Authors: Papagiannopoulou P. MD, PhD, Ntritsou V. MD, PhD, Pistofidou K. MD, Mademli A. MD, Stefanovits D. MD, Isaakidis A. MD, Kostoglou Ch. MD, Zachariadou Ch. MD.
Anesthesia Department “G. Gennimatas” General Hospital, Thessaloniki, Greece
ABSTRACT
There are various formulas and algorithms for the prediction of body weight and appropriate ETT size, in pediatric patients. Body Weight estimation is of paramount importance in pediatrics, especially in emergencies. Predicting the appropriate size of the endotracheal tube saves time, money and reduces complications. The goal of this study was to evaluate the validity of two commonly used formulas for predicting the body weight and the size of the appropriate endotracheal tube, both based on age.353 consecutive pediatric surgical patients aged 2 to 12 years, who required general anesthesia and oral endotracheal intubation were included in this study. Patients were stratified according to their age in two groups: group 25 (79 children, 2 to 5 years) and group 612 (274 children, 6 to 12 years). At the end of surgery an anesthesiologist, who was not involved in the perioperative treatment, recorded the demographic data and also the size and type of the endotracheal tube used. The prediction of Body Weight (BW) was made according to the following formula: 25 y.o.: Weight (kg) = (2 x age in years) + 8 and 612 y.o.: Weight (kg) = (3 x age in years) + 7. The formula for calculating the size (size= internal diameter=I.D.) of the endotracheal tube (ETT) was: I.D. for cuffed ETT (mm) = (age / 4) + 3.5 and I.D. for uncuffed ETT (mm) = (age / 4) + 4. For all statistical tests p value <0.05 was considered as statistically significant. In all patients as sum and in both age groups, the predicted body weight was significantly (p<0.05) lower than the actual (measured) weight. In group 25y.o, 74.7% of patients received cuffed ETT In group 612y.o. 100% of patients received cuffed ETT. In group 25 y.o, all patients showed a significantly (p<0.05) lower predicted internal diameter of the ETT, either cuffed or uncuffed, compared to ETT ultimately used. In group 6 12y.o, there was no statistically significant difference between the predicted and the actually used ETT size. The prediction of body weight in children, by the use of the particular formula, led to underestimation. In children aged 2 to 5 years, the application of the inner diameter calculation of the ETT formula also underestimated the appropriate ETT size. It seems that the traditional agebased formulas often fail to predict the correct ETT size in smaller children which probably does not seem to apply to older children.
Introduction
The pediatric surgical patients have significant anatomical and physiological differences compared to adults, which must be taken into consideration when selecting techniques, tools and equipment.^{1}. Endotracheal intubation in children presents many challenges. If the predicted size of ETT is inappropriate, either larger or smaller, the number of intubation attempts increases, leading to prolonged intubation time, tracheal edema or air leakage^{2}. Multiple intubation attempts may result in hypoxemia and in increased morbidity and mortality^{3}.
Many formulas and algorithms have been proposed for the selection of the appropriate size of an ETT^{3}. Due to variable rate of child development, demographic databased prediction of the ETT size has been considered controversial^{3}. The most commonly used formula for ETT size is the modified agebased Cole’s formula for children aged 2 and older^{46}: ETT size = 4 + (age/4). Sometimes pediatric patients do not conform to these formulas^{7}.
Body Weight (BW) estimation is of paramount importance in pediatrics, especially in emergency situations. There are many different methods used to estimate children’s weights. One of the most popular is the age based Advanced Pediatric Life Support (APLS) formula. In the recent edition of the APLS manual, three different formulas are being suggested for the estimation of weight in children according to their age: one for children between 1–5y.o., another one (Luscombe and Owens) for those aged 612y.o. and a specific infant formula for those aged less than 1y.o.^{8,9}.
The goal of this study was to determine the accuracy of commonly used formulas for body weight and appropriate E.T.T. size estimation, in the pediatric population who present for surgery in our Institution.
