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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 cuf...
Contexts in source publication
Context 1
... wide range of pressures from 19- 40cmH2O have been reported as 'safe' (Goodnough 1988, Tyler et al 1991, Boggs & Wooldridge-King 1993. Some authors recommend 25cmH2O 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 >24cmH2O 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 30cmH2O, 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 16cmH2O and 4-7cmH2O respectively ( Nordin et al 1977), an ET tube cuff pressure maintained below 30cmH2O 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 ...
Context 2
... 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 ...
Citations
... [1] The cuff, which is located near the distal end of the endotracheal tube (ETT), is typically inflated with air to create an airtight seal. [2,3] The proper cuff pressure is an essential aspect of airway management. Failing to maintain the appropriate pressure can lead to complications. ...
Background
The present study aims to determine the impact of different cuff diameters on the cuff pressure of endotracheal tubes (ETTs) when the trachea is adequately sealed.
Methods
In the present single-center clinical trial, adult patients who underwent cardiothoracic surgery were assigned to use ETTs from 2 brands (GME and GZW). The primary endpoint comprised of the following: cuff diameter, inner diameter of the ETT, manufacturer, and the number of subjects with tracheal leakage when the cuff pressure was 30 cm H 2 O.
Results
A total of 298 patients were assigned into 2 groups, based on the 2 distinct brands of ETTs: experimental group (n = 122, GME brand) and control group (n = 176, GZW brand). There were no significant differences in baseline characteristics. However, the cuff diameter was significantly smaller in the control group, when compared to the experimental group ( P = .001), and the incidence of tracheal leakage was significantly higher in the control group ( P = .001). Furthermore, the GME brand ETT had a significantly larger cuff diameter, when compared to the GZW brand ETT.
Conclusion
The cuff size would mismatch the tracheal area in clinical practice. Therefore, chest computed tomography is recommended to routinely evaluate the tracheal cross-sectional area during anesthesia, in order to ensure the appropriate cuff size selection.
... Several scholarly investigations propound that high cuff pressure within the endotracheal tube can be a paramount determinant contributing to POST [5,6]. The optimal cuff pressure is the one that maintains unimpaired blood perfusion to the tracheal mucosa while ensuring no escape of air during the process of ventilation and concurrently thwarting ventilator-associated pneumonia (VAP) by precluding the aspiration of subglottic secretions. ...
Background: Postoperative sore throat (POST) is a common complication following endotracheal tube removal, and effective preventive strategies remain elusive. This trial aimed to determine whether actively regulating intraoperative cuff pressure below the tracheal capillary perfusion pressure threshold could effectively reduce POST incidence in patients undergoing gynecological laparoscopic procedures. Methods: This single-center, randomized controlled superiority trial allocated 60 patients scheduled for elective gynecological laparoscopic procedures into two groups: one designated for cuff pressure measurement and adjustment (CPMA) group, and a control group where only cuff pressure measurement was conducted without any subsequent adjustments. The primary outcome was POST incidence at rest within 24 h post-extubation. Secondary outcomes included cough, hoarseness, postoperative nausea and vomiting (PONV) incidence, and post-extubation pain severity. Results: The incidence of sore throat at rest within 24 h after extubation in the CPMA group was lower than in the control group, meeting the criteria for statistically significant superiority based on a one-sided test (3.3% vs. 26.7%, P < 0.025). No statistically significant differences were observed in cough, hoarseness, or pain scores within 24 h post-extubation between the two groups. However, the CPMA group had a higher incidence of PONV compared to the control group. Additionally, the control group reported higher sore throat severity scores within 24 h post-extubation. Conclusions: Continuous monitoring and maintenance of tracheal tube cuff pressure at 18 mmHg were superior to merely monitoring without adjustment, effectively reducing the incidence of POST during quiet within 24 h after tracheal tube removal in gynecological laparoscopic surgery patients.
Trial registration: The study was registered at www.chictr.org.cn (ChiCTR2200064792) on 18/10/2022.
... It is known that tracheal capillary perfusion pressure is between 30 and 44 cmH 2 O in vivo studies. When the ETT cuff pressure exceeds 30 cm H 2 O, the blood supply to local tissue and perfusion of the tracheal mucosal wall and surrounding anatomical structures begin to deteriorate 16,17 . It has been reported that the blood supply, especially to the anterolateral portion of the trachea, is compromised at pressures exceeding 30 cm H 2 O, causing it to become obstructed at pressures exceeding 50 cm H 2 O, and the tracheal circulation may completely stop at pressures above 60 cm H 2 O 18 . ...
... There may be damage to any part of the pharynx, larynx, or trachea. The reasons for the increase in ETT cuff pressures include lateral wall pressure, ETT insertion time, patient position, head position, cuff volume, temperature, nitrous oxide use, and other lesser-known factors 16,[19][20][21][22][23] . ...
