Evaluating the Knowledge of Endotracheal Cuff Pressure Monitoring Among Critical Care Providers by Palpation of Pilot Balloon and By Endotracheal Tube Cuff Manometer (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.
Anesthesiology and Pain Medicine, 2015
Background: Endotracheal Tube Cuff Pressure (ETCP) should be kept in the range of 20-30 cm H 2 O. Earlier studies suggested that ETCP assessment by palpation of pilot balloon results in overinflation or underinflation and subsequent complications such as tracheal wall damage and aspiration. Objectives: The current study aimed to evaluate the effect of an in vitro educational program on the ability of anesthesia personnel to inflate Endotracheal Tube Cuffs (ETT) within safe pressure limits. Patients and Methods: The survey included two series of blinded ETCP measurements in intubated patients before and two weeks after an in vitro educational intervention. The in vitro educational program included two separate trials. The anesthesia personnel were asked to inflate an ETT cuff inserted in a tracheal model using their usual inflation technique. In the same session, six ETTs at different pressure levels were examined by the participants and their estimation of ETCP was recorded. After the in vitro assessment, the participants were informed about the actual pressure of the in vitro ETCPs and were allowed to train their fingers by in vitro pilot balloon palpation with validated manometer measurements. Results: The mean ETCP after the in vitro survey was significantly lower than the mean ETCP before the intervention (45 ± 13 vs. 51 ± 15 cm H 2 O, P = 0.002). The rate of measurements within the safe pressure limits significantly improved after the in vitro education (24.2% vs. 39.7%, P = 0.002). Conclusions: Implementing educational programs with the introduction of estimation techniques besides the use of manometer as a standard intraoperative monitoring will improve the safety of the practice.
Signa Vitae - A Journal In Intensive Care And Emergency Medicine
Introduction. Endotracheal tube (ETT) cuff pressure is not usually measured by manometer and the providers rely on their estimation of cuff pressure by palpating the pilot balloon. In this study, we evaluated the pressure of ETT cuffs inserted by emergency physicians or anesthesiologists, and assessed the accuracy of manual pressure testing in different settings using a standard manometer. Methods. In this cross sectional study, the cuff pressure of 100 patients in emergency department (ED) and intensive care units (ICU) of two university hospitals was evaluated by using a sensitive and accurate analog standard manometer after insertion of the ETT and checking the pilot balloon by the provider. All measurements were performed by a person who was blinded to the study purpose and an ideal pressure range of 20 to 30 cmH 2 O was used for analysis. Results. Emergency physicians (n=58) and anesthesiologists (n=42) performed the intubations. The mean measured cuff pressure in our study was 69.2±29.8 cmH 2 O (range: 10-120 cmH 2 O) which was significantly different from the recommended standard value of 25 cmH 2 O (P<0.0001, one-sample t-test). No difference was found between anesthesiologists and emergency physicians in cuff inflation pressures (Anesthesiologists = 71.1 ± 25.7; Emergency physicians = 67.9±32.6). Conclusion. Estimation of cuff pressure using palpation techniques is not accurate. In order to prevent adverse effects of cuff overinflation, it is better to recheck the pressure using a manometer, regardless of place, time and the inserter of the endotracheal tube.
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.
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.
Background: Appropriate management of endotracheal tube (ETT) cuff pressure is essential during mechanical ventilation of an intubated patient. The ETT cuff should be inflated in order to seal the airway without volume loss or pharyngeal content aspiration. It is desirable that the cuff seal the airway without exerting high pressure on the trachea to compromise mucosal circulation. The aim of this study is to assess importance of monitoring of ETT cuff pressure in intubated patients and effect of intervention in preventing complications related to over and under inflation of ETT cuff . Method: An observational prospective study performed between January and April 2015. All patients having cardiac surgery with cuffed ETT insertion were included. In Group1 cuff pressure manometer was used to monitor the cuff pressure and adjusted in the range of 20-30 cm H2O within 15 min before going on cardiopulmonary bypass. In Group2 only minimal leak test (MLT) done to guide inflation and cuff pressure measured by cuff pressure manometer but no intervention was made. Patients were followed in postsurgical care till extubation and observed till discharge for complication like sore throat, voice changes and tracheomalacia. Results: In group 1 9(25.7%) patient had cuff pressure within normal limit whereas 25 (71.4%) patient had cuff pressure higher than normal and 1 (2.9%) patient had cuff pressure measurement less than 20 cm H2O. Volume of air added or removed from cuff was -0.89 ± 1.14 to optimize cuff pressure. Cuff pressure ranged from 15 to 120(47 ± 23) cm H2O.In group 2 11(32.4%) patient had cuff pressure within normal limit whereas 22 (64.7%) patients had cuff pressure higher than normal and 1 (2.9%) patient had cuff pressure measurement less than 20 cm H2O. Cuff pressure ranged from 18 to 100(47.4±20.3) cm H2O. In group 1, 11 patients developed hoarse voice compared to 32 patients in group 2. P=0.000 In group 1, 15 patient developed sore throat versus 21 patients in group 2, P = 0.187. Conclusion: Measurements of endotracheal tube intra cuff pressure are essential to avoid over or under inflation of ETT cuff. Adjusting the cuff pressure to 20-30cmH2O will prevent volume loss during ventilation and complications like sore throat, hoarseness of voice and tracheomalacia. Measurement of cuff pressure with timely intervention should be made standard of care in operation theatre and ICU.
