Pediatric Anesthesia 2006 16: 734–742 doi:10.1111/j.1460-9592.2006.01844.

Comparison of cuffed and uncuffed preformed oral

pediatric tracheal tubes
M A R K U S W E I S S M D * , V ER A B E R N E T M D †, K A T H A R I N A
STUTZ MD*, ALEXANDER DULLENKOPF MSc* AND
PAOLO MAINO MD*
*Departments of Anaesthesia and †Neonatology and Intensive Care Medicine, University
Children’s Hospital, Zurich, Switzerland

Summary
Background: In preformed cuffed tracheal tubes the position of the cuff
within the airway is given by its distance to the tube bend placed at
the lower teeth. The aim of this study was to compare the design of
cuffed and uncuffed preformed pediatric oral tracheal tubes with
regard to anatomical landmarks.
Methods: Complete series of cuffed and uncuffed preformed oral
pediatric tracheal tubes sized from internal diameter 3.0–7.0 mm if
available were ordered from five different manufacturers. The
distance from the bend to the distal tube tip and to the upper border of
the cuff were measured and compared with anatomical airway
landmarks in the developing child.
Results: Between cuffed and uncuffed tracheal preformed tubes up to
37 mm differences in the bend-to-tracheal tube tip distances were
found for given age groups. Thus uncuffed preformed tracheal tubes
were more at risk for inadvertent endobronchial intubation than
cuffed preformed tracheal tubes. Comparison of bend-to-upper border
of the cuff distances with teeth-to-vocal cord distances calculated from
anatomical data revealed that several of the tracheal tube cuffs become
positioned within the subglottic larynx or even within the vocal cords
when inserted according to the bend.
Conclusions: There is a need for improvement in cuffed preformed
pediatric tracheal tubes, namely a standard bend-to-tracheal tube tip
distance to allow a safe insertion depth, a short cuff placed on the tube
shaft as distally as possible and an intubation depth mark to verify a
proper position of the cuff in the trachea.

Keywords: pediatric tracheal tubes: preformed; RAE: cuff; airway

morbidity: complications

introduced in the late 1970s (1). They are premould-

Introduction
Preformed oral tracheal tubes were first described by
Ring, Adair and Elwyn (RAE tubes) and were
Correspondence to: Markus Weiss, Department of Anaesthesia,
University Children’s Hospital, Steinwiesstrasse 75, 8032 Zurich,
Switzerland (email: markus.weiss@kispi.unizh.ch).
ed, with an angle to be placed at the patient’s mouth
which reduces the likelihood of kinking. This makes
them suitable for surgery of the mouth and face.
These tubes fit better into an oral gag, are easier to
secure to the lower lip and may reduce the risk of
unintended extubation. Preformed tracheal tubes are

734
2006 Blackwell Publishing Ltd

 PR E F O R M ED O R A L T R A C H E A L T U B E S I N C H I L D R E N
made of PVC, available in oral and nasal versions
and are traditionally used without a cuff in children
aged <8 years (2). RAE tubes have a rectangular
mark at the center of the bend. The distance from
this mark to the distal end of the tube is printed on
the tube shaft.
In the last decade, the use of cuffed tracheal tubes
has become increasingly popular for infants and
children (3–6). Preformed cuffed tracheal tubes for
ENT, and cleft surgery are of special interest as the
tube cuff allows to compensate for an excessive air
leak and protects against pulmonary aspiration of
blood. Environmental pollution by anesthetic gases
is reduced, being of particular interest for the
surgeon working at the patient’s head.
Recently, the position of the cuff in pediatric
tracheal tubes has become of interest, as cuff-related
laryngeal injury in children is mainly related to
inadequately designed cuffed tracheal tubes and
cuff hyperinflation (7–9). As cuffed tracheal tubes
are selected 0.5–1.0 mm internal diameter (ID) smal-
ler than uncuffed tracheal tubes, the bend and shape
of a given cuffed preformed tracheal tube should be
manufactured according to the 0.5–1.0 mm larger
sized uncuffed preformed tracheal tube.
In our clinical experience, cuffed preformed tra-
cheal tubes often need to be inserted further than
indicated by the bend, so as to avoid positioning of
the cuff in the glottic region.
This prompted us to systematically evaluate and
compare the design of cuffed with uncuffed pre-
formed oral pediatric tracheal tubes.
Materials and methods
Complete series of cuffed and uncuffed preformed
oral pediatric tracheal tubes sized from ID 3.0–
7.0 mm if available were ordered from five different
manufacturers (Table 1).
The following measures were taken from the
preformed tracheal tubes: presence and number of
Murphy eyes and intubation depth marks; the
distance from the rectangular mark at the center of
the bend being printed on the shaft of each tracheal
tube to the distal tube tip; the distance from the
distal tube tip to the upper border of the tube cuff;
the distance from the bend to the upper border of the
cuff, and the length of the cuff (Figure 1). Measure-
ments were performed at the lateral tube wall

