Printer Friendly

Endotracheal tube cuff pressure monitoring: a review of the evidence.

This review describes the pathophysiology associated with inflated ET tube cuffs and the complications associated with excessive cuff pressure on the tracheal mucosa. Current practice in the specialties of anaesthesia, emergency medicine and intensive care is described. The review finally describes practical techniques of minimising complications secondary to cuff overinflation and provides 'safe' cuff pressure limits and monitoring recommendations based on best current scientific evidence.

Introduction

The first documented case of endotracheal intubation was described by Hippocrates (460-380 BC). Today endotracheal intubation forms a core skill of anaesthetic practice and training worldwide. Intubation of the trachea with an endotracheal tube (ET tube) is a very common anaesthetic procedure estimated to be performed 13-20 million times annually in the United States alone (Lovett et al 2006).

ET tubes are commonly used to either facilitate positive pressure ventilation (PPV) or to protect a patient's airway from aspiration of gastric contents. The cuff near the distal tip of the ET tube is inflated with air to create an airtight seal to allow PPV and to prevent passage of pharyngeal or gastric contents into the airway. In order to prevent aspiration, the pressure exerted by the cuff onto the wall of the trachea should exceed the sum of the hydrostatic pressure generated by a column of liquid above the cuff and the negative pressure generated during inspiration (Mehta & Myat 1984). Two main approaches for creating an adequate seal using an ET tube cuff are recommended: the minimal leak technique (MLT) (Crimlisk et al 1996) and the minimal occlusive volume (MOV) (Crimlisk et al 1996, Guyton et al 1997). MLT is the smallest volume of air in the ET tube cuff that allows for a small air leak of 50-100 ml tidal volume decrease on inspiration (St John 2004). MOV is the smallest volume of air needed in the ET tube cuff to prevent any air leak on inspiration. Many clinicians prefer MOV in ventilator-dependent patients because it improves the likelihood that the set ventilator volume will be delivered.

Most modern tubes are made from polyvinyl chloride. They have a high-volume, low-pressure cuffed design that conforms to the shape of the trachea. Damage to the tracheal mucosa caused by high volume cuffs is more superficial than that caused by low volume high pressure cuffs (Loeser et al 1978a). These polyvinyl ET tubes have largely replaced the older red rubber tubes which have a small-volume, high-pressure cuff (Figure 1) which predisposes patients to tracheal ischaemic complications, particularly during long-term use (Riley et al 1999).

Pathophysiology: ET tube cuff pressure overinflation

The pressure of the cuff against the tracheal wall depends on the compliance of the trachea and cuff. Pressure measured at the pilot balloon of an ET tube cuff can be considered a good estimate of the pressure exerted onto the tracheal mucosa by the cuff. Sengupta (Sengupta et al 2004) and Hoffman (Hoffman et al 2009) described a linear relationship between the measured cuff pressure and the volume of air inserted into the cuff. Hoffman et al (2009) described this relationship with a 97% linear correlation. In addition to this they found that no correlation existed between the measured cuff pressure and the age, sex or height of the patients studied. The measured cuff pressure as a function of ET tube size also did not differ. The pressure inside the ET tube cuff is increased by a variety of factors including: patient position (Godoy et al 2008), head position (Brimacombe et al 1999), cuff position (Bernhard et al 1985), cuff volume (Sengupta et al 2004), temperature (Atlas 2005), and nitrous oxide anaesthesia (Mitchell et al 1999). Regression equation calculations indicate that injected cuff volumes between 2 and 4ml usually produce cuff pressures between 20 and 30cm[H.sub.2]O independent of tube size (Sengupta et al 2004). However, there is variability between patients in the volume of air required to achieve these pressures. Measuring cuff pressures of individual patients therefore is superior to injecting a pre-determined volume of air into the cuff (Sengupta et al 2004).

[FIGURE 1 OMITTED]

Overinflation of an ET tube cuff is defined as the injection of a volume of air larger than that needed to create an adequate seal between the cuff and the tracheal wall. This excess volume of air can cause excessive pressure inside the cuff which can subsequently be transmitted onto the tracheal mucosal wall and surrounding anatomical structures. Cuff-related tracheal damage is influenced by the amount of lateral wall pressure and the duration of intubation. Direct measurements of mucosal pressures exerted by ET tube cuffs on the tracheal wall demonstrate that cuff pressures are highest anteriorly and lowest posteriorly (Brimacombe et al 1999). Blood flow in the antero-lateral part of the trachea has been reported to be compromised at pressures exceeding 30cm[H.sub.2]O and obstructed at pressures exceeding 50cm[H.sub.2]O in normotensive patients (Seegobin & van Hasselt 1984). The membranous posterior tracheal wall, however, shows less evidence of reduction in blood flow because it is more distensible than the cartilaginous antero-lateral wall. The higher anterior tracheal wall pressure may explain why cuff-related tracheal damage is most severe over the anterior trachea (Cooper & Grillo 1969).

A study by Brimacombe et al (1999) indicated that, compared with the neutral head-neck position, mucosal pressure exerted on the tracheal wall by the ET tube increased by 22mmHg on the anterior aspect of the ET tube in the flexed position (p = 0.003) and by 11mmHg in the extended position (p = 0.002). The pressure increased by 5 mmHg at the anterior tip and lateral aspect of the cuff in the rotated position. Although evidence from human studies is lacking, cuff overinflation for greater than 15 minutes appears to be an important determinant of tracheal capillary hypoperfusion in animal models (Nordin et al 1977). A diagrammatic representation of mechanism of tracheal mucosal perfusion injury secondary to endotracheal tube cuff overinflation is shown in Figure 2.