MATERIAL AND METHODS
After the approval of the Institutional Ethics Committee and parent’s informed consent, 353 consecutive pediatric surgical patients ASA I and II, aged between 2 and 12 years, undergoing surgical procedures, were enrolled in this prospective, observational study. All study patients submitted to elective or nonelective surgical procedures requiring general anesthesia and oral endotracheal intubation using pharmacological paralysis.
Exclusion criteria aimed at eliminating patients who might be at increased risk of intubationrelated and/or other studyrelated complications such as: suspected difficulty with mask ventilation and intubation and children with certain congenital disorders (Pierre Robin sequence, Treacher Collins, Down’s syndrome, Goldenhar syndrome, Crouzon syndrome, Pfeiffer syndrome, SaethreChotzen syndrome, Hurler’s/Hunter’s syndrome, BeckwithWiedemann syndrome). Additional exclusion criteria were: known allergy to anesthetics, patients’ or family history of malignant hyperthermia, history of prematurity, asthma, bronchospasm or cardiac disease.
Study patients were divided into two age groups: group 25y.o. and group 612y.o.
On arrival to the operating theater, an intravenous (IV) access was established. Standard monitoring {electrocardiogram, noninvasive blood pressure, peripheral oxygen saturation (SpO_{2})} was applied. Anesthesia was induced with atropine 0.01 mg/kg, fentanyl 2μg/kg, propofol 3 mg/kg, titrated to loss of consciousness and loss of eyelash reflex and endotracheal intubation was facilitated with rocuronium bromide 0.6 mg /Kg. After intubation, the lungs were ventilated mechanically with FiO_{2} 0.4 and sevoflurane was used for anesthesia maintenance. Ventilation was adjusted to keep P_{ET}CO_{2} in the range 4.55.5 pKa.
The choice of ETT type (cuffed or uncuffed) and size was made by the anesthetist appointed for each case. All the ETT tubes used in the study were of the same brand (RÜSCHELIT^{®}). The appropriate ETT size was estimated with the formulas as follows: Internal diameter (mm) = (age / 4) + 3.5 for cuffed ETT and internal diameter (mm) = (age / 4) + 4 for uncuffed ETT^{6}. According to the pediatric anesthesia department protocol, additional tubes one half size larger and smaller than the calculated were always available, during endotracheal intubation attempts, regardless of whether an uncuffed or cuffed endotracheal tube was used. The ETT size was regarded as suitable when it smoothly passed the glottis, provided minimal air leakage as the ventilation circuit was subjected to pressure of 1525 cmH_{2}O. When cuffed ETT type was used, cuff pressure was measured using a cuff manometer and was adjusted appropriately. Extubation was taking place in the operating room after completion of the surgical procedure.
After surgical procedure, an anesthesiologist who was not involved in the perioperative treatment of the patient, recorded the demographic data, the size and type (cuffed or uncuffed) of ETT used. The formulas used to estimate the body weight (BW) based on age were: 25y.o., BW (kg) = (2 x age in years) + 8 and for children 6 to 12y.o.^{8,9} BW (kg) = (3 x age in years) + 7.
All data recorded were analyzed using “SPSS Statistics for Windows, v.17.0 (SPSS Inc., Chicago, Ill., USA)”. Data were expressed as the mean (SD) and number of cases (%). ShapiroWilk normality test was conducted for each parameter. Paired ttests were used to analyze the differences between actual and predicted values. The level of significance was set at p < 0.05.
RESULTS
The study included 353 patients aged 2 to 12 years. Patients demographic and anesthesiasurgery related data are shown in Table 1. All patients in group 612 and 74.7% (n=59) of patients in group 25 were intubated with cuffed ETT (Table 1). Cuffed ETT was used in 94.3% of all patients (n=333).Thirty patients udergoing CABG surgery were enrolled into this study. Patient characteristics and comorbidities are described in Table 1.
