Anesthesiology features a review of an old but vigorous debate in pediatrics, whether cuffed or uncuffed endotracheal tubes are best. A brief two page review by Drs. Ronald S. Litman and Lynne G. Maxwell nicely highlights the prescient issues on both sides and concludes that cuffed ETTs best serve most patients in this population.

As discussed in the article, the argument for uncuffed ETT use revolves around two primary points. First, the pediatric glottic/subglottic anatomy is different than that of an adult. The pediatric subglottis is often described as cone shaped, transforming to adult cylindrical anatomy at about the age of 8 years. This difference has drawn many practitioners to use of uncuffed ETTs because they believe the narrow cone neck of the pediatric trachea forms a natural cuff. As the authors point out, there is actually very little evidence that this anatomic difference exists and even if it did would matter very little. Should a narrowing exist, the chance of a given size ETT fitting that narrowing for any particular patient would be very small. Not every child wears the same size sock, why would they wear the same size ETT? Secondly, the uncuffed ETT has a larger internal diameter as compared to a cuffed ETT when outer diameter is controlled for. Put another way, a 3.0 cuffed ETT has roughly the same outer diameter of a 3.5 uncuffed ETT. Under spontaneous ventilation, this difference matters as the work of breathing through a larger tube is less than that of a smaller tube. However, very few children are intubated and then asked to breathe spontaneously for any significant amount of time and nobody cares how hard the ventilator works, poor poor ventilator.

The argument for use of cuffed ETT follows. The incidence of postextubation stridor is low and comparable to that of uncuffed ETTs. Use of cuffed ETTs allows for more accurate capnography as well as spirometry, less waste of inhaled anesthetic and less concomitant OR pollution, decreased risk of OR fire, less repeat laryngoscopy with ETT changes, increased ability to adjust ventilatory strategy based on compliance change, and less incidence of microaspiration.

This article has a valuable discussion of postextubation subglottic stenosis in neonates that may be it's most interesting section. The authors highlight that the subglottic mucosa of the neonate has one critical feature: a lack of submucosal connective tissue layer. This feature creates a unique physiologic environment in that the neonate's subglottic region is both very small and very prone to edema/scarring following intubation. Given this uniqueness, the use of cuffed ETTs in this population remains an area of discussion.