[FIGURE 2 OMITTED]

The development of tracheal mucosal damage can be seen as a direct consequence of tracheal mucosal hypoperfusion. Tu et al (1999) related elevated cuff pressures (associated with general anaesthesia using nitrous oxide) to significantly increased frequency and severity of tracheal mucosal lesions on fibreoptic examination prior to extubation. ET tube cuffs filled with a 50:50 mixture of nitrous oxide and oxygen (equating to the gas mixture used during anaesthesia) compared to air, resulted in lower cuff pressures throughout the procedure and a reduced incidence of tracheal lesions (p<0.001). Combes et al (2001) similarly demonstrated the effect of nitrous oxide anaesthesia on cuff pressures in ET tube cuffs filled with air versus saline. In this study cuffs filled with air were associated with an increased incidence of sore throat and related tracheal mucosal erosion evidenced by bronchoscopy on extubation. It should also be noted that additional patient factors can predispose the larynx and trachea to injury, in particular diabetes mellitus, congestive cardiac failure, stroke, and infection (Volpi et al 1987).

Complications of increased ET tube cuff pressures

Tracheal and laryngeal morbidity occur frequently after tracheal intubation, with an incidence ranging from 15 to 94% (Loeser et al 1976, Loeser et al 1978a,b, Jensen et al 1982, Mandoe et al 1992, Suzuki et al 1999, Bennet et al 2000). Serious complications associated with increased ET tube cuff pressures are outlined in Table 1. The true incidence of many of these complications is unknown, since they may not be diagnosed or investigated. Furthermore, low lateral tracheal wall pressure alone does not guarantee prevention of tracheal injury (Wu et al 1973), and a case of tracheal dilatation and rupture despite careful monitoring and keeping cuff pressures below 30 cm[H.sub.2]O has been previously reported (Luna et al 1993).

The most frequently reported symptoms following tracheal intubation are sore throat and hoarseness with an incidence between 15% and 80% (Winkel & Knudsen 1971, Loeser et al 1976, Loeser et al 1978a,b, Jensen et al 1982, Harding & McVey 1987, Stout et al 1987, Stride 1990, Herlevsen et al 1992, Christensen et al 1994, Joshi et al 1997, Bennet et al 2000). Historically, these symptoms were often considered to be minor unavoidable complications of general anaesthesia (Riding 1975). The influence of limiting ET tube cuff pressure on the incidence of sore throat is unclear. Sore throat and hoarseness are associated with different types of endotracheal tubes regardless of ET tube cuff pressure (Jensen et al 1982, Stenqvist & Nilsson 1982, Combes et al 2001). Intubation can cause sore throat with an incidence of 40% when uncuffed ET tubes are used (Loeser et al 1980). The incidence of dysphagia following intubation ranges between 15 and 94% (Mandoe et al 1992, Suzuki et al 1999) and does not appear to be associated with excessive ET tube cuff pressures (Combes et al 2001, Braz et al 2004).

The incidence of sore throat was reduced in one randomised study of 190 patients with pressures <20cm[H.sub.2]O compared with 2034cm[H.sub.2]O (Suzuki et al 1999). Similar results were demonstrated by Mandoe et al (1992) who studied 48 patients and demonstrated a lower incidence of sore throat in patients with pressures maintained <20 cm[H.sub.2]O. However, another randomised study of 126 patients did not corroborate these results and concluded that, although the use of saline rather than air to inflate the ET tube cuff during nitrous oxide anaesthesia lowers intra-cuff pressure, this is not an important factor in the development of sore throat or hoarseness postoperatively (Bennet et al 2000). A drawback of a number of these studies is the lack of standardised intubating conditions, anaesthetic technique and the use of further adjuncts such as nasogastric tubes (Bennet et al 2000).

More recently a prospective, randomised, controlled, multi-centre trial in China studied over 500 patients receiving a standard anaesthetic technique and evaluated complications in the first 24 hours postoperatively. In the control group ET tube cuffs were inflated by the anaesthetist according to personal experience with no pressure measurement. The study group patients had cuff pressures adjusted to within a range of 20-34cm[H.sub.2]O using a pressure monometer. The 273 control group patients demonstrated a higher incidence of postoperative sore throat (p= 0.03), hoarseness (p= 0.001) and blood streaked expectorations (p= 0.002) when compared to the 236 study group patients. The incidence of these symptoms was found to increase in both control and study groups with increasing duration of endotracheal intubation. Additionally, fibreoptic examination of 20 randomly selected patients from each group at the end of surgery demonstrated increased tracheal mucosal injury in the control group (p= 0.043) (Liu et al 2010). One limitation of this study was the failure to blind the researchers when following up the patients. In addition, the study did not describe symptoms caused by different ET tube types, cuff pressures were only measured at the beginning of the cases, follow-up did not exceed 24 hours, and no tracheal histology was examined.

A ratio of greater than 1.5:1.0 of cuff: tracheal diameter on a plain chest radiograph has been found to be predictive of severe tracheal injury in ICU patients (Crimlisk et al 1996). This technique is obviously impractical during anaesthesia. Special equipment and various practices have been introduced to help reduce the risk of excessive ET tube cuff pressure and potential related tracheal injury. Examples of these are outlined in Table 2. Maintenance of a constant and low ET tube cuff pressure is the key to minimising tracheal injury. The ideal cuff may be one that would be inflated in synchrony with the inspiratory phase and partially deflated on exhalation to prevent tracheal injury. The Brandt(tm) anaesthesia tube contains such a pressure-regulated cuff system designed to prevent cuff pressure in excess of 34cm[H.sub.2]O by allowing the cuff to communicate with the pilot balloon through the inflation line, but this has a prohibitive cost making its routine use unlikely in daily anaesthetic practice (Mandoe et al 1992).

