Showing papers on "Pain medicine published in 2005"
TL;DR: A "universal precautions" approach to the assessment and ongoing management of the chronic pain patient is described and a triage scheme for estimating risk that includes recommendations for management and referral is offered.
Abstract: The heightened interest in pain management is making the need for appropriate boundary setting within the clinician-patient relationship even more apparent. Unfortunately, it is impossible to determine before hand, with any degree of certainty, who will become problematic users of prescription medications. With this in mind, a parallel is drawn between the chronic pain management paradigm and our past experience with problems identifying the "at-risk" individuals from an infectious disease model. By recognizing the need to carefully assess all patients, in a biopsychosocial model, including past and present aberrant behaviors when they exist, and by applying careful and reasonably set limits in the clinician-patient relationship, it is possible to triage chronic pain patients into three categories according to risk. This article describes a "universal precautions" approach to the assessment and ongoing management of the chronic pain patient and offers a triage scheme for estimating risk that includes recommendations for management and referral. By taking a thorough and respectful approach to patient assessment and management within chronic pain treatment, stigma can be reduced, patient care improved, and overall risk contained.
493 citations
TL;DR: It is demonstrated that, in contrast to the highly significant role for Nav1.7 in determining inflammatory pain thresholds, the development of neuropathic pain does not require the presence of either Nav 1.7 orNav1.8 alone or in combination.
Abstract: Two voltage gated sodium channel α-subunits, Nav1.7 and Nav1.8, are expressed at high levels in nociceptor terminals and have been implicated in the development of inflammatory pain. Mis-expression of voltage-gated sodium channels by damaged sensory neurons has also been implicated in the development of neuropathic pain, but the role of Nav1.7 and Nav1.8 is uncertain. Here we show that deleting Nav1.7 has no effect on the development of neuropathic pain. Double knockouts of both Nav1.7 and Nav1.8 also develop normal levels of neuropathic pain, despite a lack of inflammatory pain symptoms and altered mechanical and thermal acute pain thresholds. These studies demonstrate that, in contrast to the highly significant role for Nav1.7 in determining inflammatory pain thresholds, the development of neuropathic pain does not require the presence of either Nav1.7 or Nav1.8 alone or in combination.
206 citations
203 citations
TL;DR: Initial support is provided that intrathecal gene therapy to drive the production of IL-10 may prove to be an efficacious treatment for neuropathic pain.
Abstract: Despite many decades of drug development, effective therapies for neuropathic pain remain elusive. The recent recognition of spinal cord glia and glial pro-inflammatory cytokines as important contributors to neuropathic pain suggests an alternative therapeutic strategy; that is, targeting glial activation or its downstream consequences. While several glial-selective drugs have been successful in controlling neuropathic pain in animal models, none are optimal for human use. Thus the aim of the present studies was to explore a novel approach for controlling neuropathic pain. Here, an adeno-associated viral (serotype II; AAV2) vector was created that encodes the anti-inflammatory cytokine, interleukin-10 (IL-10). This anti-inflammatory cytokine is known to suppress the production of pro-inflammatory cytokines. Upon intrathecal administration, this novel AAV2-IL-10 vector was successful in transiently preventing and reversing neuropathic pain. Intrathecal administration of an AAV2 vector encoding beta-galactosidase revealed that AAV2 preferentially infects meningeal cells surrounding the CSF space. Taken together, these data provide initial support that intrathecal gene therapy to drive the production of IL-10 may prove to be an efficacious treatment for neuropathic pain.
180 citations
156 citations
TL;DR: Behavioral testing of cold allodynia, hyperalgesia and pain will greatly facilitate the study of the neurobiological mechanisms involved in cold/cool sensations and enable measurement of the efficacy of pharmacological treatments to reduce these symptoms.
Abstract: Background
Pain is elicited by cold, and a major feature of many neuropathic pain states is that normally innocuous cool stimuli begin to produce pain (cold allodynia). To expand our understanding of cold induced pain states we have studied cold pain behaviors over a range of temperatures in several animal models of chronic pain.
153 citations
TL;DR: The preliminary data would seem to suggest that a direct move to the third step of the WHO analgesic ladder is feasible and could reduce some pain scores but also requires careful management of side effects.