Table 1. Demographic and anesthesiasurgery related data
All study groups
(n=353) 
Group 25
(n=79) 
Group 612
(n=274) 

Cuffed
ETT (n=59) 
Uncuffed
ETT (n=20) 
Total
(n=79) 
Cuffed
ETT (n=274) 

Age*
(yr) 
8
(3.7) 
3.9
(1.1) 
2.5
(1.1) 
3.5
(1.3) 
9.1
(2.2) 
Weight*
(kg) 
32.7
(16.2) 
18.2
(5.6) 
13.1
(2.9) 
16.9
(5.5) 
36.2
(13.2) 
Height *(m)  1.5
(5.7) 
1
(0.1) 
0.9
(0.1) 
1.3
(0.1) 
1.4
(0.1) 
BMI (kg)/(m^{2})  17.5
(3.98) 
16.2
(3.1) 
15.2
(2) 
15.7
(2.9) 
18.2
(4.1) 
Gender (M/F)
N (%) 
163/190 (46/57) 
34/25 
8/12

42/37 (53/46) 
121/153 (44/55) 
ASA ps(I/II)
N (%) 
307/46 (87/12) 
48/11

16/4

64/15 (81/19) 
243/31 (89/10) 
Type of
surgery N (%) elective /emergent 
240/113
(68/32) 
29/30

14/6

43/36
(54/45) 
197/77
(72/28) 
*Values are mean (SD), N= number of patients
In patients of group 25, regardless the type of ETT used (cuffed or uncuffed), the predicted ETT size was significantly lower than the actual size used (p<0.05) (Table 2).
Table 2. Group 25 ETT internal diameter predicted and used
Group 25yo
uncuffed ETT (n=20) 
Group 25yo
cuffed ETT (n=59) 

Predicted size

4.56(0.32)  4.58(0.38) 
Selected size  5(0.6)  4.82(0.67) 
pvalue

0,016*  0.000* 
CI (95%)  (0.240.72)  (0.108.036) 
Values are mean(SD), *p<0.05, CI: Confidence interval 95%
In patients of group 612 no statistically significant difference was noted between the predicted and selected internal diameter of the ETT (Table 3).
Table 3.Group 612 ETT internal diameter predicted and used
Group 612yo
cuffed ETT (n=274) 
pvalue  CI (95%)  
Predicted size  5.8(0.5)  0.462  (0,1060,002) 
Selected size  5.78(0.5) 
Values are mean(SD), *p<0.05, CI: Confidence interval 95%
In the individual age groups, the predicted body weight was significantly lower than the measured body weight (Table 4).
Table 4. Body Weight (BW) comparison using the APLS formula in study’s age groups
Measured BW  Predicted
BW 
p
value 
CI (95%)  
Group
25yrs (n=79) 
16.9(5.5)  15.1(.5)  0.002*  (0.852.77) 
Group
612yrs (n=274) 
36.2(13.2)  34.4(6.2)  0.003*  (1.213.62) 
Values are mean(SD), *p<0.05, CI: Confidence interval 95%
DISCUSSION
This study demonstrated that in our hospital, the traditional age based Cole’s formula for selecting the appropriate ETT size, was not reliable for children 2 – 5y.o. On the other hand, Cole’s formula was quite reliable when applied in children 612y.o. Also, this study suggested that the APLS formula, for the estimation of body weight, tends to underestimate the weight of children.