Current clinical practice

Although palpation of the ET tube pilot balloon is common practice (Pollard & Lobato 1995), several studies have demonstrated the inability of intensive care physicians, anaesthetists prehospital, emergency physicians and critical care nursing staff to accurately determine ET tube cuff pressure by palpation alone (Foroughi & Sripada 1997, Hoffman et al 2006, Fernandez et al 1990, Ganner 2001). Moreover, no correlation exists between years in practice or number of intubations performed yearly and the ability to properly inflate ET tube cuffs or detect overinflation (Hoffman et al 2006).

The pressure in the ET tube cuff can be determined with a small aneroid cuff pressure manometer (Bouvier 1981, Stewart et al 2003, Fan et al 2004). A variety of different devices are commercially available from multiple manufacturers. They are relatively inexpensive and virtually indestructible (Willis et al 1988, Abdelatti & Kamath 1997, Francis 1998, Farre et al 2002).

Anaesthesia

Cuff pressure measurement during anaesthesia has been recommended to limit the incidence of postoperative complications. However, it does not appear to be widely practiced (Latto 1997, Combes et al 2001).

National anaesthetic associations around the world have not committed to mandatory intra-operative ET tube cuff pressure monitoring. Extensive perioperative guidelines by the American Society of Anesthesiologists (ASA) do not cover ET tube cuff monitoring during anaesthesia (ASA 2011). ET tube cuff pressure measurement does not feature as a minimum standard of anaesthetic monitoring in guidelines published by the Association of Anaesthetists of Great Britain and Ireland (AAGBI 2007). The German Association for Anesthesia and Intensive Care Medicine (DGAI; Deutsche Gesellschaft fur Anasthesiologie und Intensivmedizin), the German equivalent to the ASA and AAGBI, has published a limited number of perioperative guidelines on their website (http://www.dgai.de), none of which cover ET tube monitoring standards. Despite the ease with which ET tube cuff pressure can be measured, such devices are not widely available in operating rooms across the United States (Sengupta et al 2004).

To date there have been no studies comparing the practice of ET tube cuff pressure measurements within operating rooms of different countries. In a survey involving three different hospitals in the UK where cuff pressure measurement does not constitute routine practice, cuff pressure levels were found to be 46[+ or -]26cm[H.sub.2]O in 111 patients measured at the start of anaesthesia after a 15-30min period of stabilisation (Rose et al 2009). A comprehensive telephone audit across all acute NHS Trusts in England also revealed that intraoperative cuff pressure monitoring is not mandatory in any department, and cuff manometers were only available in a third of Trusts (Rose et al 2010). A recent study from Denmark also demonstrated that 54/119 patients had cuff pressures >30cm[H.sub.2]O (Rokamp et al 2010). Two small studies in North America, one assessing 40 anaesthesia providers and the other investigating ET tube cuff pressures in 93 patients, also demonstrated that less than one-third of anaesthesia providers inflated the ET tube cuff to within 20-30cm[H.sub.2]O (Sengupta et al 2004) and 25-40cm[H.sub.2]O (Stewart et al 2003).

Prehospital care and the emergency department

ET tube cuff pressures are not routinely measured and adjusted in the prehospital setting or in emergency departments (Byrd & Mascia 1996). Svenson et al (2007) demonstrated that 58% patients intubated by either helicopter physicians or ambulance personnel (n=62) had initial cuff pressures of >40cm[H.sub.2]O, with a mean first recorded cuff pressure of 63[+ or -]34cm[H.sub.2]O (Svenson et al 2007). In another study, the mean ET tube cuff pressure inflated by 53 paramedics was found to be 108cm[H.sub.2]O, and provider's sensitivity for detecting cuffs >25cm[H.sub.2]O was only 13% (95% CI 7.3-17.8) (Parwani et al 2007). A prospective observational study measuring ET tube cuff pressures in 85 patients in the prehospital setting and 22 patients transferred between hospitals showed cuff pressures >27 cm[H.sub.2]O in 79% of patients, with a mean cuff pressure of 56cm[H.sub.2]O (Galinski et al 2006). These studies suggest that in the prehospital setting ET tube cuff pressures significantly supercede recommended levels to an extent which may compromise patient care.

Studies evaluating other emergency personnel have yielded similar results. Emergency medicine residents (Guyton 1990), experienced emergency medicine physicians (Hoffman et al 2006) as well as paramedic students (Parwani et al 2007) all showed similar poor performances in ET tube cuff inflation inability to identify cuffs >25cm[H.sub.2]O. These studies highlight the importance of education, training and assessing competence in this field of airway management during training and clinical practice within these specialties.

Intensive care unit

A study of 85 endotracheally intubated intensive care unit (ICU) and post anaesthesia care unit (PACU) patients found that patients in these areas typically had excessively high ET tube cuff pressures. 91% of PACU patients (after anaesthesia with nitrous oxide) and 55% of ICU patients had reported pressures >40cm[H.sub.2]O (Braz et al 1999). Another study of 19 patients on ICU endotracheally intubated for varying periods of time found that 63% had early laryngeal lesions such as tracheal granulomas, 31% exhibited ring shaped tracheitis at the level of the ET tube cuff, and there was a 10% incidence of tracheal stenosis (Kastanos et al 1983). It should be noted that tracheal related injury may be greater in this population compared to the operating room population not only due to greater length of intubation but also due to varying levels of sedation and agitation which inevitably exist in the ITU population. This may subsequently result in increased movement and coughing which may cause morbidity.