Abstract: The aims of the present study were to verify whether an innovative therapeutic strategy for the treatment of mild-moderate chronic cancer pain, passing directly from step I to step III of the WHO analgesic ladder, is more effective than the traditional three-step strategy and to evaluate the tolerability and therapeutic index in both strategies. Patients aged 18 years or older with multiple viscera or bone metastases or with locally advanced disease were randomized. Pain intensity was assessed using a 0–10 numerical rating scale based on four questions selected from the validated Italian version of the Brief Pain Inventory. Treatment-specific variables and other symptoms were recorded at baseline up to a maximum follow-up of 90 days per patient. Fifty-four patients were randomized onto the study, and pain intensity was assessed over a period of 2,649 days. The innovative treatment presented a statistically significant advantage over the traditional strategy in terms of the percentage of days with worst pain ≥5 (22.8 vs 28.6%, p<0.001) and ≥7 (8.6 vs 11.2%, p=0.023). Grades 3 and 4 anorexia and constipation were more frequently reported in the innovative strategy arm, although prophylactic laxative therapy was used less in this setting. Our preliminary data would seem to suggest that a direct move to the third step of the WHO analgesic ladder is feasible and could reduce some pain scores but also requires careful management of side effects.
124 citations
TL;DR: There has been little examination of the use of distraction in chronic pain, but some ancillary evidence suggests that it should be used with caution.
Abstract: Engaging in thoughts or activities that distract attention from pain is one of the most commonly used and highly endorsed strategies for controlling pain. The process of distraction appears to involve competition for attention between a highly salient sensation (pain) and consciously directed focus on some other information processing activity. In this article, the evidence for distraction from pain is examined and the qualities of pain, the distractor, and some individual difference variables that have been shown influence the effectiveness of distraction are described. There has been little examination of the use of distraction in chronic pain, but some ancillary evidence suggests that it should be used with caution.
117 citations
TL;DR: There is definitely a place for weak opioids in the treatment of moderate cancer pain, and data on pharmacology, mechanisms of action, pharmacokinetics, side effects and clinical experience assessing analgesic efficacy, adverse reactions and safety of tramadol in cancer pain are summarized.
Abstract: In most cancer patients pain can be successfully treated with pharmacological measures using opioid analgesics alone or in combination with adjuvant analgesics (coanalgesics). Weak opioids are usually recommended in the treatment of moderate cancer pain. There is still a debate as to whether the second step of the WHO analgesic ladder comprising opioid analgesics such as tramadol, codeine, dihydrocodeine, and dextropropoxyphene is still needed for the treatment of cancer pain. On the basis of our experience and review of the literature we think that there is definitely a place for weak opioids in the treatment of moderate cancer pain. One of the most interesting and useful weak opioids is tramadol (Adolonta, Contramal, Nobligan, Top-Algic, Tramal, Tramal Long, Tramal Retard, Tramundin, Trodon, Ultram, Zydol). Its unique mechanism of action, analgesic efficacy and profile of adverse reactions have been the reason of performing many experimental and clinical studies with tramadol. In this article we summarize data on pharmacology, mechanisms of action, pharmacokinetics, side effects and clinical experience assessing analgesic efficacy, adverse reactions and safety of tramadol in cancer pain.
108 citations
TL;DR: Furlan AD, van Tulder MW, Cherkin DC, Tsukayama H, Lao L, Koes BW, Berman BM The Cochrane Database of Systematic Reviews 2005, Issue 1.
105 citations
TL;DR: Methadone is an opioid with complex properties, and a patient that is taking methadone can represent a unique challenge to the anesthesiologist, so a good understanding of the pharmacology of Methadone and of the type of patients on this medication will help to improve their perioperative care.
Abstract: Purpose
Methadone, an opioid traditionally associated with the management of opioid addictive disorders, has been prescribed increasingly as an analgesic for the management of various chronic pain conditions. Despite the increasing popularity of methadone, most anesthesiologists are not familiar with its complex pharmacology. The purpose of this article is to review the pharmacology of methadone and to suggest a management algorithm for the perioperative care of methadone patients.
TL;DR: Adenosine compounds have significant potential for alleviating various types of pain, and can reduce allodynia/hyperalgesia more consistently than spontaneous pain, suggesting that these compounds affect neuronal pathophysiological mechanisms involved in central sensitization.
