air cells. Spread is from the middle ear via the aditus ad antrum.

The rate is 1.2-1.4 per 100,000. Age at presentation is upwards of 2 months (median of 1 to 4 years of age).


  • Ear or retroauricular pain
  • Fever (often)
  • Irritability
  • Otorrhoea in 16-36%

Examination findings

Patients have protrusion of the ear. There is post-auricular redness, warmth, oedema and tenderness. Otoscopy shows ear canal narrowing. The tympanic membrane looks just like it looks in acute otitis media.


A CT scan can be carried out, looking for a sub-periosteal collection, if there are signs of a complication. Usually patients are treated with IV antibiotics and only scanned if they fail to improve.


Usually causes by strep pneumoniae, strep pyogenes, or pseudomonas.


Treatment is with IV antibiotics (third generation cephalosporin plus a quinolone).

Patients may require grommets if the mastoiditis fails to settle with antibiotics. This isn’t something that is rushed into. This is because a grommet inserted in the presence of infection is likely to extrude more quickly than when there is no infection. So one might put grommets in at a later date, unless a cortical mastoidectomy is required, in which case a grommet will be inserted at the time of that op.

Cortical mastoidectomy can sometimes be necessary.


These include:

  • Subperiosteal abscess
  • Facial nerve palsy
  • Sigmoid sinus thrombosis
  • Epidural abscess
  • Meningitis


This is uncommon in the paediatric population. If the patient is less than 12 months, consider non-accidental injury (look for other signs).

Trauma is usually unilateral and is more common in males.

It can present as lacerations, bruising, abrasions, and haematomas.

If there is blood in the canal, the tympanic membrane may be damaged.


Minor lacerations can be steristripped, glued, or sutured.

Complex lacerations should be referred to ENT.

Haematomas can cause cartilage necrosis and require incision and drainage.

Foreign bodies

These are common in paediatrics. There are visualise via otoscopy. Removal from the lateral third of canal is easier than the medial two thirds, as the medial part is osseous, narrow, vascular and more sensitive – it often needs ENT.

Removal requirements

  • Good restraint
  • Good light source
  • Possibly sedation
  • Irrigation is simplest. but contraindicated if the tympanic membrane is ruptured.
  • Suction
  • Forceps – alligator, Hartmanns
  • Right angle hook

Remember that button batteries cause necrosis – remove them ASAP.

Insects can be killed with 2% lignocaine.


These include:

  • Trauma to canal
  • Tympanic membrane rupture
  • Otitis externa

Post-removal care is to use ciproxin HC drops and avoid water.