ET tube cuff pressure measurement has been practiced for many years in the intensive care community. A prospective study of 95 patients with ET tubes or tracheostomies demonstrated that in the 55 patients that were followed up six months after discharge with fibreoptic laryngotracheal endoscopy, cuff pressure measurements taken three-times per day appeared to be associated with decreased tracheal stenosis and ischemic lesions of the trachea (Granja et al 2002). Nevertheless practice varies greatly between institutions since no consensus exists as to the recommended frequency of ET tube cuff pressure measurement. In one survey, more than two-thirds of critical care nurses measured ET tube cuff pressure either every shift or daily (Crimlisk et al 1996). Pressure measurement recommendations range from 2-3 measurements per day (Stauffer & Silvestri 1982, Granja et al 2002), to every 4-8 hours (Nelson et al 1983, Snowberger 1986, Goodnough 1988, Tyler et al 1991). Some authors make no recommendations about the frequency of measurement at all (Carroll & Grenvik 1973, Burton & Hodgkin 1984, McCulloch & Bishop 1991, Boggs & Wooldridge-King 1993).

Recommendations for obtaining and maintaining 'safe' ET tube cuff pressures

A wide range of pressures from 19-40cm[H.sub.2]O have been reported as 'safe' (Goodnough 1988, Tyler et al 1991, Boggs & Wooldridge-King 1993). Some authors recommend 25cm[H.sub.2]O as the maximal 'safe' pressure to prevent aspiration and air leaks past the cuff (Bernhard et al 1985, Guyton 1990, Lomholt 1992) as well as tracheal injury (Guyton et al 1991). However, a pressure of >24cm[H.sub.2]O has been suggested as being required to reduce the risk of aspiration (Tyler et al 1991). Tracheal arterial capillary pressure decreases at cuff pressures exceeding 30cm[H.sub.2]O, both in animal models (Nordin et al 1977) and patients undergoing surgery (Seegobin & van Hasselt 1984). It is important to note that, since venous and lymphatic pressures are much lower at 16cm[H.sub.2]O and 4-7cm[H.sub.2]O respectively (Nordin et al 1977), an ET tube cuff pressure maintained below 30cm[H.sub.2]O may impair venous and lymphatic drainage of the trachea (Nordin 1977). Cuff pressures above a critical value may cause congestion and oedema of the tracheal mucosa which can potentially increase the frequency of symptoms after tracheal extubation.

On balance, current evidence suggests that the MOV, the minimum volume of air to obviate air-flow past the cuff, up to a maximum pressure of less than 25cm[H.sub.2]O, is probably the safest practice to minimise high ET tube cuff pressures. However, the ability to ventilate and the prevention of aspiration must take precedence over cuff pressure. Once ET tube cuff pressure has exceeded 25cm[H.sub.2]O, regular reassessment should be performed to identify changes in the MOV in order to allow subsequent reduction in ET tube cuff pressure. There are a number of practical techniques of minimising complications secondary to cuff overinflation. Aneroid gauges are effective for intermittent ET tube cuff pressure monitoring in the operating theatre and ICU.

Conclusion

At present there is insufficient long term outcome evidence to warrant mandatory intra-operative cuff pressure monitoring. The evidence available does suggest that cuff pressure may be an important contributing factor to the development of complications related to ET tubes, however morbidity secondary to ET tubes is invariably multifactorial. There is clearly an inability amongst clinicians to adequately and reliably inflate ET tube cuffs to within recommended levels, which highlights the importance for the requirement of training, education and increased awareness of this aspect of airway management. Since anaesthetists regularly perform ET intubation and teach this skill to other specialties they must appreciate and recognise the morbidity and potential complications associated with endotracheal tube cuff overinflation, and become more comfortable with measuring ET tube cuff pressures. Further studies are required to explore the relationship between cuff pressure (exerted by different ET tubes) and long-term outcome measures of commonly occurring postoperative morbidity. In addition, studies to determine the efficacy of various techniques (MOV, MLT, cuff design and intermittent ET tube cuff pressure measurements) are needed.

Competing interests

Support for this study was provided solely from institutional and/or departmental sources.

No external funding and no competing interests declared.

References

Abdelatti MO, Kamath BS 1997 A cuff inflator for tracheal tubes Anaesthesia 52 (8) 765-769

American Society of Anesthesiologists 2011 Standards, guidelines and statements and other documents London, ASA Available from: www.asahq.org/For-HealthcareProfessionals/Standards-Guidelines-and- Statements.aspx [Accessed September 2011]

Association of Anaesthetists of Great Britain and Ireland 2007 Recommendations for standards of monitoring during anaesthesia and recovery London, AAGBI Available from: www.aagbi.org/sites/default/files/standardsofmonitor ing07.pdf [Accessed September 2011]

Atlas GM 2005 A mathematical model of differential tracheal tube cuff pressure: effects of diffusion and temperature Journal of Clinical Monitoring and Computing 19 (6) 415-425

Bennet MH, Isert PR, Cumming RG 2000 Postoperative sore throat and hoarseness following tracheal intubation using air or saline to inflate the cuff: A randomized controlled trial Anaesthesia and Intensive Care 28 (4) 408-413

Berlauk JF 1986 Prolonged endotracheal intubation vs. tracheostomy Critical Care Medicine 14 (8) 742-745

Bernhard WN, Yost L, Joynes D, Cothalis S, Turndorf H 1985 Intracuff pressures in endotracheal and tracheostomy tubes. Related cuff physical characteristics Chest 87 (6) 720-725