Abstract: This review summarizes clinical application of adenosine and adenosine 5'-triphosphate (ATP) in pain conditions. Investigations have been performed in patients with acute perioperative pain or chronic neuropathic pain treated with intravenous adenosine or ATP, or intrathecal adenosine. Characteristic central adenosine A1 receptor-mediated pain-relieving effects have been observed after intravenous adenosine infusion in human inflammation/sensitization pain models and in patients with chronic neuropathic pain. Adenosine compounds, in low doses, can reduce allodynia/hyperalgesia more consistently than spontaneous pain, suggesting that these compounds affect neuronal pathophysiological mechanisms involved in central sensitization. Such pain-relieving effects, which are mostly mediated via central adenosine A1 receptor activation, have a slow onset and long duration of action, lasting usually for hours or days and occasionally for months. With acute perioperative pain, treatment with a low-dose infusion of adenosine compounds and the A1 receptor-mediated central antisensitization mechanisms may play only a minor part in the total perioperative pain experience. By administering sufficient doses of adenosine compounds during surgery, however, significant and long-lasting perioperative pain relief can be achieved via central A1 receptor-mediated antinociceptive/analgesic actions as well as via peripheral A2a or A3 receptor-mediated antiinflammatory actions. Thus, adenosine compounds have significant potential for alleviating various types of pain.
TL;DR: Behaviors that would cause the majority of all three nurse groups to refer to a patient as drug seeking were as follows: going to different emergency departments to get opioids, telling inconsistent stories about pain or medical history, or asking for a refill because the prescription was lost or stolen.
TL;DR: Molecular Pain, an Open Access, peer-reviewed, online journal, will provide a forum for molecular pain scientists to communicate their research findings in a targeted manner to others in this important and growing field.
Abstract: Molecular pain is a relatively new and rapidly expanding research field that represents an advanced step from conventional pain research. Molecular pain research addresses physiological and pathological pain at the cellular, subcellular and molecular levels. These studies integrate pain research with molecular biology, genomics, proteomics, modern electrophysiology and neurobiology. The field of molecular pain research has been rapidly expanding in the recent years, and has great promise for the identification of highly specific and effective targets for the treatment of intractable pain. Although several existing journals publish articles on classical pain research, none are specifically dedicated to molecular pain research. Therefore, a new journal focused on molecular pain research is needed. Molecular Pain, an Open Access, peer-reviewed, online journal, will provide a forum for molecular pain scientists to communicate their research findings in a targeted manner to others in this important and growing field.
TL;DR: The data suggest the importance of NMDA receptors in the genesis of chronic cancerPain and indicate that NMDA antagonists should be further studied for the management of cancer pain and, in particular, intractable pain.
Abstract: Despite medical awareness, intractable pain is a serious problem in cancer and occurs in up to 2% of advanced cancer patients. However, few data are available concerning the optimal treatment of such patients. The emergence of intractable pain may notably be due to the activation of N-methyl-D-aspartate (NMDA) receptors located in the central nervous system. NMDA antagonists might thus be an interesting approach in such pain syndromes. Twelve patients with intractable cancer pain received a test dose of 5–10 mg of ketamine, a strong NMDA antagonist, in order to determine their response and tolerance to the drug. Continuous intravenous infusions of ketamine associated with morphine were then administered. The acute test dose was successful in all cases (VAS <3/10 after 5 min). The prolonged use of ketamine allowed us to reduce the total daily dose of morphine required (range: 200–1,200 mg) by 50% and allowed eight patients to go home with a portable pump with morphine and ketamine during a relatively long period of time (range: 7–350 days, median: 58 days). Side effects were moderate (dizziness) and they were limited to the test phase. Our data suggest the importance of NMDA receptors in the genesis of chronic cancer pain and indicate that NMDA antagonists should be further studied for the management of cancer pain and, in particular, intractable pain.
TL;DR: There is an urgent need for an evidence-based set of exercise guidelines to be developed for patients and survivors based on the quality of evidence on which they were based.
Abstract: The benefit of exercise for cancer patients is starting to become recognized. The purposes of this paper were to review the literature to examine whether research findings are being converted into guidelines for patients and survivors and to examine the quality of evidence on which they were based. A computer search of major health databases was conducted for peer-reviewed literature and books on exercise and cancer, and an Internet search was conducted for cancer websites reporting any exercise guidelines/recommendations for cancer patients. Seven peer-reviewed articles, eight books and eight cancer websites were identified that suggested exercise guidelines for cancer patients and survivors. None of the published guidelines identified appeared to have been developed via a process that would allow them to be cited as evidence-based guidelines. Based on the studies to date, no direct cancer-specific evidence about the best type, frequency, duration or intensity of exercise is currently available in the peer-reviewed literature. It is currently not known what would be most beneficial for which cancers, at which stage of disease or treatment. Given the current interest in cancer and exercise, there is an urgent need for an evidence-based set of exercise guidelines to be developed.