2006 Blackwell Publishing Ltd, Pediatric Anesthesia, 16, 734–742
7 35
leading to the distal tip and with the cuff inflated
to 20 cmH2O cuff pressure (Cuff Manometer, Mall-
inckrodt Medical, Athlone, Ireland). The measure-
ments were repeated four times in two exemplars of
each brand and size using a sliding calliper by two
investigators.
In tracheal tubes intended to be used for children
aged 2 years and older, the cuffed and uncuffed
tracheal tubes were matched using the modified
Cole’s formula for the selection of uncuffed pre-
formed tracheal tubes [ID (mm) ¼ (age/4) + 4.0],
and the formula of Motoyama [ID (mm) ¼ (age/
4) + 3.5] and Khine [ID (mm) ¼ (age/4) + 3.0] for
the selection of cuffed tracheal tubes (4,10,11). In
children below the age of 2 years the recommenda-
tions of Khine for the selection of uncuffed trachea
tubes were used (4).
The bend-to-tracheal tube tip distance was set into
relation to age-corresponding distances from teeth to
the carina with the head in neutral position and with
regard to caudal tube tip displacement caused by
head–neck flexion. The bend-to-upper border of the
cuff distances were related to age-corresponding
teeth-to-vocal cord distance, and teeth-to-cricoid
distances with the head in neutral position and to
cranial tube displacement caused by head–neck
extension (12–17).
Results
Uncuffed preformed oral tracheal tubes were avail-
able from size ID 3.0 mm in all brands, but not in
cuffed preformed tracheal tubes except in the
Microcuff PET. In uncuffed tracheal tubes one or
two Murphy eyes were present whereas in the
cuffed tracheal tubes only one Murphy eye was
found, except in the Microcuff PET tubes without
any Murphy eye. Intubation depth marks were only
found in the uncuffed Portex preformed and in the
Microcuff PET preformed tracheal tubes (Table 2).
The distances from bend-to-tracheal tube tip were
similar between similar-sized (ID) cuffed and un-
cuffed Rusch tracheal tubes. The distances were
longer in similar-sized (ID) cuffed compared with
uncuffed Portex tracheal tubes and Mallinckrodt
tracheal tubes. In the Sheridan preformed tracheal
tubes, the differences were not consistent with bend-
to-tracheal tube tip distances being shorter in smal-
ler sized cuffed and longer in larger sized cuffed
7 36 M . WE I S S ET AL .

Table 1
Studied cuffed and uncuffed oral pediatric preformed tracheal tubes

Manufacturer Tube brand Cuffed/uncuffed ID available Reference number

Rusch AGT-Trachealtubus oral Uncuffed ID 3.0 fi 7.0 10 01 80 fi 10 01 80

Rusch AGT-Trachealtubus oral Cuffed ID 3.5 fi 7.0 11 17 80 fi 11 17 80
Portex Polar South preformed tube oral Uncuffed ID 3.0 fi 7.0 B 100134 030 fi B 100134 070
Portex Polar South preformed tube oral Cuffed ID 5.0 fi 7.0 B 100136 050 fi B 100136 070
Sheridan Preformed Tracheal Tube oral Uncuffed ID 3.0 fi 7.0 5-22006 fi 5-22014
Sheridan Preformed Tracheal Tube oral Cuffed ID 4.0 fi 7.0 5-22208 fi 5-22214
Mallinckrodt RAE Tracheal Tube performed Uncuffed ID 3.0 fi 7.0 113-30 fi 113-70
Mallinckrodt RAE Tracheal Tube performed Cuffed ID 4.0 fi 7.0 115-40 fi 115-70
Microcuff PET Oral Curved Tracheal Tube Cuffed ID 3.0 fi 7.0 I-MPEDC-30 fi I-MPEDC-70

The distance from the upper border of the cuff to

Figure 1
Measurements performed in cuffed and uncuffed preformed
pediatric tracheal tubes: (A) distance from the rectangular mark at
the center of the bend to the distal tube tip; (B) length of the cuff;
(C) distance from the distal tube tip to the upper border of the
tube cuff, and (D) distance from the bend to the upper border of
the cuff. Measurements were performed with the cuff inflated to
20 cmH2O cuff pressure.
tracheal tubes. In the Microcuff PET tubes, the
distances from the bend to tracheal tube tip were
similar to those in the cuffed Mallinckrodt pre-
formed pediatric tracheal tubes (Table 2).
the tracheal tube tip was shortest in the Microcuff
PET, and longest in the Rusch preformed tracheal
tubes (Table 3) and was in general longer in tracheal
tubes with Murphy eye and longer cuffs (Table 4)
vice versa, the distance from the bend to the upper
border of the cuff was longest in the Microcuff
tracheal tubes and shortest in the Rusch tubes
(Table 5).
Between cuffed tracheal tubes and uncuffed tubes
selected by the modified Cole’s formula up to
23 mm differences in the bend-to-tracheal tube tip
distances were found for given age groups using
Motoyama’s formula and up to 37 mm using Khi-
ne’s formula for cuffed tracheal tube size selection
(Tables 6 and 7). Hereby, uncuffed preformed tra-
cheal tubes were more at risk for inadvertent
endobronchial intubation than cuffed preformed
tracheal tubes.
Comparison of bend-to-upper border of the cuff
distances with teeth-to-vocal cord distances calcula-
ted from anatomical data revealed that several of the