Boggs RL, Wooldridge-King M, Eds 1993 AACN procedure manual for critical care Philadelphia, W B Saunders

Bouvier JR 1981 Measuring tracheal tube cuff pressures-tool and technique Heart and Lung 10 (4) 686-690

Braz JR, Navarro LH, Takata IH, Nascimento Junior P 1999 Endotracheal tube cuff pressure: need for precise measurement Sao Paulo Medical Journal 117 (6) 243-247

Braz JRC, Volney A, Navarro LHC, Braz LG, Nakamura G 2004 Does sealing endotracheal tube cuff pressure diminish the frequency of postoperative laryngotracheal complaints after nitrous oxide anesthesia? Journal of Clinical Anesthesia 16 (5) 320-325

Brimacombe J, Keller C, Giampalmo M, Sparr HJ, Berry A 1999 Direct measurement of mucosal pressures exerted by cuff and non-cuff portions of tracheal tubes with different cuff volumes and head and neck positions British Journal of Anaesthesia 82 (5) 708-711

Burton GG, Hodgkin IE, Eds. 1984 Respiratory care New York, J B Lippincott Co.

Byrd RA, Mascia MF 1996 What is the endotracheal tube cuff pressure in a cross-section of intubated patients? Anesthesiology 85 Supple 3A 982

Carroll RG, Grenvik 1973 A Proper use of large diameter, large residual volume cuffs Critical Care Medicine 1 (3) 153-154

Christensen AM, Willemoes-Larsen H, Lundby L, Jakobsen KB 1994 Postoperative throat complaints after tracheal intubation British Journal of Anaesthesia 73 (6) 786-787

Combes X, Schauvliege F, Peyrouset O et al 2001 Intracuff pressure and tracheal morbidity: influence of filling with saline during nitrous oxide anesthesia Anesthesiology 95 (5) 1120-1124

Cooper JD, Grillo HC 1969 Experimental production and prevention of injury due to cuffed tracheal tubes Surgeiy, Gynecology and Obstetrics 129 (6) 1235-1241

Crimlisk JT, Horn MH, Wilson DJ, Marino B 1996 Artificial airways: a survey of cuff management practices Heart and Lung 25 (3) 225-235

Dullenkopf A, Gerber A, Weiss M 2003 Fluid leakage past tracheal tube cuffs: evaluation of the new Microcuff endotracheal tube Intensive Care Medicine 29 (10) 1849-1853

Efferen LS, Elsakr A 1998 Post-extubation stridor; risk factors and outcome Journal of the Association for Academic Minority Physicians 9 (4) 65-68

Evrard C, Pelouze GA, Quesnel J 1990 [Iatrogenic tracheal and left bronchial stenoses. Uncommon complication of Carlens tube. Apropos of a case surgically treated in a single stage] Annales de Chirurgie 44 (2) 149-156

Fan CM, Ko PC, Tsai KC et al 2004 Tracheal rupture complicating emergent endotracheal intubation American Journal of Emergency Medicine 22 (4) 289-293

Farre R, Rotger M, Ferre M, Torres A, Navajas D 2002 Automatic regulation of the cuff pressure in endotracheally-intubated patients European Respiratory Journal 20 (4) 1010-1013

Fernandez R, Blanch L, Mancebo J, Bonsoms N, Artigas A 1990 Endotracheal tube cuff pressure assessment: pitfalls of finger estimation and need for objective measurement Critical Care Medicine 18 (12) 1423-1426

Foroughi V, Sripada R 1997 Sensitivity of tactile examination of endotracheal tube intra-cuff pressure Anesthesiology 87 3S 965A

Francis J 1998 Cuff inflator for tracheal tubes Anaesthesia 53 (1) 92-93

Fujiwara M, Mizoguchi H, Kawamura J et al 1995 A new endotracheal tube with a cuff impervious to nitrous oxide: constancy of cuff pressure and volume Anesthesia & Analgesia 81 (5) 1084-1086

Galinski M, Treoux V, Garrigue B et al 2006 Intracuff pressures of endotracheal tubes in the management of airway emergencies: the need for pressure monitoring Annals of Emergency Medicine 47 (6) 545-547

Ganner C 2001 The accurate measurement of endotracheal tube cuff pressures British Journal of Nursing 10 (17) 1127-1134

Godoy AC, Vieira RJ, Capitani EM 2008 Endotracheal tube cuff pressure alteration after changes in position in patients under mechanical ventilation Jornal Brasileiro de Pneumologia 34 (5) 294-297

Goodnough SK 1988 Reducing tracheal injury and aspiration Dimensions of Critical Care Nursing 7 (6) 324-332

Granja C, Faraldo S, Laguna P, Gois L 2002 [Control of the endotracheal cuff balloon pressure as a method of preventing laryngotracheal lesions in critically ill intubated patients] Revista Espanola de Anestesiologia y Reanimacion 49 (3) 137-140

Guyton DC 1990 Endotracheal and tracheotomy tube cuff design: influence on tracheal damage Critical Care Update 1 1-10

Guyton DC, Banner MJ, Kirby RR 1991 High-volume, tow-pressure cuffs: are they always low pressure? Chest 100 (4) 1076-1081

Guyton DC, Barlow MR, Besselievre TR 1997 Influence of airway pressure on minimum occlusive endotracheal tube cuff pressure Critical Care Medicine 25 (1) 91-94

Harding CJ, McVey FK 1987 Interview method affects incidence of postoperative sore throat Anaesthesia 42 (10) 1104-1107