... management of mechanically ventilated patients [3] and various complications are associated with the improper adjusting of the tube cuff pressure [8]. Overinflation of the cuff may result in tracheal damage, including subglottic stenosis, scarring, hoarseness, nerve damage, fistula, and damage to the tracheal wall [9], [10]. ...
This work presents the design and implementation of an IoT enabled Endotracheal Tube Cuff Pressure Controller Device. This device, a fusion of electronics, control, and software engineering, aims to automatically regulate the cuff pressure of an Endotracheal Tube placed in a patient’s trachea, ensuring that it remains within the optimal pressure range. The ideal pressure range, established to be between 20-30 cmH2O, can be adjusted to accommodate different patients’ needs. The device is designed as an IoT device and includes an emergency button for shutting down the system in case of an emergency. The total cost of the system, which amounts to approximately 70 USD, makes it a cost-effective solution compared to other commercially available options. In order to verify the device’s capability to accurately read and supply pressure, it is benchmarked against the gold standard (Fluke 729 300G FC) using quantitative tests including Pearson’s r test, the paired t-test, and Bland-Altman analysis. The results from these assessments confirmed that the performance characteristics of the device are notably comparable to the Fluke 729 300G FC, which will be further examined in this study. These outcomes, along with the device’s economic viability, validate it as a workable and reasonable alternative. The necessity for an automated and continuous monitoring system is further reinforced by the fact that manual cuff pressure measurement is prone to error and may even put the patient through discomfort.
... There is a clear shortage of regional, national, or international guidelines defining the "optimal" ETCPs, the frequency of cuffpressure monitoring, and the methods to be employed for the same. 1 The "safe" cuff-pressure range described by researchers often varies between 19 and 40 cm H 2 O. 6 Few studies have noted increased complications when the cuff-pressure is below 20 cm H 2 O, with another study observing a 4 times increased risk for ventilatorassociated pneumonia in a similar pressure settings. 7-9 Seegobin RD and van Hasselt GL. published two studies almost 4 decades ago suggesting that ETCP exceeding 30 cm H 2 O may compromise local tracheal mucosal blood flow, especially in the anterolateral wall. ...
How to cite this article: Kumar AKA. Endotracheal Cuff-pressure Monitoring in ICU: A Standard of Care Yet to be Standardized, and Often Neglected. Indian J Crit Care Med 2024;28(1):8–10.
... Factors leading to increased ETCP include positive pressure ventilation, N 2 O, high altitudes such as during helicopter transport, laryngospasm, bronchoconstriction, and edema. 6 The excess ETCP is transmitted to the tracheal wall, resulting in tracheal hypoperfusion which causes tracheal ischemia, ulceration, stenosis, and may even lead to fistula formation. 6,7 Increased ETCP may also cause other complications, such as sore throat, hoarseness, dry cough etc. 6,8 It is estimated that exposures to ETCP higher than 30 cm H 2 O for even short periods of time can cause significant tracheal lesions. ...
... 6 The excess ETCP is transmitted to the tracheal wall, resulting in tracheal hypoperfusion which causes tracheal ischemia, ulceration, stenosis, and may even lead to fistula formation. 6,7 Increased ETCP may also cause other complications, such as sore throat, hoarseness, dry cough etc. 6,8 It is estimated that exposures to ETCP higher than 30 cm H 2 O for even short periods of time can cause significant tracheal lesions. 6 ETCP below optimal levels may also result in adverse course, due to increased risk of accidental extubation and inadequate ventilation as well as microaspiration of secretions, leading to ventilator-associated pneumonia. ...
... 6 The excess ETCP is transmitted to the tracheal wall, resulting in tracheal hypoperfusion which causes tracheal ischemia, ulceration, stenosis, and may even lead to fistula formation. 6,7 Increased ETCP may also cause other complications, such as sore throat, hoarseness, dry cough etc. 6,8 It is estimated that exposures to ETCP higher than 30 cm H 2 O for even short periods of time can cause significant tracheal lesions. 6 ETCP below optimal levels may also result in adverse course, due to increased risk of accidental extubation and inadequate ventilation as well as microaspiration of secretions, leading to ventilator-associated pneumonia. ...
Aims and background
Endotracheal tube cuff pressure (ETCP) is an important factor to determine the development of complications associated with invasive mechanical ventilation. To avoid preventable complications arising out of immobilization, frequent changes in body positioning are necessary. Such variations in body position can affect ETCP in critically ill patients who are on mechanical ventilation. So, our study aimed to assess the effect of changes in body position on ETCP in patients who are on mechanical ventilation.