Table 2
Distances from the bend of preformed tracheal tubes to the tracheal tube tip

Murphy Depth
Manufacturer Cuff eye mark ID 3.0 ID 3.5 ID 4.0 ID 4.5 ID 5.0 ID 5.5 ID 6.0 ID 6.5 ID 7.0

Rusch Uncuffed 2 ) 106 (105) 119 (120) 130 (130) 143 (145) 156 (155) 164 (165) 175 (180) 185 (190) 193 (200)
Rusch Cuffed 1 ) NA 122 (120) 132 (130) 147 (145) 156 (155) 166 (165) 180 (180) 188 (190) 200 (200)
Portex Uncuffed 1 + 109 (105) 112 (110) 122 (120) 138 (135) 140 (140) 147 (145) 153 (150) 163 (160) 177 (175)
Portex Cuffed 1 ) NA NA NA NA 162 (160) 172 (170) 182 (180) 191 (190) 200 (200)
Sheridan Uncuffed 2 ) 106 (105) 121 (120) 129 (130) 152 (150) 168 (165) 170 (170) 177 (175) 185 (185) 185 (195)
Sheridan Cuffed 1 ) NA NA 131 (130) 145 (145) 156 (155) 165 (165) 180 (180) 191 (190) 200 (200)
Mallinckrodt Uncuffed 2 ) 101 (100) 115 (115) 126 (125) 137 (140) 150 (150) 166 (165) 176 (175) 188 (185) 196 (195)
Mallinckrodt Cuffed 1 ) NA NA 130 (130) 147 (145) 157 (155) 167 (165) 184 (180) 190 (190) 200 (200)
Microcuff Cuffed 0 + 105 (105) 120 (120) 130 (130) 150 (150) 155 (155) 165 (165) 180 (180) 190 (190) 200 (200)

Data are median values for four measurements in two exemplars per tube size. Data in parenthesis are values indicated on the tube shaft.
NA, not available.

2006 Blackwell Publishing Ltd, Pediatric Anesthesia, 16, 734–742

 PR E F O R M ED O R A L T R A C H E A L T U B E S I N C H I L D R E N 7 37

Table 3
Distance (mm) from the tube tip to the upper border of the cuff in preformed oral pediatric tracheal tubes

Manufacturer ID 3.0 ID 3.5 ID 4.0 ID 4.5 ID 5.0 ID 5.5 ID 6.0 ID 6.5 ID 7.0

Rusch NA 36 38 38 41 41 51 51 58
Portex NA NA NA NA 40 49 56 49 56
Sheridan NA NA 27 31 39 41 42 46 49
Mallinckrodt NA NA 26 34 35 34 39 40 51
Microcuff 17 22 21 23 26 32 33 38 40

Data are median values for four measurements in two exemplars per tube size. NA, not available.

Table 4
Measured length (mm) of the cuff in preformed oral pediatric tracheal tubes

Manufacturer Cuff material ID 3.0 ID 3.5 ID 4.0 ID 4.5 ID 5.0 ID 5.5 ID 6.0 ID 6.5 ID 7.0

Rusch Polyvinyl chloride NA 21 21 22 21 21 27 30 36

Portex Polyvinyl chloride NA NA NA NA 19 20 22 26 28
Sheridan Polyvinyl chloride NA NA 10 17 15 17 18 21 26
Mallinckrodt Polyvinyl chloride NA NA 9 14 18 19 20 20 23
Microcuff Polyurethane 7 9 9 14 14 17 18 21 21

Data are median values for four measurements in two exemplars per tube size. NA, not available.