TL;DR: It is indicated that there is marked heterogeneity in ICUs discharge practices, and that discharge decisions may be influenced by institutional factors.
Abstract: Objective
To describe intensive care unit (ICU) discharge practices, examine factors associated with physicians’ discharge decisions, and explore ICU and hospital characteristics and clinical determinants associated with the discharge process.
TL;DR: Percutaneous cervical cordotomy remains a valuable treatment in patients with treatment–resistant cancer pain and still deserves a place in the treatment of terminal cancer patients with severe unilateral neuropathic or incidence pain.
Abstract: The results obtained by percutaneous cervical cordotomy (PCC) were analysed in 43 terminally ill cancer patients treated in our institution from 1998 to 2001. We wished to determine whether there is still a place for PCC in the actual clinical situation with its wide choice of pain therapies. All patients had severe unilateral pain due to cancer, resistant to opioids and co–analgesics. Following PCC, mean pain intensity was reduced from Numeric Rating Scale (NRS) 7.2 to 1.1. At the end of life, pain had increased to NRS 2.9. Initially following PCC a good result (NRS<3) was obtained in 95% of patients. At the end of life, a good result was still present in 69% of patients. Mean duration of survival after the intervention was 118 days (2–1460). In general, complications were mild and mostly subsided within 3–4 days. There was one case of partial paresis of the ipsilateral leg. PCC remains a valuable treatment in patients with treatment–resistant cancer pain and still deserves a place in the treatment of terminal cancer patients with severe unilateral neuropathic or incidence pain.
TL;DR: The IASP curriculum is well covered in the present programmes in the Finnish medical faculties, however, the quality and the methods of teaching still need improvement.
Abstract: Little is known about how other than cancer pain related issues are represented in medical education. A standardised questionnaire was mailed to all medical students who graduated from the five Finnish medical schools in 2001. A total of 387 students received the questionnaire and 41% responded. The students had to evaluate the quantity and the quality of pain teaching. The availability and the participation in the advanced courses or research in pain medicine were asked. The students reported how the IASP curriculum on pain had been covered during the studies. Two clinical cases were presented for diagnosis and treatment. In addition to integrated pain teaching, specific pain education was received by 27% of the students. The departments of anaesthesiology were reported as the major deliverers of teaching of pain. The overall ratings of the pain-related teaching of the faculties varied from 3.4 to 4.6 on a scale of 10. Anatomy, biochemistry, physiology and pharmacology of pain were covered well. The definitions of pain, pain research, sociological issues, paediatric, geriatric and mentally retarded patients' pain were taught most poorly. Only 34% of the students had been offered advanced studies and 15% had been offered research projects in pain medicine. The lack of teaching about the concept of a multidisciplinary pain clinic was recognised by almost all students. The clinical problems were excellently solved. In conclusion, the IASP curriculum is well covered in the present programmes in the Finnish medical faculties. However, the quality and the methods of teaching still need improvement.
TL;DR: Factors that affect the efficacy and tolerability of opioid analgesics and clinical strategies for successful pain mangement are reviewed.
Abstract: Opioids are the oldest and most effective agents for the short- and long-term control of severe pain, particularly chronic cancer pain palliation. However, morphine and other opioids display wide variations in pharmacological efficacy and tolerability, and a significant number of patients are unable to achieve adequately controlled pain at doses that do not produce intolerable adverse effects. This article reviews factors that affect the efficacy and tolerability of opioid analgesics and clinical strategies for successful pain mangement.
TL;DR: Most ICU nurses in New Zealand reported that they are often involved in end-of-life EOL decisions, especially senior and European nurses.
Abstract: Objective
To investigate the prevalence and predictors of intensive care nurses’ active involvement in end-of-life (EOL) decisions.
TL;DR: A brief review of the evidence shows a link between marital functioning and pain, and the marital problems reported by patients with chronic pain in studies in this article are described.
Abstract: Throughout the past two decades, researchers have studied the close relationships of patients to understand the role that these relationships play in the maintenance and alleviation of pain and the role that pain plays in affecting relationships. In this article, a brief review of the evidence is provided, showing a link between marital functioning and pain, and the marital problems reported by patients with chronic pain in our studies also are described. We provide information about several promising couples pain management and couples therapy approaches that appear to help couples manage pain together. Recommendations for clinical and research directions also are offered.