Harris R, Joseph A 2000 Acute tracheal rupture related to endotracheal intubation: case report Journal of Emergency Medicine 18 (1) 35-39

Herlevsen P, Bredahl C, Hindsholm K, Kruhoffer PK 1992 Prophylactic laryngo-tracheal aerosolized lidocaine against postoperative sore throat Acta Anaesthesiologica Scandinavica 36 (6) 505-507

Hofmann HS, Rettig G, Radke J, Neef H, Silber RE 2002 Iatrogenic ruptures of the tracheobronchial tree. European Journal of Cardiothoracic Surgery 21 (4) 649-652

Hoffman RJ, Dahlen JR, Lipovic D, Sturmann KM 2009 Linear correlation of endotracheal tube cuff pressure and volume Western Journal of Emergency Medicine 10 (3) 137-139

Hoffman RJ, Parwani V, Hahn IH 2006 Experienced emergency medicine physicians cannot safely inflate or estimate endotracheal tube cuff pressure using standard techniques American Journal of Emergency Medicine 24 (2) 139-143

Holley HS, Gildea JE 1971 Vocal cord paralysis after tracheal intubation Journal of the American Medical Association 215 (2) 281-284

Jensen PJ, Gaard H, Sondergaard P, Eriksen S 1982 Sore throat after operation: influence of tracheal intubation, intracuff pressure and type of cuff British Journal of Anaesthesia 54 (4) 453-457

Joshi GP, Inagaki Y, White PF et al 1997 Use of the laryngeal mask airway as an alternative to the tracheal tube during ambulatory anesthesia Anesthesia & Analgesia 85 (3) 573-577

Karasawa F, Takita A, Mori T et al 2003 The Brandt(tm) tube system attenuates the cuff deflationary phenomenon after anesthesia with nitrous oxide Anesthesia & Analgesia 96 (2) 606-610

Kastanos N, Estopa MR, Marin Perez A, Xaubet Mir A, Agusti-Vidal A 1983 Laryngotracheal injury due to endotracheal intubation: incidence, evolution, and predisposing factors. A prospective long-term study Critical Care Medicine 11 (5) 362-367

Klainer AS, Turndorf H, Wu HW, Maewal H, Allender P 1975 Surface alterations due to endotracheal intubation American Journal of Medicine 58 (5) 674-683

Latto P (Ed) 1997 The Cuff: Difficulties in tracheal intubation London, Saunders

Lee JA, Atkinson RS 1973 A Synopsis of Anaesthesia Baltimore Williams and Wilkins

Liu H, Chen JC, Holinger LD, Gonzalez-Crussi F 1995 Histopathologic fundamentals of acquired laryngeal stenosis Pediatric Pathology & Laboratory Medicine 15 (5) 656-677

Liu J, Zhang X, Gong W et al 2010 Correlations between controlled endotracheal tube cuff pressure and postprocedural complications: a multicenter study Anesthesia & Analgesia 111 (5) 1133-1137

LoCicero J 3rd 1984 Tracheo-carotid artery erosion following endotracheal intubation Journal of Trauma 24 (10) 907-909

Loeser EA, Hodges M, Gliedman J et al 1978a Tracheal pathology following short-term intubation with low- and high-pressure endotracheal tube cuffs Anesthesia & Analgesia 57 (5) 577-579

Loeser EA, Machin R, Colley J 1978b Postoperative sore throat: importance of endotracheal tube conformity versus cuff design Anesthesiology 49 (6) 430-433

Loeser EA, Orr DL, Bennett GM, Stanley TH 1976 Endotracheal tube cuff design and postoperative sore throat Anesthesiology 45 (6) 684-687

Loeser EA, Stanley TH, Jordan W, Machin R 1980 Postoperative sore throat: influence of tracheal tube lubrication versus cuff design Canadian Anaesthetists Society Journal 27 (2) 156-158

Lomholt N 1992 A device for measuring the lateral wall cuff pressure of endotracheal tubes Acta Anaesthesiologica Scandinavica 36 (8) 775-778

Lovett PB, Flaxman A, Sturmann KM, Bijur P 2006 The insecure airway: a comparison of knots and commercial devices for securing endotracheal tubes BMC Emergency Medicine 6 7

Luna CM, Legarreta G, Esteva H, Laffaire E, Jolly EC 1993 Effect of tracheal dilatation and rupture on mechanical ventilation using a low-pressure cuff tube Chest 104 (2) 639-640

Mandoe H, Nikolajsen L, Lintrup U, Jepsen D, Molgaard J 1992 Sore throat after endotracheal intubation Anesthesia & Analgesia 74 (6) 897-900

McCulloch TM, Bishop MJ 1991 Complications of translaryngeal intubation Clinics in Chest Medicine 12 (3) 507-521

McHardy FE, Chung F 1999 Postoperative sore throat: cause, prevention and treatment Anaesthesia 54 (5) 444-453

Mehta S, Myat HM 1984 The cross-sectional shape and circumference of the human trachea Annals of the Royal College of Surgeons of England 66 (5) 356-358

Mitchell V, Adams T, Calder I 1999 Choice of cuff inflation medium during nitrous oxide anaesthesia Anaesthesia 54 (1) 32-36

Navarro LH, Braz JR, Pletsch AK, Amorim RB, Modolo NS 2001 [Comparative study of tracheal tube pressures with or without Lanz pressure regulation system] Revista Brasileira de Anestesiologia 51 (1) 17-27

Nelson El, Morton EA, Hunter PM (Eds) 1983 Critical care respiratory therapy: A laboratory and clinical manual. Boston, Little, Brown and Company

