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Anesthesia, Weiss et al. evaluate the new Microcuff® pediatric endotracheal tube.1 These authors demonstrate convincingly that use of this tube may "allow safe placement of the tracheal tube with a cuff-free laryngeal zone, without the risk for endobronchial intubation."1 This represents an advance in pediatric tracheal tube design, and leads us to re-examine the role of cuffed tracheal tubes in children. In the past, cuffed tubes were not recommended for use in young children, but recent clinical studies have shown that they may be safely used for anesthesia and critical care, even in the neonatal period.2,3 Concern about the inappropriate design of tubes,4 however, is driving the need to develop improved cuffed tubes for pediatric use. Endotracheal intubation for adult anesthesia was developed in the 1920s, however techniques and equipment for children were not readily available at that time. Intubation in children therefore was rarely attempted until the 1940s, and even then, the tubes available were potentially damaging to the airway. If a child required long-term airway control, this was usually achieved by tracheostomy, which carried its own hazards.5 In the 1960s, prolonged nasotracheal intubation with uncuffed tubes became accepted in pediatric intensive care units6 and subsequent experience has shown that this practice is very unlikely to lead to subglottic stenosis.7 Uncuffed endotracheal tubes therefore have a good record of safety in pediatric patients. With the recent reports of the safe use of cuffed tubes in both pediatric anesthesia2 and critical care3 environments, it is timely to consider the relative merits of cuffed and uncuffed tubes in children. Uncuffed endotracheal tubes are popular in pediatric anesthesia and critical care because of the flow dynamics of gas through these airways and the perceived low incidence of airway complications following their use. When cuffed endotracheal tubes are used in children, however, the practitioner must select a tube with a smaller internal diameter than with an uncuffed tube. This may not be that important when an eight-year-old is being intubated, but for an infant or smaller child, the increase in airway resistance with a smaller tube may be clinically significant. For example, the trachea of a one-year-old may only be able to accept a 3.5 or even a 3.0 mm internal diameter (ID) tube when a cuff is present. For a one-year-old to breathe through a 3.0 tube as opposed to a 4.0 tube represents something in the order of a threefold increase in airway resistance (Poisseuille’s law). This increase in airway resistance translates to an increased work of breathing. In most clinical situations, compensation for the increase in airway resistance can be achieved by using positive pressure ventilation and adjusting ventilator settings appropriately. However, there may be other complications from tubes with small ID, notably their tendency to occlude partially or completely with secretions. Clinical experience in the early days of prolonged intubation in neonatal intensive care units, and the associated occurrence of iatrogenic subglottic stenosis, lead to very reasonable concerns about potential damage to the airway. It was speculated that a tracheal cuff might cause undue pressure on the subglottic area and induce damage. It is difficult, however, to demonstrate a significant difference in airway complications between children intubated with either cuffed or uncuffed tubes. Several studies have compared outcomes with cuffed and uncuffed endotracheal tubes in the pediatric critical care area. Most recently, Newth et al. reported on 860 critically ill children who underwent endotracheal intubation at the Children’s Hospital EDITORIAL 669

Should cuffed endotracheal tubes be used routinely in children?