TL;DR: The GlideScope® videolaryngoscope (Saturn Biomedical System Inc., Burnaby, BC, Canada) can exceed the utility of other instruments formerly considered indispensable in cases of foreseen difficult airway.
Abstract: To the Editor: The GlideScope® videolaryngoscope (Saturn Biomedical System Inc., Burnaby, BC, Canada) can exceed the utility of other instruments formerly considered indispensable in cases of foreseen difficult airway.1,2 On the basis of our experience with this device, which includes 200 patients to date, we would like to offer a series of considerations: 1) Following difficulties to appropriately insert the laryngoscope blade when we began to use the device, we decided to modify the insertion technique in such a way as to use the instrument like a Guedel tube; that is, to insert the blade in the patient’s mouth with the concave side looking up, before turning it 180o anticlockwise from the left to the right, to set it in place in the pharynx. This makes it possible to displace the tongue to the left and to minimize neck mobilization, while also allowing use of the device in cases of moderately limited mouth aperture. 2) “Steaming up” occurs to a greater or lesser degree. In our experience, optimal vision can be ensured with the GlideScope® by immersing the blade area containing the camera in lukewarm water for a few minutes before using the device. 3) We agree with Dr. Cooper3 that the main problem of intubation with the GlideScope® has to do with passing the endotracheal tube (ETT) through a glottis that is in full view; this is because the lens invades the blade channel. We have managed to solve this problem by using a thick, firm, 5.6-mm stylet. We also angulate the tube a little more than 60o. The ETT should be inserted with the concave side up, and must be turned clockwise from right to left while it is slid behind the videolaryngoscope, in such a way that it fits in between the device and the pharynx. This positions the tip of the ETT under the tip of the blade, and aims it correctly in the direction of the glottal orifice. Intubation difficulties with this device sometimes occur because the tip of the ETT collides with the anterior comissure of the glottis, a problem that can be minimized by turning the tube while it is inserted. On two occasions we solved this problem using a Fastrack® laryngeal-mask tube (LMA North America Inc., San Diego, CA, USA), which has a blunter tip than a conventional ETT. In both cases, we were able to slide it through the glottis easily, without causing trauma.
TL;DR: In this paper, the authors found that the magnitude of wind-up after-sensations appeared to be one of the best predictors for clinical pain intensity of fibromyalgia syndrome patients (27%).
Abstract: Central changes in pain processing have been previously reported in patients with fibromyalgia syndrome. These changes include decreased thresholds to mechanical and thermal stimuli (allodynia) and central sensitization, both of which are fundamental to the generation of clinical pain. Therefore, psychophysical measures of central pain processing may be useful predictors of clinical pain intensity of fibromyalgia syndrome patients. Previous studies of fibromyalgia syndrome patients have shown statistically significant correlations of psychophysical test results with clinical pain intensity. The tests used to characterize this important relationship were dependent on spinal cord pain mechanisms and included temporal summation of pain or wind-up and wind-up after-sensations. Particularly, the magnitude of wind-up after-sensations appeared to be one of the best predictors for clinical pain intensity of fibromyalgia syndrome patients (27%). Furthermore, the combination of tender point count, negative affect, and wind-up after-sensations accounted for approximately 50% of the variance in clinical pain intensity of fibromyalgia syndrome patients. Therefore, wind-up after-sensations, tender point count, and negative affect not only seem to represent relevant pain mechanisms but also strongly emphasize their importance for fibromyalgia syndrome pain.
TL;DR: In this article, the authors used levosimendan in two cases of septic shock with cardiac failure unresponsive to standard treatment (Table 1) and reported improvement in pulmonary venous oxygen saturation and a decline in serum lactate levels.