Nordin U 1977 The trachea and cuff-induced tracheal injury: an experimental study on causative factors and prevention Acta Oto-Laryngologica S1-S71 345

Nordin U, Lindholm CE, Wolgast M 1977 Blood flow in the rabbit tracheal mucosa under normal conditions and under the influence of tracheal intubation Acta Anaesthesiologica Scandinavica 21 (2) 81-94

Otani S, Fujii H, Ishizu T et al 1998 Recurrent nerve palsy after endotracheal intubation 47 (3) 350-355

Parwani V, Hoffman RJ, Russell A et al 2007 Practicing paramedics cannot generate or estimate safe endotracheal tube cuff pressure using standard techniques Prehospital Emergency Care 11 (3) 307-311

Pelc P, Prigogine T, Bisschop P, Jortay A 2001 Tracheoesophageal fistula: case report and review of literature Acta Oto-Rhino-Laryngologica Belgica 55 (4) 273-278

Pollard RJ, Lobato EB 1995 Endotracheal tube location verified reliably by cuff palpation Anesthesia & Analgesia 81 (1) 135-138

Reali-Forster C, Kolobow T, Giacomini M et al 1996 New ultrathin-walled endotracheal tube with a novel laryngeal seal design. Long-term evaluation in sheep Anesthesiology 84 (1) 162-172; discussion 127A

Reed MF, Mathisen DJ 2003 Tracheoesophageal fistula Chest Surgery Clinics of North America 13 (2) 271-289

Riding JE 1975 Minor complications of general anaesthesia British Journal of Anaesthesia 47 (2) 91-101

Riley E, DeGroot K, Hannallah M 1999 The high pressure characteristics of the cuff of the intubating laryngeal mask endotracheal tube Anesthesia & Analgesia 89 (6) 1588

Rokamp KZ, Secher NH, Moller AM, Nielsen HB 2010 Tracheal tube and laryngeal mask cuff pressure during anaesthesia--mandatory monitoring is in need BMC Anesthesiology 10 20

Rose BO, Kyle B, Koshy-Delaffon A, Cregg R 2009 Endotracheal tube cuff pressures are too high during anaesthesia European Journal of Anaesthesiology 26 26

Rose BO, Kyle B, Blunt N et al Cuff manometry during anaesthesia in the United Kingdom--a case for mandatory measurement 2010. Abstract A1388. Presented at ASA, San Diego 2010. Available from: www.asaabstracts.com/strands/asaabstracts/abstrac t.htmjsessionid=35738EF90DE843FA0CD3FA35EE653 3CC?year=2010&index=8&absnum=26 [Accessed September 2011)

Seegobin RD, van Hasselt GL 1984 Endotracheal cuff pressure and tracheal mucosal blood flow: endoscopic study of effects of four large volume cuffs British Medical Journal 288 (6422) 965-968

Sengupta P, Sessler DI, Maglinger P et al. 2004 Endotracheal tube cuff pressure in three hospitals, and the volume required to produce an appropriate cuff pressure BMC Anesthesiology 4 (1) 8

Shelly WM, Dawson RB, May IA 1969 Cuffed tubes as a cause of tracheal stenosis Journal of Thoracic and Cardiovascular Surgery 57 (5) 623-627

Snowberger P 1986 Decreasing tracheal damage due to excessive cuff pressures Dimensions of Critical Care Nursing 5 (3) 136-142

St John RE 2004 Airway management Critical Care Nurse 24 (2) 93-96

Stanley TH, Liu WS 1975 Tracheostomy and endotracheal tube cuff volume and pressure changes during thoracic operations Annals of Thoracic Surgery 20 (2) 144-151

Stauffer J, Olson DE, Petty TL 1981 Complications and consequences of endotracheal intubation and tracheostomy. A prospective study of 150 critically ill adult patients American Journal of Medicine 70 (1) 65-76

Stauffer JL, Silvestri RC 1982 Complications of endotracheal intubation, tracheostomy and artificial airways Respiratory Care 27 (41) 7-34

Stenqvist O, Nilsson K 1982 Postoperative sore throat related to tracheal tube cuff design Canadian Anaesthetists Society Journal 29 (4) 384-386

Stewart S, Secrest J, Norwood B, Zachary R 2003 A comparison of endotracheal tube cuff pressures using estimation techniques and direct intracuff measurement American Journal of Nurse Anesthestists 71 (6) 443-447

Stout DM, Bishop MJ, Dwersteg JF, Cullen BF 1987 Correlation of endotracheal tube size with sore throat and hoarseness following general anesthesia Anesthesiology 67 (3) 419-421

Stride PC 1990 Postoperative sore throat: topical hydrocortisone Anaesthesia 45 (11) 968-971

Suzuki N, Kooguchi K, Mizobe T et al 1999 Postoperative hoarseness and sore throat after tracheal intubation: Effect of a low intracuff pressure of endotracheal tube and the usefulness of cuff pressure indicator Masui 48 (10) 1091-1095

Svenson JE, Lindsay MB, O'Connor JE 2007 Endotracheal intracuff pressures in the ED and prehospital setting: is there a problem? American Journal of Emergency Medicine 25 (1) 53-56

Tu HN, Saidi N, Leiutaud T et al 1999 Nitrous oxide increases endotracheal cuff pressure and the incidence of tracheal lesions in anesthetized patients Anesthesia & Analgesia 89 (1) 187-190

Tyler DO, Clark AP, Ogburn-Russell L 1991 Developing a standard for endotracheal tube cuff care Dimensions of Critical Care Nursing 10 (2) 54-61