Table 5
Calculated distances (mm) from the bend to the upper border of the cuff in preformed oral pediatric tracheal tubes

Manufacturer Murphy eye ID 3.0 ID 3.5 ID 4.0 ID 4.5 ID 5.0 ID 5.5 ID 6.0 ID 6.5 ID 7.0

Rusch 1 NA 86 94 109 115 125 129 137 142

Portex 1 NA NA NA NA 122 123 126 142 144
Sheridan 1 NA NA 104 114 117 124 138 145 151
Mallinckrodt 1 NA NA 104 113 122 133 145 150 149
Microcuff – 88 98 109 127 129 133 147 152 161

Data are median values for four measurements in two exemplars per tube size. NA, not available.

tracheal tube cuffs become positioned within the
subglottic larynx or even within the vocal cords
when inserted according to the mark. Again, with
the Khine formula more cuffs would become placed
within the larynx than with the Motoyama formula.
In all studied preformed tracheal tubes the cuff
would become placed within the cricoid and/or
glottic opening with head–neck extension (Table 8).
Discussion
The first preformed tracheal tubes were designed by
defining the maximal depth to which the tube could
be placed without resulting in endobronchial intu-
bation by means of auscultation (1). In addition, the
tubes were provided with two Murphy eyes near the
bevel. One port is on the long side of the bevel and
the other is on the opposite short side of the bevel to
provide some measure of safety if the tracheal tube
is accidentally advanced into the right main-stem
bronchus. In such an event, one port shall provide
ventilation of the right upper lobe, and the other
ventilation of the left lung. In none of the tested
cuffed and uncuffed preformed tracheal tubes a
formula for age-related tube size selection is provi-
ded by the manufacturers or has been thoroughly
assessed. In the last 30 years adequacy and inad-
equacy of preformed tracheal tubes in children has
only been confirmed in one clinical study by Black
and Mackersie in 1990 (18).
A problem of previous uncuffed preformed tra-
cheal tubes was that they were too long, in particular
for smaller children. Thus, they required to be
withdrawn slightly and to be secured with a swab
taped under the tube shaft at the chin. Mallinckrodt
reduced the lengths of their preformed RAE

2006 Blackwell Publishing Ltd, Pediatric Anesthesia, 16, 734–742

 7 38

Table 6
Distances from the bend to the tracheal tube tip in preformed oral pediatric tracheal tubes

Age (years) 0 0.33 1 2 3 4 5 6 7 8 9 10 11 12 15 13 14

Difference of bend-to-tip
Uncuffed TT size – Cole’s 3.0 3.5 4.0 4.5 4.5 5.0 5.0 5.5 5.5 6.0 6.0 6.5 6.5 7.0 7.0 7.5
7.5 distance in cuffed and
formula (ID) uncuffed TTs from
M . WE I S S ET AL .

Cuffed TT size – 3.0 3.0 3.5 4.0 4.0 4.5 4.5 5.0 5.0 5.5 5.5 6.0 6.0 6.5 6.5 7.0 7.0 the same manufacturer,
Motoyama’s formula (ID) median (range)
Distance from teeth to carina 115 126 147 160 167 174 181 189 196 203 210 218 225 232 239 246 254
Caudal TT-displacement 9 10 10 11 12 13 14 14 15 16 17 18 18 19 20 21 22
by HN-flexion
Maximal allowed TT 106 116 137 149 155 161 167 175 181 187 193 200 207 213 219 225 232
insertion length at
teeth for TT-displacement
by HN-flexion
Rusch uncuffed 106 119 130 143 143 156 156 164 164 175 175 185 185 193 193 – – )9 ()5 fi )11)
Rusch cuffed NA NA 122 132 132 147 147 156 156 166 166 180 180 188 188 200 200
Portex uncuffed 109 110 122 138 138 140 140 147 147 153 153 163 163 177 177 – – 17 (15 fi 19)
Portex cuffed NA NA NA NA NA NA NA 162 162 172 172 182 182 191 191 200 200
Sheridan uncuffed 106 121 129 152 152 168 168 170 170 177 177 185 185 185 185 – – )13 ()23 fi 5)
Sheridan cuffed NA NA NA 131 131 145 145 156 156 165 165 180 180 191 191 200 200
Mallinckrodt uncuffed 101 115 126 137 137 150 150 166 166 176 176 188 188 196 196 – – )6 ()9 fi )3)
Mallinckrodt cuffed NA NA NA 130 130 147 147 157 157 167 167 184 184 190 190 200 200
Mallinckrodt uncuffed 101 115 126 137 137 150 150 166 166 176 176 188 188 196 196 – – )5 ()10 fi 5)
Microcuff PET 105 105 120 130 130 150 150 155 155 165 165 180 180 190 190 200 200
Largest difference between 9 16 10 22 22 28 28 23 23 24 24 22 22 25 25 – – 23 (9 fi 28)
all tubes tested

Comparison of cuffed and uncuffed tracheal tubes using the modified Cole’s formula [ID (mm) ¼ (age/4) + 4.0] (10) for size selection in uncuffed tracheal tubes and using the
formula of Motoyama (11) [ID (mm) ¼ (age/4) + 3.5] for tracheal tube size selection in cuffed tracheal tubes. Distance from teeth to carina {¼ oral tube insertion depth to mid-
trachea [mm ¼ 12 + (age/2)] (12) + half of minimal tracheal length (13)} and caudal TT-displacement by head–neck (HN) flexion (17) are provided for each age group. Shaded
areas indicate tracheal tubes with <10 mm margin of safety regarding bronchial intubation with head–neck flexion. Values are in mm. TT, tracheal tube; NA, not available.

