Cuffed Versus Uncuffed Endotracheal Intubation in Pediatric Population: A Systematic Review and Meta-analysis

Abstract Background: Over the last two decades, the decision of choosing cuffed versus uncuffed endotracheal tubes (ETTs) in the pediatric population has been widely debated. Oftentimes, uncuffed tubes took preference because of concerns regarding cuff-related injury. However, recent evidence suggests that modern cuffed tubes may offer improved safety and practicality. Objectives: This meta-analysis aims to evaluate the safety and efficacy of cuffed versus uncuffed ETTs in the pediatric population by focusing on airway-related complications and procedural outcomes. Methods: Using Preferred Reporting Items for Systematic Review and Meta-analyses guidelines, a systematic literature search was conducted with the assistance of PubMed, Web of Science, Embase, and Cochrane Central Register of Controlled Trials. Randomized controlled trials (RCTs) and prospective cohort studies (CS) published up to March 2024 were included. Primary outcomes included the incidence of postintubation and change of tube; secondary outcomes included the need for use of steroids, attempts for ETT insertion, need for use of racemic epinephrine, and reintubation for post-extubation stridor. Results: Five RCTs and four prospective CS were included. There was reduced rate of change of sizes or types of tubes (risk ratio [RR] 0.08; 95% confidence interval [CI]: 0.04–0.16; P = 0.0005), number of attempts of intubation (RR: 0.29; 95% CI: 0.14–0.57; P = 0.02), and use of epinephrine for croup or stridor or edema (RR: 0.62; 95% CI: 0.54–0.71; P = 0.0003); in cuffed ETTs. Conclusions: Cuffed tubes are associated with a reduced rate of change of tubes, number of intubation attempts, and use of epinephrine, providing evidence in favor of cuffed endotracheal intubation compared to uncuffed ETTs.