Materials and methods
This prospective observational study included 31 critically ill intubated patients. Each study subject was first placed in a neutral starting position with a 30º head elevation. Then, they were subjected to a sequential change in body position based on the 16 most used positions as part of the critical care unit's (CCUs) daily routine. Endotracheal tube cuff pressure was measured after each position change. Data were analyzed using standard statistical tests.
Results
Statistically significant difference in ETCP was observed during anteflexion of neck, hyperextension of neck, left lateral flexion of neck, right lateral flexion of neck, left lateral rotation of neck, right lateral rotation of neck, 10o recumbent position, supine position, Trendelenburg position, and right lateral 30° and 45° positions. Maximum increase in ETCP was seen during anteflexion of neck (31 ± 4.5; 22–42 cm H2O).
Conclusion
Our study demonstrates significant deviations in ETCP from the recommended range following changes in the body position of mechanically ventilated patients, highlighting the need for the measurement of ETCP after each position change and maintenance of the same within the target range.
How to cite this article
Roy O, Dasgupta S, Chandra A, Biswas P, Choudhury A, Ghosh S, et al. Relationship of Endotracheal Tube Cuff Pressures with Changes in Body Positions of Critically Ill Patients on Mechanical Ventilation: An Observational Study. Indian J Crit Care Med 2024;28(1):36–40.
... However, after an in vitro study, Seegobin and Hasselt recommended that cuff ination pressure not exceed 30cm H2O. It is essential to maintain cuff pressures in the 12 range of 20-30cm of H2O. ...
Background And Objective: The endotracheal tube (ETT) cuff seals the airway, preventing leakage and aspiration of pharyngeal contents into the trachea during ventilation. The Endotracheal tube cuff (ETT) endorses effective mechanical ventilation by ensuring a seal within the subglottic tracheal structures. Maintaining an appropriate intracuff pressure is critical for optimal mechanical ventilation, avoiding difculties caused by under ination or over ination of the cuff. The purpose of this study is to compare the ETT cuff pressure and its variation with the prexed volume air method of cuff ination and employing a pressure manometer in terms of cuff pressure variation, under ination, and over ination. This study included 100 adult patients over the age of 18 who underwent elective Methods: surgery. Patients were randomized using prospective comparative study into 2 groups of 50 each: Group A - cuff inated by Prexed volume air; Group B - cuff inated by pressure manometer. Cuff pressures were monitored on a regular basis. Under ination of an ET tube cuff is dened as a cuff pressure less than 25 cm H2O and over ination as a cuff pressure greater than 35 cm H2O. The cuff Results: pressure assessed at different time intervals was statistically signicant in this study. At each interval, the cuff pressure in Group B was within the safe range. Patients in Group A, on the contrary hand, had cuff pressures that were above the normal range. Routine use of cuff pressure manometer at regular intervals helps to maintain cuff pressure a Conclusion: t a safe range and prevents abnormal variations in mechanically ventilated patients in elective surgeries.
... Immediate side effects on the endotracheal and larynx were reported 15-94% after intubation. Voice violence and sore throat are 15% and 80%, respectively [3]. An excessive increase in ETCP leads to hypoperfusion, which is associated with tracheal ischemia, stenosis, necrosis, inflammation, wound, nerve damage, or fistula [3]. ...
... Voice violence and sore throat are 15% and 80%, respectively [3]. An excessive increase in ETCP leads to hypoperfusion, which is associated with tracheal ischemia, stenosis, necrosis, inflammation, wound, nerve damage, or fistula [3]. Conversely, if ECTP is too low, secretions can be microaspirated, leading to ventilator-associated pneumonia (VAP) [4]. ...
Background
Endotracheal intubation and mechanical ventilation are prevalent interventions in the operating room and intensive care unit. Recently, the complications of endotracheal tube cuff pressure have been a topic of interest. Therefore, this study compared the effect of pressure control and volume control ventilation modes on the endotracheal cuff pressure rate in patients undergoing general anesthesia and mechanical ventilation.
Methods
In this triple-blinded randomized clinical trial, 50 patients undergoing open limb surgery and inguinal hernia were allocated to two groups of 25 based on inclusion criteria. After intubation, one group underwent ventilation on the pressure control ventilation mode, and the other underwent ventilation on the volume control ventilation mode. In both groups, using a manometer, the cuff’s pressure was first adjusted in the range of 25–30 cm of water. Then, the cuff pressure was measured at 10, 20, and 30 min intervals. The data were statistically analyzed using independent t-test, and two-way repeated measures ANOVA.
Results
The present study’s findings showed that cuff pressure has significantly decreased over time in both study groups (F = 117.7, P < 0.001). However, a repeated measures ANOVA with a Greenhouse-Geisser correction showed no interaction between time and groups (F = 0.019, P = 0.98). The two groups had no significant difference in cuff pressure (F = 0.56, P = 0.458).