2006 Blackwell Publishing Ltd, Pediatric Anesthesia, 16, 734–742

 Table 7
Distances from the bend to the tracheal tube tip in preformed oral pediatric tracheal tubes

Age (years) 0 0.33 1 2 3 4 5 6 7 8 9 10 11 12 13

15 14
Difference of bend-to-tip
Uncuffed TT size – Cole’s 3.0 3.5 4.0 4.5 4.5 5.0 5.0 5.5 5.5 6.0 6.0 6.5 6.5 7.0 7.0 7.5
7.5 distance in cuffed and
formula (ID) uncuffed TTs from the
Cuffed TT size – Khine’s 3.0 3.0 3.5 3.5 4.0 4.0 4.5 4.5 5.0 5.0 5.5 5.5 6.0 6.0 6.5 6.5 7.0 same manufacturer
formula (ID) median (range)
Distance from teeth to carina 115 126 147 160 167 174 181 189 196 203 210 218 225 232 239 246 254
Caudal TT-displacement 9 10 10 11 12 13 14 14 15 16 17 18 18 19 20 21 22
by HN-flexion
Maximal allowed TT 106 116 137 149 155 161 167 175 181 187 193 200 207 213 219 225 232
insertion length at
teeth for TT-displacement
by HN-flexion
Rusch uncuffed 106 119 130 143 143 156 156 164 164 175 175 185 185 193 193 – – )11 ()24 fi )5)

2006 Blackwell Publishing Ltd, Pediatric Anesthesia, 16, 734–742

Rusch cuffed NA NA 122 122 132 132 147 147 156 156 166 166 180 180 188 188 200
Portex uncuffed 109 110 122 138 138 140 140 147 147 153 153 163 163 177 177 – – 14 (5 fi 19)
Portex cuffed NA NA NA NA NA NA NA NA 162 162 172 172 182 182 191 191 200
Sheridan uncuffed 106 121 129 152 152 168 168 170 170 177 177 185 185 185 185 – – )20 ()37 fi 6)
Sheridan cuffed NA NA NA NA 131 131 145 145 156 156 165 165 180 180 191 191 200
Mallinckrodt uncuffed 101 115 126 137 137 150 150 166 166 176 176 188 188 196 196 – – )9 ()21 fi 3)
Mallinckrodt cuffed NA NA NA NA 130 130 147 147 157 157 167 167 184 184 190 190 200
Mallinckrodt uncuffed 101 115 126 137 137 150 150 166 166 176 176 188 188 196 196 – – )11 ()23 fi 4)
Microcuff PET 105 105 120 120 130 130 150 150 155 155 165 165 180 180 190 190 200
Largest difference between 8 16 10 32 22 38 28 22 19 24 24 25 25 19 19 – – 22 (8 fi 38)
all tubes tested

Comparison of cuffed and uncuffed tracheal tubes using the modified Cole’s formula [ID (mm) ¼ (age/4) + 4.0] (10) for size selection in uncuffed tracheal tubes and using the
formula of Khine (4) [ID (mm) ¼ (age/4) + 3.0] for tracheal tube size selection in cuffed tracheal tubes. Distance from teeth to carina {¼ oral tube insertion depth to mid-trachea
[mm ¼ 12 + (age/2)] (12) + half of minimal tracheal length (13)} and caudal TT-displacement by head–neck (HN) flexion (17) are provided for each age group. Shaded areas
indicate tracheal tubes with <10 mm margin of safety regarding bronchial intubation with head–neck flexion. Values are in mm. TT, tracheal tube; NA, not available.
PR E F O R M ED O R A L T R A C H E A L T U B E S I N C H I L D R E N
7 39
7 40 M . WE I S S ET AL .

Table 8
Distance from the bend of preformed oral pediatric tracheal tubes to the vocal cords and to the upper border of the cuff