In children undergoing general anesthesia, with the application of oral ETT, is very important to use the correct size ETT, in order to reduce morbidity and mortality related to postintubation complications^{2,3}. Many different algorithms and formulas, sometimes complex, have been described in order to accurately choose the correct ETT size^{46}. Cole’s formula was introduced in 1954 and since then it has been used widely in anesthetic practice. Today, still remains one of the most used formulas in children^{4,5}. Although this formula gives a good estimation of the optimal internal diameter of the ETT, based on patient’s age, it’s not always accurate^{7,10,11}. Schramm et al demonstrated that the rate of agreement of age based Cole’s formula for ETT selection is low as 4777%^{12}. Raphael et al showed that ultrasound measurement of subglottic diameter had a significant advantage. The rate of agreement between clinically optimal and ultrasound guided ETT size was 98.5%. The rate of agreement between clinically optimal and formuladerived ETT size was 95.9%^{11}. Another limitation of Cole’s formula is that this formula cannot consider variation of growth in various internal organs during childhood. In our days also, the epidemic of childhood obesity means that a large population of overweight or obese children undergo surgery under general anesthesia. In these children the appropriate size of ETT cannot be accurately estimated due to the comparative increase in their airways size. Consequently, Cole’s formula which was applied more than 60 years ago, is likely to significantly underestimate the appropriate ETT size. Shibasaki et al noted that age based formulas generally predicted larger sizes than proved clinically optimal, sometimes by two or even three sizes^{13}. This does not follow our results, where age based formula significantly underestimated the correct ETT size in small children (2 to 5 years). In older children (6 to 12 years) the predicted ETT size was slightly, but not significantly, larger compared to the ETT size that was finally used. Our findings agreed with the results of Shiroyama et al where ETT size estimated by Cole’s formula tended to be smaller than practically appropriate ETT size for pediatric cardiac anesthesia patients^{14}.
The number of study patients of age group 25 who received uncuffed was small (n=20). That shows that the majority of anesthesiologists who delivered anesthesia in this age group preferred cuffed ETTs over uncuffed. In the past, cuffed ETTs were recommended only for use with specific circumstances in children below 8 years^{15,16}. Since then many authors suggested the use of cuffed ETTs in children younger than 8 years^{15,17}. The advantages are less gas leak around tracheal tube with improved efficiency of ventilation, reduced atmospheric pollution and more reliable endtidal CO_{2}^{15,18}. Furthemore, with cuffed ETT there is a decreased risk of aspiration and reduced need to change illfitting ETT and less use of over large uncuffed ETT, a main cause of subglottic stenosis^{15}. Khine et al found that the rate of reintubation required with uncuffed ETT was 30% in children younger than 2 years and 18% in children 2 years and older^{7,17}. Also, Clementes et al showed that, in elective anesthetized children between 1 to 8 years, the rate of ETT change in 251 children randomized to cuffed ETT was significantly lower compared to 237 children randomized to uncuffed ETT^{19}. In 2003, Litman et al examined the airways in children aged 2 months to 13 years with magnetic resonance imaging (MRI). The authors found an elliptical cricoid ring and that the narrowest portion of the larynx is at level of the vocal cords, although the functionally narrowest portion is at level of the nondistensible cricoid ring. These findings have implications for the fitting of uncuffed ETT, which provides adequate sealing not within a circular cricoid ring, where pressure would be distributed evenly upon the mucosa, but within an eclipse, where a leak around the tube could be present despite increased pressure against areas of the mucosa^{20,21}. In our study, we used a cuff manometer in order to measure the cuff pressure, when cuffed type ETT was used. It is known that proper management of cuff pressure is very important to the patient’s airway, especially in the pediatric patient^{22}. One crosssectional study performed among the pediatric population recommended that cuff pressures be set and monitored with a pressure manometer^{23}.
