Endotracheal tube cuff pressure monitoring: a review of the evidence.
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).
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.
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.
Support for this study was provided solely from institutional and/or departmental sources.
No external funding and no competing interests declared.
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Specialist Registrar, University College Hospital,
Associate Professor, Stanford University School of
Medicine, Stanford, California, USA
Bernd Oliver Rose
MD, FRCA, EDIC, FFICM
Consultant, University Hospital Lewisham
Specialist Registrar, University College Hospital,
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.
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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: email@example.com
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
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|Title Annotation:||CLINICAL FEATURE|
|Author:||Sultan, Pervez; Carvalho, Brendan; Rose, Bernd Oliver; Cregg, Roman|
|Publication:||Journal of Perioperative Practice|
|Date:||Nov 1, 2011|
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