Abstract: calcium and opening the adenosine-triphosphate-sensitive potassium channels. In addition, it has phosphodiesterase-inhibiting properties [2]. Animal data (in vitro [2] and pre-treatment in vivo [3]) showed a positive effect when used in septic shock, as well as in different types of shock in humans, some of which were septic [4]. The drug’s mode of action in septic cardiac failure could also be different from calcium sensitivity [2]. We used levosimendan in two cases of septic shock with cardiac failure unresponsive to standard treatment (Table 1). Patient A was a 26-year-old, previous healthy female, admitted in shock due to bacterial pneumonia. Day 1: mechanical ventilation, fluid loading and continuous infusion of vasopressors improved the hemodynamic status but myocardial competence was getting worse with anuria, gut ischemia, intestinal bleeding, and cutaneous necrosis (Day 2). Patient B was a 79-year-old male, with dilated cardiomyopathy, admitted in shock due to acute cholangitis. Day 1: despite mechanical ventilation, fluid loading and continuous infusion of vasopressors, a severe hypo-dynamic state was present. Day 2: we tried to adjust vasopressor dosages without significant clinical change. In both cases, on day 3, a loading dose of levosimendan (12 μg/kg, but not in patient B because of atrial fibrillation at high frequency) followed by a 24-h continuous infusion at 0.1 μg·kg·min was administered. A clinical improvement of shock was recorded at 2 h of levosimendan administration. There was improvement of pulmonary venous oxygen saturation and a decline in serum lactate levels. The peak of the hemodynamic effect was reached between 6–18 h allowing a concomitant deIntensive Care Med (2005) 31:164–165 DOI 10.1007/s00134-004-2502-3 C O R R E S P O N D E N C E
TL;DR: It is demonstrated convincingly that use of this tube may "allow safe placement of the tracheal tube with a cuff-free laryngeal zone, without the risk for endobronchial intubation".
Abstract: Anesthesia, Weiss et al. evaluate the new Microcuff® pediatric endotracheal tube.1 These authors demonstrate convincingly that use of this tube may \"allow safe placement of the tracheal tube with a cuff-free laryngeal zone, without the risk for endobronchial intubation.\"1 This represents an advance in pediatric tracheal tube design, and leads us to re-examine the role of cuffed tracheal tubes in children. In the past, cuffed tubes were not recommended for use in young children, but recent clinical studies have shown that they may be safely used for anesthesia and critical care, even in the neonatal period.2,3 Concern about the inappropriate design of tubes,4 however, is driving the need to develop improved cuffed tubes for pediatric use. Endotracheal intubation for adult anesthesia was developed in the 1920s, however techniques and equipment for children were not readily available at that time. Intubation in children therefore was rarely attempted until the 1940s, and even then, the tubes available were potentially damaging to the airway. If a child required long-term airway control, this was usually achieved by tracheostomy, which carried its own hazards.5 In the 1960s, prolonged nasotracheal intubation with uncuffed tubes became accepted in pediatric intensive care units6 and subsequent experience has shown that this practice is very unlikely to lead to subglottic stenosis.7 Uncuffed endotracheal tubes therefore have a good record of safety in pediatric patients. With the recent reports of the safe use of cuffed tubes in both pediatric anesthesia2 and critical care3 environments, it is timely to consider the relative merits of cuffed and uncuffed tubes in children. Uncuffed endotracheal tubes are popular in pediatric anesthesia and critical care because of the flow dynamics of gas through these airways and the perceived low incidence of airway complications following their use. When cuffed endotracheal tubes are used in children, however, the practitioner must select a tube with a smaller internal diameter than with an uncuffed tube. This may not be that important when an eight-year-old is being intubated, but for an infant or smaller child, the increase in airway resistance with a smaller tube may be clinically significant. For example, the trachea of a one-year-old may only be able to accept a 3.5 or even a 3.0 mm internal diameter (ID) tube when a cuff is present. For a one-year-old to breathe through a 3.0 tube as opposed to a 4.0 tube represents something in the order of a threefold increase in airway resistance (Poisseuille’s law). This increase in airway resistance translates to an increased work of breathing. In most clinical situations, compensation for the increase in airway resistance can be achieved by using positive pressure ventilation and adjusting ventilator settings appropriately. However, there may be other complications from tubes with small ID, notably their tendency to occlude partially or completely with secretions. Clinical experience in the early days of prolonged intubation in neonatal intensive care units, and the associated occurrence of iatrogenic subglottic stenosis, lead to very reasonable concerns about potential damage to the airway. It was speculated that a tracheal cuff might cause undue pressure on the subglottic area and induce damage. It is difficult, however, to demonstrate a significant difference in airway complications between children intubated with either cuffed or uncuffed tubes. Several studies have compared outcomes with cuffed and uncuffed endotracheal tubes in the pediatric critical care area. Most recently, Newth et al. reported on 860 critically ill children who underwent endotracheal intubation at the Children’s Hospital EDITORIAL 669