Journal of clinical anesthesia and pain management, 2022
Objective: The purpose of this study was to examine cuff inflation techniques and corresponding pressure estimations, as well as associated complications, in patients undergoing general anaesthesia with intubation for cesarean delivery at the Tamale Teaching Hospital's obstetric unit. Methods: Finger palpation of the pilot balloon, predetermined volume of air, and a pressure gauge were used to measure endotracheal tube (ETT) cuff pressure after intubation. Associated side effects were determined after 24 hours of endotracheal tube extubation. Results: Data for 384 patients were included in the analysis. Cuff pressure measured among patients varied from < 20-30 cmH 2 O for the standard manometer group, 20 to 50 cmH 2 O for the predetermined volume of air group and < 20 to > 50 cmH 2 O for the finger palpation group. Side effects were recorded in 2.4% of patients from the standard manometer group, 53.2% from the predetermined volume of air group and 83.6% from the finger palpation group. Conclusion: The finger palpation of a pilot balloon technique for cuff pressure estimation was unreliable and prone to cuff over inflation and associated with post-extubation airway complaints. Cuff pressure estimation using the standard manometer was associated with satisfactory patient outcomes.
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
Anesthesiology Research and Practice, 2017
Background Both under- and overinflation of endotracheal tube cuffs can result in significant harm to the patient. The optimal technique for establishing and maintaining safe cuff pressures (20–30 cmH2O) is the cuff pressure manometer, but this is not widely available, especially in resource-limited settings where its use is limited by cost of acquisition and maintenance. Therefore, anesthesia providers commonly rely on subjective methods to estimate safe endotracheal cuff pressure. This study set out to determine the efficacy of the loss of resistance syringe method at estimating endotracheal cuff pressures. Methods This was a randomized clinical trial. We enrolled adult patients scheduled to undergo general anesthesia for elective surgery at Mulago Hospital, Uganda. Study participants were randomized to have their endotracheal cuff pressures estimated by either loss of resistance syringe or pilot balloon palpation. The pressures measured were recorded. Results One hundred seventy-...
Evaluation of an Intervention to Maintain Endotracheal Tube Cuff Pressure Within Therapeutic Range
American Journal of Critical Care, 2011
Background Endotracheal tube cuff pressure must be kept within an optimal range that ensures ventilation and prevents aspiration while maintaining tracheal perfusion. Objectives To test the effect of an intervention (adding or removing air) on the proportion of time that cuff pressure was between 20 and 30 cm H 2 O and to evaluate changes in cuff pressure over time. Methods A repeated-measure crossover design was used to study 32 orally intubated patients receiving mechanical ventilation for two 12-hour shifts (randomized control and intervention conditions). Continuous cuff pressure monitoring was initiated, and the pressure was adjusted to a minimum of 22 cm H 2 O. Caregivers were blinded to cuff pressure data, and usual care was provided during the control condition. During the intervention condition, cuff pressure alarm or clinical triggers guided the intervention. Results Most patients were men (mean age, 61.6 years). During the control condition, 51.7% of cuff pressure values were out of range compared with 11.1% during the intervention condition (P < .001). During the intervention, a mean of 8 adjustments were required, mostly to add air to the endotracheal tube cuff (mean 0.28 [SD, 0.13] mL). During the control condition, cuff pressure decreased over time (P < .001). Conclusions The intervention was effective in maintaining cuff pressure within an optimal range, and cuff pressure decreased over time without intervention. The effect of the intervention on outcomes such as ventilator-associated pneumonia and tracheal damage requires further study.