Body weight is one of most important measurements in pediatric anesthesia. BW is used to determine intravenous fluid requirements, shock voltage administered during cardiorespiratory arrest, endotracheal tube size and to assess nutritional status. Given that the majority of pediatric drug doses are calculated per kilogram of bodyweight basis, it is essential that the anesthesiologist have an accurate knowledge of the child’s BW. There are number of methods used to estimate weight in children^{2427}. The most commonly used is the age based Advanced Pediatric Life Support (APLS) formula. Several studies have shown that the original APLS formula tended to underestimate the actual weight and the margin of error increased with age^{9,28,29}. Following this, Luscombe and Owens developed a new formula, which had been found to be more accurate than APLS^{9,30}. So, as of July 2011, the APLS guidelines for weight estimation based on age have been altered according to child’s age. So, the original APLS formula is applied for children between the ages of 1–5, the Luscombe and Owens formula for those aged 6–12 and a specific infant formula for those aged less than 1 year old^{8}. These formulas were applied in our study population. Our findings suggest that the formulas used to predict BW underestimated all study patients BW. That means that both the original APLS formula and the Luscombe and Owens formula seem to be unreliable regarding BW estimation. The results of this study agreed with several subsequent studies in Australia and the UK, which also demonstrated the tendency of the APLS formula to underestimate BW in children^{8,9,29,31}. On the other hand, studies from India and South Africa found the original APLS to be more accurate. However, these populations are regarded as (rapidly) developing countries and perhaps these findings are not to be generalized, given the variation in body habitus between children from developed and developing countries^{30}. Also, it must be noted that in this study the patient’s weight was measured before surgery, although the parental estimation of child’s weight is considered a reliable method of BW estimation^{26}.
There are several limitations in this study. We assumed that the ETT size used in this study was the correct one, because we routinely checked the audible air leakage around the tube, to verify the accepted level between 15 and 25 cmH_{2}O. Many different anesthesiologists delivered anesthesia in study patients, which means that many different leak pressures were assessed. In addition, this study includes patients from a single center and lack of control for other variables, which may have influenced the ETT size.
CONCLUSION
This study suggests that Cole’s formula for predicting the correct ETT size (cuffed or uncuffed) is applicable in children aged 6 to 12 years. In younger children (2 to 5 years) it seems as if the above formula does not apply neither for cuffed nor for uncuffed ETT. We can speculate that larger population and a more accurate ETT estimation formula will affect clinical outcome. Our study also demonstrates that when the actual body weight cannot be obtained, the widely used APLS formula, tends to underestimate the weight of children in our geographical region.
References
 Harless J, Ramaiah R, Bhananker SM. Pediatric airway management. Int J Crit Illn Inj Sci. 2014;4:65–70.
 Davis D, Barbee L, Ririe D. Pediatric endotracheal tube selection: a comparison of agebased and heightbased criteria. AANA J. 1998;66:299303.
 Kim HY, Cheon JH, Baek SH, et al. Prediction of endotracheal tube size for pediatric patients from the epiphysis diameter of radius.Korean J Anesthesiol. 2017;70:527.
 Coté CJ, Todres ID, Goudsouzian NG, et al. A Practice of Anesthesia for Infants and Children. 3rd ed. Philadelphia, PA: WB Saunders Company; 2001.
 Bell C, Kain ZN, Hughes C. The Pediatric Anesthesia Handbook. 2nd ed. Philadelphia, PA: Mosby; 1997.
 Cole F. Selection of the proper endotracheal tube for a child. Anaesthesiol 1953;14:5067.
 Taylor C, Subaiaya L, Corsino D. Pediatric cuffed endotracheal tubes: an evolution of care. Ochsner J 2011;11:526.
 Advanced Life Support Group. Chapter 3 – Structured approach to emergency paediatrics. In: Kevin MJ, editor. Advanced Paediatric Life Support. The Practical Approach.5. Oxford: Blackwell Publishing; 2011. pp. 14–8.
 Luscombe M, Owens B. Weight estimation in resuscitation: is the current formula still valid? Arch Dis Child.2007;92:412–5.
 Saeed R, Sheikh NA, Qamar I, et al. Frequency of correctly estimated size of ETT with new age Base formula in children requiring general anesthesia with ETT. PJMHS 2013;4:10869.
 Raphael PO, Thasim E, Simon BP, et al. Comparative study on prediction of pediatric endotracheal tubes size by ultrasonography and by age based formulas. Inter J Res Med Sci 2016;4:252832.
 Schramm C, Knop J, Jensen K, et al. Role of ultrasound compared to age related formulas for uncuffed endotracheal intubation in a pediatric population. Paediatr Anaesth 2012; 22:7816.