Age (years) 0 0.33 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Distance from teeth to midtrachea 90 100 120 130 135 140 145 150 155 160 165 170 175 180 185 190 195
Mean tracheal length 50 52 54 59 63 68 72 77 81 86 90 95 99 103 108 112 117
Distance from teeth to vocal cords 65 74 93 101 103 106 109 112 114 117 120 123 126 128 131 134 137
Cricoid–vocal cords distance 10 10 10 11 12 12 13 13 14 14 15 15 16 16 17 18 19
Distance from teeth to cricoid 75 84 103 112 115 118 122 125 128 131 135 138 142 144 148 152 156
Cranial TT-displacement 10 10 11 11 12 13 14 14 15 16 16 17 17 18 19 20 21
by HN-extension
Safe distance from bend 85 94 114 123 127 131 136 139 143 147 151 155 159 162 167 172 177
to upper cuff border
for TT-displacement
by HN-extension
Cuffed TT size – 3.0 3.0 3.5 4.0 4.0 4.5 4.5 5.0 5.0 5.5 5.5 6.0 6.0 6.5 6.5 7.0 7.0
Motoyama’s formula (ID)
Distance from bend
to upper cuff border
Rusch cuffed NA NA 86 94 94 109 109 115 115 125 125 129 129 137 137 142 142
Portex cuffed NA NA NA NA NA NA NA 122 122 123 123 126 126 142 142 144 144
Sheridan cuffed NA NA NA 104 104 114 114 117 117 124 124 138 138 145 145 151 151
Mallinckrodt cuffed NA NA NA 104 104 113 113 122 122 133 133 145 145 150 150 149 149
Microcuff PET 88 88 98 109 109 127 127 129 129 133 133 147 147 152 152 160 160
Cuffed TT size – Khine’s 3.0 3.0 3.5 3.5 4.0 4.0 4.5 4.5 5.0 5.0 5.5 5.5 6.0 6.0 6.5 6.5 7.0
formula (ID)
Distance from bend to
upper cuff border
Rusch cuffed NA NA 86 86 94 94 109 109 115 115 125 125 129 129 137 137 143
Portex cuffed NA NA NA NA NA NA NA NA 122 122 123 123 126 126 142 142 144
Sheridan cuffed NA NA NA NA 104 104 114 114 117 117 124 124 138 138 145 145 151
Mallinckrodt cuffed NA NA NA NA 104 104 113 113 122 122 133 133 145 145 150 149 149
Microcuff PET 88 88 98 98 109 109 127 127 129 129 133 133 147 147 152 152 160

Distances are caluclated using the formula of Motoyama (11) [ID (mm) ¼ (age/4) + 3.5] and the formula of Khine (4) [ID (mm) ¼ (age/
4) + 3.0] for tracheal tube size selection in cuffed tracheal tubes. Oral tube insertion depth [Length (mm) ¼ 12 + (age/2)] (16), minimal
tracheal length (12), distance from the vocal cords to lower border of the cricoid (13–25) and cranial TT-displacement for head–neck (HN)
extension are provided for each age group (17). Shaded areas indicate tracheal tubes at risk for cuff position at or above the level of the
cricoid with the head in neutral position. Values are in mm. TT, tracheal tube; NA, not available.

pediatric tracheal tubes of ID 5.5 mm size and less in
1986 by 0.5–1.5 cm (depending on the ID) for the
European market (19–21). Nevertheless, endobron-
chial intubation has been reported to be still a
frequent event, when using uncuffed preformed
tracheal tubes in children (18). This confirms our
findings in uncuffed preformed tracheal tubes, to be
critically long, particularly those for younger chil-
dren. The risk of endobronchial intubation is further
increased in smaller sized children, because of a
reduced distance from the teeth to the vocal cords
and a shorter trachea, and especially when a mouth
gag is inserted pushing the preformed tracheal tube
further down into the trachea.
A major limitation of preformed tracheal tubes is
that their flexion point is fixed and that for a given
ID, the tube sizes are available in only one length.
Therefore, if a patient with a narrow cricoid ring
requires a preformed tracheal tube that is smaller
than usual for his age, the tube may be too short and
may become dislodged accidentally during surgery.
If a larger uncuffed tracheal tube is used for a patient
with an unusually wide trachea, the tube may be too
long and its tip entering a main bronchus (22). The
latter problem can easily be overcome by the use of a
smaller sized cuffed preformed tracheal tube fitting
in the cricoid with a high chance and sealing the
airway with the cuff within the trachea (23). How-
ever, our findings reveal that cuffed preformed
pediatric tracheal tubes have some shortcomings
with regard to tube length, cuff position and pres-
ence of an intubation depth mark. Their bend-to-
tracheal tube tip distances are shorter not only than
the age-related sized uncuffed preformed tracheal
tubes but even identically sized uncuffed tubes. The
reduced bend-to-tracheal tube tip distance, and the

2006 Blackwell Publishing Ltd, Pediatric Anesthesia, 16, 734–742

 PR E F O R M ED O R A L T R A C H E A L T U B E S I N C H I L D R E N
presence of a Murphy eye and longer cuffs, especi-
ally in cuffs made of PVC, contribute to a relatively
high cuff position on many of the investigated
tracheal tubes, leading to intralaryngeal cuff place-
ment, when the tracheal tube is placed according to
the bend. The cuff will become positioned even
higher in larger sized children with a longer distance
from the teeth to the vocal cords and when using
Khine’s formula, which results in the selection of
smaller sized and shorter cuffed tracheal tubes for
older children (Table 6). Although in preformed
tracheal tubes the bend defines the insertion depth,
an intubation depth mark or ‘security mark’ should
be printed on the tracheal tube shaft above the cuff.
Once the tracheal tube is in place, the mark should
be visualized at least at the glottic level or below so
as to guarantee that the cuff is sufficiently positioned
below the vocal cords, so as to avoid cuff-induced
pressure on the mucosa in the subglottic region (24).
The clinical consequences of cuffs in preformed
pediatric tracheal tubes being placed too high on the
tube shaft are that either the preformed tube has to
be advanced further down into the trachea or the
cuff may become placed within the larynx. The
former results in an artificial, not preformed ‘bend’
at the teeth with the risk of kinking, particularly
when an oral gag is inserted.
Intralaryngeal cuff position can result in laryngeal
damage, if not recognized. However, it can be
argued that low relevant clinical morbidity is to be
expected, as this kind of tube is commonly inserted
only for short procedures and mostly cuffs are only
inflated in case of excessive leak. If inflated at all, the
cuff pressure is restricted to allow a small residing
‘security leak’ by a majority of anesthetists using
cuffed tracheal tubes in children (2). Nevertheless, if
cuffed tracheal tubes become increasingly popular
for smaller children, a correct and safe design is
mandatory to avoid airway injury and accidents by
inexperienced users. Correct design of tracheal tube
tip is easier in tracheal tubes without a Murphy eye,
because there is a larger margin for cuff positioning.
It can be argued that the lack of a Murphy eye carries
the risk for inadequate exhalation and barotrauma if
the tube tip is placed inadvertently against the
tracheal wall or can lead to unilateral ventilation, if
the tube tip is placed near the tracheal carina.
However, there are more reports to be found of
complications than benefits from the Murphy eye. In

