Pediatric Endotracheal Tube Cuff Management at Altitude: Implications for Aeromedical Retrieval and Other Austere Environments

Abstract

Background and Objectives: Children are sometimes transported via fixed or rotary wing aircraft for medical care. If they are intubated with a cuffed endotracheal tube (ETT), changes in environmental pressure during transport can alter cuff pressure. Cuff management in this setting varies widely by region and by organization. In this historical review, we sought to delineate the evolution of ETT cuff management in children undergoing aeromedical retrieval in order to progress the field toward an optimum strategy in the future. Descriptions and Conclusions: Problems with extremely high ETT cuff pressures in adults due to altitude gain were identified by the 1970s. During subsequent decades, this topic was the subject of fervent research and device development, with a relative waning in interest more recently. Children, being transported less frequently and almost always with non-cuffed ETTs, were not included in these research efforts. During a similar epoch, the field of hyperbaric medicine also recognized the issue of ETT cuff pressure changes and almost uniformly changed to cuff insufflation with an incompressible liquid. This was based on cuff pressure measurements and deductive reasoning, rather than on evidence from patient outcome trials. Aeromedical retrieval has not consistently adopted this technique. Further investigation and discussion on an optimum strategy of cuff management in aeromedical transport of children is needed to reach an agreement on best practice.