 Shibasaki M, Nakajima Y, Ishii S, et al. Prediction of pediatric endotracheal tube size by ultrasonography. Anesthesiol 2010; 113:81924.
 Shiroyama K, Izumi H, Kubo T. Estimation of size of the uncuffed endotracheal tube for pediatric cardiac anesthesiaCole’s formula cannot estimate the appropriate tube size.Masui 2001;50:2846.
 Weiss M, Dullenkopf A, Gysin C, et al. Shortcomings of cuffed paediatric tracheal tubes. BJA 2004; 92:78–88.
 Fisher DM. Anesthesia equipment for pediatrics. In: Gregory GA, ed. Pediatric Anesthesia, 4th Edn. New York: Churchill Livingstone, 2001; 2078.
 Khine HH, Corddry DH, Kettrick RG, et al. Comparison of cuffed and uncuffed tracheal tubes in young children during general anesthesia. Anesthesiol 1997; 86:62731.
 Main E, Castle R, Stocks J, et al. The influence of tracheal tube leak on the assessment of respiratory function in ventilated children. Intens Care Med 2001; 27:178897.
 Clements RS, Steel AG, Bates AT, et al. Cuffed endotracheal tube use in paediatric prehospital intubation: challenging the doctrine? Emerg Med J, 2007; 24:57–8.
 Litman RS, Weissend EE, Shibata D, et al. Developmental changes of laryngeal dimensions in unparalyzed, sedated children. Anesth Analg.2003;98:41–5.
 Bhardwaj Pediatric cuffed endotracheal tubes. J Anaesthesiol Clin Pharmacol. 2013; 29:13–8.
 Sole ML, Penoyer DA, Su X, et al. Assessment of endotracheal cuff pressure by continuous monitoring: A pilot study. Am J Crit Care, 2009;18:13343.
 Sengupta P, Sessler DI, Maglinger P, et al. Endotracheal tube cuff pressure in three hospitals, and the volume required to produce an appropriate cuff pressure. BMC Anesthesiol 2004; 4:8.
 Thompson MT, Reading MJ, Acworth JP. Best Guess method for agebased weight estimation in paediatric emergencies: validation and comparison with current methods. Emerg Med Australas. 2007; 19:4903.
 Krieser D, Nguyen K, Kerr D, et al. Parental weight estimation of their child’s weight is more accurate than other weight estimation methods for determining children’s weight in an emergency department? Emerg Med J. 2007; 24:7569.
 Partridge RL, Abramo TJ, Haggarty KA, et al. Analysis of parental and nurse weight estimates of children in the pediatric emergency department. Pediatr Emerg Care. 2009; 25:8168.
 Gravesa L, Chayena G, Peat J, et al. A comparison of actual to estimated weights in Australian children attending a tertiary children’s’ hospital, using the original and updated APLS, Luscombe and Owens, Best Guess formulae and the Broselow tape. Resuscitation 2014;85:392–6.
 Argall JA, Wright N, MackwayJones K, et al. A comparison of two commonly used methods of weight estimation. Arch Dis Child 2003;88:789–90.
 Kelly AM, Nguyen K, Krieser D. Validation of the Luscombe weight formula forestimating children’s weight. Emerg Med Australas 2011;23:59–62.
 Tinning K, Acworth J. Make your Best Guess: an updated method for paediatric weight estimation in emergencies. Emerg Med Australas 2007;19:52834.
 Geduld H, Hodkinson PW, Wallis LA. Validation of weight estimation by age andlength based methods in the Western Cape: South Africa population. Emerg Med J 2011;28:856–60.
Author Disclosures:
Authors Papagiannopoulou P, Ntritsou V, Pistofidou K, Mademli A, Stefanovits D, Isaakidis A, Kostoglou Ch and Zachariadou Ch. have no conflicts of interest or financial ties to disclose.
Corresponding author:
Papagiannopoulou Pinelopi
Ad. Emmanouil 3 G. 54454,
Thessaloniki, Greece
email: