Evaluation of an Intervention to Maintain Endotracheal Tube Cuff Pressure Within Therapeutic Range (original) (raw)
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Endotracheal tube cuff pressure: An overlooked risk
Anaesthesia, Pain & Intensive Care, 2021
The endotracheal tube (ETT) cuff's principal function is to implement proper tracheal sealing at a pressure high enough to prevent both gas leak and fluid aspiration, and low enough to maintain tracheal perfusion. Clinicians are often concerned primarily with the volume of air required to inflate an ETT cuff. However, the most important factor is how much pressure will be exerted on the tracheal mucosa when the cuff is properly distended. Cuff over-inflation complications range from sore throat to tracheal ischemia with tracheal rupture and fistula formation. The ideal ETT cuff pressure has not been defined with a high degree of certainty however most anesthesiologists generally recommend a target pressure of 20 to 30 cmH2O. Although trachea-gas sealing can be achieved at ETT cuff pressure of 20 cmH2O, microaspiration can occur at a cuff pressure of 60 cmH2O. Since the introduction of cuffed ETT in the mid-20th century, several modifications in the cuff's shape and material have been done to address these challenges. It has been proven that the pressure within the inflated cuff is a dynamic process. As such, various clinical factors will significantly impact the pressure reading. Thus, continuous regulation of ETT cuff pressure should be routine practice. Our review included 158 articles that addressed the background into the development of cuffed ETT, function and anatomy of the ETT cuff system, cuff pressure and sealing characteristics, ETT cuff pressure regulation, microaspiration, and factors affecting ETT cuff pressure.
BMC Anesthesiology, 2015
Background: Maintaining the cuff pressure of endotracheal tubes (ETTs) within 20-30 cmH 2 O is a standard practice. The aim of the study was to evaluate the effectiveness of standard practice in maintaining cuff pressure within the target range. Methods: This was a prospective observational study conducted in a tertiary-care intensive care unit, in which respiratory therapists (RTs) measured the cuff pressure 6 hourly by a handheld manometer. In this study, a research RT checked cuff pressure 2-4 h after the clinical RT measurement. Percentages of patients with cuff pressure levels above and below the target range were calculated. We identified predictors of low-cuff pressure. Results: We analyzed 2120 cuff-pressure measurements. The mean cuff pressure was 27 ± 2 cmH 2 O by the clinical RT and 21 ± 5 cmH 2 O by the research RT (p < 0.0001). The clinical RT documented that 98.0 % of cuff pressures were within the normal range. The research RT found the cuff pressures to be within the normal range in only 41.5 %, below the range in 53 % and above the range in 5.5 %. Low cuff pressure was found more common with lower ETT size (OR, 0.34 per 0.5 unit increase in ETT size; 95 % CI, 0.15-0.79) and with lower peak airway pressure (OR per one cm H 2 O increment, 0.93; 95 % CI, 0.87-0.99) on multivariate analysis. Conclusions: Cuff pressure is frequently not maintained within the target range with low-cuff pressure being very common approximately 3 h after routine measurements. Low cuff pressure was associated with lower ETT size and lower peak airway pressure. There is a need to redesign the process for maintaining cuff pressure within the target range.
Endotracheal tube cuff pressure monitoring: a review of the evidence
Journal of perioperative practice, 2011
Tracheal intubation constitutes a routine part of anaesthetic practice both in the operating theatre as well as in the care of critically ill patients. The procedure is estimated to be performed 13-20 million times annually in the United States alone. There has been a recent renewal of interest in the morbidity associated with endotracheal tube cuff overinflation, particularly regarding the rationale and requirement for endotracheal tube cuff monitoring intra-operatively.
Pilot Study Assessment of Endotracheal Cuff Pressure by Continuous Monitoring: A
2010
Background Endotracheal tube cuff pressure must be maintained within a narrow therapeutic range to prevent complications. Cuff pressure is measured and adjusted intermittently. Objectives To assess the accuracy and feasibility of continuous monitoring of cuff pressure, describe changes in cuff pressure over time, and identify clinical factors that influence cuff pressure. Methods In a pilot study, data were collected for a mean of 9.3 hours on 10 patients who were orally intubated and receiving mechanical ventilation. Sixty percent of the patients were white, mean age was 55 years, and mean intubation time was 2.8 days. The initial cuff pressure was adjusted to a minimum of 20 cm H 2 O. The pilot balloon of the endotracheal tube was connected to a transducer and a pressure monitor. Cuff pressure was recorded every 0.008 seconds during a typical 12-hour shift and was reduced to 1-minute means. Patient care activities and interventions were recorded on a personal digital assistant. Results Values obtained with the cufflator-manometer and the transducer were congruent. Only 54% of cuff pressure measurements were within the recommended range of 20 to 30 cm H 2 O. The cuff pressure was high in 16% of measurements and low in 30%. No statistically significant changes over time were noted. Endotracheal suctioning, coughing, and positioning affected cuff pressure. Conclusions Continuous monitoring of cuff pressure is feasible, accurate, and safe. Cuff pressures vary widely among patients.
2019
Background: Usually, the endotracheal tube cuff pressure is controlled by cuff pressure monitoring. However, the intermittent pilot-manometer connection and disconnection may cause a change in the adjusted pressure. This study aimed to investigate changes in the endotracheal tube cuff pressure using both manual and intermittent controls. Materials and Methods: A semi-experimental within-subject design was conducted. Fifty-nine intubated patients in the Mazandaran Intensive Care Units (ICUs) participated through convenience sampling in 2018. In the control condition, first, the cuff pressure was adjusted in 25 cm H2O then it was measured without manometer-pilot disconnection at 1 and 5 min intervals. In the intervention condition, cuff pressure was immediately adjusted in 25 cm H2O then it was measured with manometer-pilot disconnection in the 1st and 5th minutes. Data analysis was performed using Independent t-test, Chi-square test, and Phi coefficient. Results: The mean and Standard Deviation (SD) change of cuff pressure after 1 minute, from 25 cm H2O, in the intervention condition was 20.22 (3.53) cm H2O. The mean (SD) of this change in the control condition was 25.22 (3.39) cm H2O. This difference was significant (t116= 7.83, p < 0.001, d = 1.44). The mean (SD) change of cuff pressure after 5 minutes, from 25 cm H2O, in the intervention condition was 19.11 (2.98) cm H2O. The mean (SD) of this change in the control condition was 25.47 (4.53) cm H2O. This difference was significant (t116= 9.24, p < 0.001, d = 1.70). Conclusions: The tracheal tube cuff pressure has been significantly reduced during manual intermittent measuring. Therefore, it is suggested that continuous cuff pressure monitoring and regulation should be used.
Factors Affecting Endotracheal Tube Cuff Pressure Measurement: A Review of Literature
2018
NahlaShaaban Ali Khalil, Reham Ahmed Mohamed Salama, Warda Youssef Mohammed, Mohamed Soliman Sayed Assist professor of Critical Care and Emergency Nursing, Faculty of Nursing, Cairo University Clinical Instructor of Critical Care and Emergency Nursing, Faculty of Nursing, Cairo University Prof. of Critical care and Emergency Nursing, Faculty of Nursing, Cairo University Lecturer of Critical Care Medicine, Faculty of Medicine, Cairo University
South African Medical Journal, 2013
Tracheal stenosis is a potentially life-threatening complication that occurs as a result of damage to the endotracheal mucosa. Healing by granulation and re-epithelialisation causes cicatricial stenosis. [1,2] The stenosis may present weeks to months after intubation, often as an airway emergency, and is difficult and costly to treat. The incidence of post-intubation tracheal stenosis in intensive care patients is as high as 20% in some centres. [2] Endotracheal intubation is associated with varying degrees of tracheal injury. Autopsy studies have shown that maximal damage always occurs at the site of the cuff. [1] An over-pressurised endotracheal cuff impairs mucosal blood flow, causing ischaemia. [3] The recommendation arising out of this study was that cuff inflation pressure should not exceed 30 cmH 2 O. Early pathological changes are superficial tracheitis and fibrin deposits to shallow ulcerations overlying the anterior portion of the cartilaginous rings. The size and extent of the ulcers increase with time, leading to exposure of the cartilaginous rings. Softening, splitting and fragmentation of the cartilage follow at a later stage. [1] Many studies have shown that digital balloon palpation corresponds poorly with the actual measured endotracheal cuff pressure. [4-11] Despite this evidence, endotracheal cuff pressure manometers are not readily available in the theatre complex at Groote Schuur Hospital (GSH), Cape Town, South Africa (SA), and there are no manometers available in the trauma and emergency departments. Previous studies have shown unacceptably high cuff pressures in the prehospital setting and in emergency departments. [9,12,13] Considering the high rates of trauma in SA, it is important to prevent iatrogenic complications in these patients. To our knowledge, no studies have measured endotracheal cuff pressures in trauma or emergency patients in SA. The purpose of this study was to evaluate cuff pressures in the GSH trauma centre and theatre complex and to assess whether objective monitoring of cuff pressures with manometers is warranted. Secondary outcomes were whether the tube make or size and the place of intubation affected cuff pressure. Method An audit was conducted over a 4-month period at GSH. The audit consisted of 91 intubated patients in the trauma centre and 100 intubated patients in the theatre complex. They were randomly selected and their cuff pressures were measured by a single investigator to decrease inter-user variability. A minimum sample size of 16 patients per group was calculated to achieve 91% power to detect a difference of 30.0 between the null hypothesis (that both group means are 55.0) and the alternative hypothesis (that the mean of group 2 is 25.0), with known group standard deviations of 33.0 and 15.0 and with a significance level (alpha) of 0.05000, using a two-sided Mann-Whitney test assuming that the actual distribution is uniform. We used a larger sample size because we wanted to perform subgroup analyses. All data collected were recorded on a standardised datasheet and transcribed to an electronic database for analysis. Cuff pressures were measured using a Mallinckrodt cuff pressure gauge, for which the Endotracheal tube cuff pressures-the worrying reality: A comparative audit of intra-operative versus emergency intubations