Valentino J, Myers RK, Baker MD, Woodring JH 1999 Utility of portable chest radiographs as a predictor of endotracheal tube cuff pressure Otolaryngology--Head and Neck Surgery 120 (1) 51-56

Volpi D, Kuriloff DB, Lin P, Kimmelman CP 1987 Risk factors for Intubation injury of the larynx Annals of Otology, Rhinology and Laryngology 96 (6) 684-686

Weber AL, Grillo HC 1978 Tracheal stenosis: an analysis of 151 cases Radiologic Clinics of North America 16 (2) 291-308

Willis BA, Latto IP, Dyson A 1988 Tracheal tube cuff pressure. Clinical use of the Cardiff Cuff Controller Anaesthesia 43 (4) 312-314

Winkel E, Knudsen J 1971 Effect on the incidence of postoperative sore throat of 1 percent cinchocaine jelly for endotracheal intubation Anesthesia & Analgesia 50 (1) 92-94

Wu W, Lira, Simpson FA, Turndorf H 1973 Pressure dynamics of endotracheal and tracheostomy cuffs Critical Care Medicine 1 (4) 197-202

Pervez Sultan

MBChB, FRCA

Specialist Registrar, University College Hospital,

London

Brendan Carvalho

MBBCh, FRCA

Associate Professor, Stanford University School of

Medicine, Stanford, California, USA

Bernd Oliver Rose

MD, FRCA, EDIC, FFICM

Consultant, University Hospital Lewisham

Roman Cregg

FRCA

Specialist Registrar, University College Hospital,

London

No competing interests declared

Members can search all issues of the BJPN/JPP published since 1998 and download articles free of charge at www.afpp.org.uk.

Access is also available to non-members who pay a small fee for each article download.

by Pervez Sultan, Brendan Carvalho, Bernd Oliver Rose and Roman Cregg

Correspondence address: Pervez Sultan, Department of Anaesthesia, University College Hospital, 230 Euston Road, London, NW1 2BU. Email: p.sultan@doctors.org.uk
Table 1 Complications associated with increased ET tube cuff pressures

Complication                          Reference

Recurrent laryngeal nerve palsy       (Otani et al 1998, McHardy
                                         & Chung 1999)
Mucosal ischemia and loss of          (Klainer et al 1975)
  ciliary function
Mucosal ulceration                    (Combes et al 2001)
Mucosal bleeding                      (Berlauk 1986)
Tracheal ulceration/granuloma         (McHardy & Chung 1999)
Tracheal stenosis                     (Shelly et al 1969, Nordin 1977,
                                      Weber & Grillo 1978, Stauffer
                                        et al 1981)
Tracheal rupture                      (Harris & Joseph 2000, Hofmann
                                         et al 2002, Fan et al 2004)
Non-malignant tracheo-esophageal      (Stauffer et al 1981, Pelc et al
  fistula                                2001, Reed & Mathisen 2003)
Vocal cord paralysis                  (Holley & Gildea 1971)
Post-extubation stridor               (Efferen & Elsakr 1998)
Tracheomalacia                        (Valentino et al 1999)
Tracheo-carotid artery erosion        (LoCicero 1984)
Laryngeal stenosis                    (Evrard et al 1990, Liu et al
                                         1995)
Death                                 (Fan et al 2004)

Table 2 Practices to reduce the risk of excessive ET tube cuff
Pressure and potential related tracheal injury

Factor reducing cuff pressure       Description / Reference

Ultra-thin polyurethane cuff        Prevent liquid flow around cuff
                                      while only inflated to 15cm
                                      [H.sub.2]O (Dullenkopf et al
                                      2003)
Ultra thin-walled ET tube           Airway seal at level of glottis
                                      with no pressure seal design
                                      (Reali-Forster et al 1996)
Pressure-limiting balloon           Prevent cuff pressure inflation
                                      beyond 27cm[H.sub.2]O (Lanz
                                      balloon) (Navarro et al 2001)
Automatic cuff-inflating device     (Abdelatti & Kamath 1997)
Cuff impervious to diffusion of     (Fujiwara et al 1995)
  [N.sub.2]O
Brandt[tm] Anaesthesia Tube         Pressure-regulated cuff system
                                      preventing excessive cuff
                                      pressure (Karasawa et al 2003)
Continuous monitoring of cuff       (Latto 1997)
  pressure
Inflation of cuff with a
  [N.sub.2]O/O2 mixture             (Tu et al 1999)
Inflation of cuff with              (Stanley & Liu 1975)
  [N.sub.2]O/O2/
  anaesthetic vapor mixture
Inflation of cuff with isotonic     (Mitchell et al 1999)
saline *

*This practice cannot be recommended as routine ET tube cuffs are not
specifically designed for this use

[N.sub.2]O--Nitrous oxide

[O.sub.2]--Oxygen
COPYRIGHT 2011 Association for Perioperative Practice
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2011 Gale, Cengage Learning. All rights reserved.

Article Details
Printer friendly Cite/link Email Feedback
Title Annotation:CLINICAL FEATURE
Author:Sultan, Pervez; Carvalho, Brendan; Rose, Bernd Oliver; Cregg, Roman
Publication:Journal of Perioperative Practice
Article Type:Report
Geographic Code:4EUUK
Date:Nov 1, 2011
Words:6567
Previous Article:The early days of arterial surgery.
Next Article:Modern perioperative teamwork: an opportunity for interprofessional learning.
Topics:

Terms of use | Privacy policy | Copyright © 2019 Farlex, Inc. | Feedback | For webmasters