2006 Blackwell Publishing Ltd, Pediatric Anesthesia, 16, 734–742
7 41
small infants the presence of a Murphy eye can make
the diagnosis of bronchial intubation more difficult
(while both lungs may ventilate on auscultation after
intubation, movement of the patient or the use of a
mouth gag may lead to inadequate ventilation and
arterial desaturation) or even hinder adequate ven-
tilation if the Murphy eye encroaches into the glottis
following head movement (25).
Finally, each manufacturer should provide a
formula for age-related tracheal tube size selection
and ‘precaution warnings’ based on clinical assess-
ment of their own preformed pediatric tracheal
tubes. Although the oral preformed Microcuff PET
seems to fulfill some of the criteria, there is place for
further improvement, as the preformed Microcuff
PET has been designed by the manufacturer mainly
by adding their ‘Microcuff cuff/depth mark princi-
ple’ to Mallinckrodt preformed tube shafts without a
Murphy eye (26).
Armored or wire-reinforced cuffed tracheal tubes
can also be used in children. They have the
advantage of tolerating extreme flexion without
kinking and large pressure without compression.
However, their wall is thicker than that of conven-
tional polyvinyl chloride tubes resulting in a larger
outer diameter for a given ID. A further disadvan-
tage is that they have a tendency to be dislodged
(22,27).
This study did not include nasal preformed
tracheal tubes as those are used infrequently in
children and it would unnecessarily enlarge the
content of this article, although similar problems in
nasal preformed tracheal tubes were reported (28).
Our study is based on in vitro assessments and mean
values of tracheal length and tube insertion depths.
Thus, our results and conclusions will not apply to
all children having a preformed cuffed or uncuffed
tracheal tube. Nevertheless, they confirm the clinical
experience of uncuffed preformed tracheal tubes
being too long in smaller sized children and pre-
formed tracheal tube cuffs being too proximally
placed in larger children. Our in vitro data have to be
confirmed by clinical studies including oral gag
insertion and with the head–neck extended or
flexed. This may prompt manufacturers to improve
the design of their preformed pediatric tracheal
tubes.
Cuffed preformed oral pediatric tracheal tubes
have some shortcomings with regard to tube length,
7 42 M . WE I S S ET AL .
cuff position and presence of a intubation depth
mark and require an improved design. Namely, a
balanced bend-to-tracheal tube tip distance to allow
a safe insertion depth, the avoidance of a Murphy
eye and an as distally as possible placed cuff with
reduced cuff length, and an intubation depth mark,
to allow and verify a proper position of the cuff in
the trachea is needed. The pediatric anesthetist has
to be aware of these problems and that preformed
tracheal tubes from different manufacturers are not
readily interchangeable.
Financial disclosure statement
The tubes were ordered from local distributors and
paid from departmental resources.
Dr Weiss is involved in designing and improving
cuffed pediatric tracheal tubes in cooperation with
Microcuff GmbH, Weinheim, Germany and Tyco
Healthcare, Athlone, Ireland.
No agreements or financial benefits arise from
these cooperations.
References
1 Ring WH, Adair JC, Elwyn RA. A new pediatric endotracheal
tube. Anesth Analg 1975; 54: 273–274.
2 Eckenhoff JE. Some anatomic considerations of the infant lar-
ynx influencing tracheal anesthesia. Anesthesiology 1954; 12:
401–410.
3 Orliaguet GA, Renaud E, Lejay M et al. Postal survey of cuffed
or uncuffed tracheal tubes used for paediatric tracheal in-
tubation. Paediatr Anaesth 2001; 11: 277–281.
4 Khine HH, Corddry DH, Kettrick RG et al. Comparison of
cuffed and uncuffed endotracheal tubes in young children
during general anesthesia. Anesthesiology 1997; 86: 627–631.
5 Murat I. Cuffed tubes in children: a 3-year experience in a
single institution. Paediatr Anaesth 2001; 11: 748–749.
6 Fine GF, Borland LM. The future of the cuffed endotracheal
tube. Pediatr Anesth 2004; 14: 38–42.
7 Weiss M, Dullenkopf A, Gysin C et al. Shortcomings of cuffed
paediatric tracheal tubes. Br J Anaesth 2004; 92: 78–88.
8 Holzki J. Laryngeal damage from tracheal intubation. Paediatr
Anaesth 1997; 7: 435–437.
9 James I. Cuffed tubes in children. Paediatr Anaesth 2001; 11:
259–263.
10 Cole F. Pediatric formulas for the anaesthesiologist. Am J Dis
Child 1957; 94: 672–673.
11 Motoyama EK. Endotracheal intubation. In: Motoyama EK ed.
Smith’s Anesthesia for Infants and Children. St. Louis: C.V.
Mosby, 1990: 269–275.
12 Pettersson H, Ringertz H. Measurements in Pediatric Radiology,
2nd edn. London: Springer, 1991.
13 Schild JA. Relationship of laryngeal dimensions to body size
and gestational age in premature neonates and small infants.
Laryngoscope 1984; 94: 1284–1292.
14 Kahance JC. Growth of the human prepubertal and pubertal
larynx. J Speech Hear Res 1982; 25: 446–455.
15 Lang J, Fischer K, Nachbaur S. Measurements, form and var-
iants of the thyroid and cricoid cartilages. Gegenbaurs Morphol
Jahrb 1984; 130: 639–657.
16 Hatch DJ. Paediatric anaesthetic equipment. Br J Anaesth 1985;
57: 672–684.
17 Weiss M, Knirsch W, Kretschmar O et al. Tube tip displace-
ment in children during head–neck movement – a radiological
assessment. Eur J Anaesthesiol 2005; 22 (Suppl. 34): 150.
18 Black AE, Mackersie AM. Accidental bronchial intubation with
RAE tubes. Anaesthesia 1991; 46: 42–43.
19 Schaefer HG, Marsch SCU, Flatt T. The length of RAE pre-
formed tubes. Anaesthesia 1991; 46: 719.
20 Hannington-Kiff JG. The length of RAE preformed tubes.
Anaesthesia 1991; 46: 719–720.
21 Mackersie AM. The length of RAE preformed tubes. Anaes-
thesia 1991; 46: 720.
22 Fisher DM. Anesthesia equipment for pediatrics. In: Gregory
GA, ed. Pediatric Anesthesia. New York: Churchill Livingstone,
2001: 207–208.
23 Dullenkopf A, Gerber AC, Weiss M. Tracheal sealing charac-
teristics of a new paediatric tracheal tube with high volume–
low pressure polyurethane cuff. Acta Anaesthesiol Scand 2005;
49: 232–237.
24 Cavo JW. True vocal cord paralysis following intubation.
Laryngoscope 1985; 95: 1352–1359.
25 Verghese ST, Hannallah RS, Slack MC et al. Auscultation of
bilateral breath sounds does not rule out endobronchial intu-
bation in children. Anesth Analg 2004; 99: 56–58.
26 Weiss M, Dullenkopf A, Gerber AC. Microcuff pediatric tra-
cheal tube. A new tracheal tube with a high volume–low
pressure cuff for children. Anaesthesist 2004; 53: 73–79.
27 Deanovic D, Gerber AC, Weiss M. Repeated accidental extu-
bation of wire-reinforced cuffed tracheal tubes in patients with
cleft palate. Pediatr Anesth 2004; 14: 798–802.
28 Brunsomann JK, Altmann VA, Johnson MA et al. A new
endotracheal tube for maxillofacial surgery. J Oral Surg 1980;
38: 847–845.
Accepted 11 November 2005

2006 Blackwell Publishing Ltd, Pediatric Anesthesia, 16, 734–742