Conclusion
Since the cuff pressure has been significantly reduced in both groups over time, continuous monitoring of endotracheal tube cuff pressure in patients undergoing mechanical ventilation is essential. Therefore, it is suggested to keep the cuff pressure within the recommended range to prevent complications resulting from cuff pressure reduction, such as aspiration and ventilation decrease.
Trial registration
The study was registered in the Iranian Registry of Clinical Trial on 23/02/2019 (trial registration number: IRCT20181018041376N1).
... Some studies suggest that high cuff pressure of the endotracheal tube may be a vital contributing factor [5,6]. The ideal cuff pressure is one that does not affect the blood perfusion of tracheal mucosa, achieves no airway leakage during ventilation, and prevents ventilatorassociated pneumonia (VAP) due to the aspiration of subglottic secretions. ...
Background
Postoperative sore throat (POST) is a common postoperative complication after endotracheal tube removal. There are still no effective preventive methods for POST. The aim of this trial is to confirm whether maintaining intraoperative cuff pressure below the tracheal capillary perfusion pressure could effectively reduce the incidence of POST among patients undergoing gynecological laparoscopic surgery.
Methods
This study is a single-center, randomized, parallel-controlled, superiority trial with a 1:1 allocation ratio. Sixty patients whose age is between 18 and 65 years and scheduled for gynecological laparoscopic surgery will be randomized to the cuff pressure measurement and adjustment (CPMA) group and the only cuff pressure measurement without adjustment group (control group). The primary endpoint is the incidence of sore throat at rest within 24 h after extubation. The secondary endpoints include the incidence of cough, the incidence of hoarseness, the incidence of postoperative nausea and vomiting (PONV), POST, and pain intensity within 24 h after extubation. Blocked randomization will be conducted with a computer-generated central randomization online service. The blind method will be applied to subjects, data collectors, outcome evaluators, and statisticians. Outcome assessments will be performed at 0 h and 24 h post-extubation.
Discussion
This randomized controlled study hypothesizes that cuff pressure is the primary influencing factor of POST. By continuous monitoring of endotracheal tube cuff pressure and maintaining it within the range of 18–22 mmHg compared with only continuous measurement without adjustment, it aims to prove that continuous measurement and adjustment of endotracheal tube cuff pressure could be effective in reducing the incidence of POST in gynecological laparoscopic surgery patients. The result of this study could be used as a reference for future multicenter studies to confirm the effect of cuff pressure on POST and provides a scientific theoretical basis for preventing POST to further support comfort medicine.
Trial registration
Chinese Clinical Trial Registry ChiCTR2200064792. Registered on 18 October 2022. This protocol (version 1.0, 16 March 2022) was approved by the Ethics Committee of Beijing Chaoyang Hospital.
... The respiratory system of intubated patients is exposed to a considerable risk of aspiration, and thus the risk of developing VAP increases. 2 The consensus regarding safe cuff pressure ranges to isolate the trachea is between 20-30 cm H 2 O. [3][4][5][6] In normotensive patients, pressures > 30 cm H 2 O compromise tracheal mucosal perfusion and increase the risk of injury. 6,7 Pressures < 20 cm H 2 O increase the risk of macroaspiration. ...
... 2 The consensus regarding safe cuff pressure ranges to isolate the trachea is between 20-30 cm H 2 O. [3][4][5][6] In normotensive patients, pressures > 30 cm H 2 O compromise tracheal mucosal perfusion and increase the risk of injury. 6,7 Pressures < 20 cm H 2 O increase the risk of macroaspiration. 4,8,9 There are different ways to monitor cuff pressure. ...
BACKGROUND: The main functions of the endotracheal tube (ETT) cuff are to prevent macroaspiration and to allow pressurization of the respiratory system. For this purpose, it is essential to maintain adequate pressure inside the cuff, thus reducing the risks for the patient. It is regularly checked using a manometer and is considered the best alternative. The objective of this study was to evaluate the cuff pressure behavior of different ETTs during the simulation of an inflation maneuver using different manometers.
METHODS: A bench study was performed. Four brands of 8-mm internal diameter single lumen with a Murphy eye ETT with cuff and 3 different brands of manometers were used. In addition, a pulmonary mechanics monitor was connected to the inside of the cuff through the body of the distal end of the ETT.
RESULTS: A total of 528 measurements were made on the 4 ETTs. During the complete procedure (connection and disconnection), there was a significant pressure drop of 7 ± 1.4 cm H2O from the initial pressure (PINITIAL) (P < .001), of which 6 ± 1.4 cm H2O was lost during connection (difference between PINITIAL and PCONNECTION). The PRECONNECTION value was 19.1 ± 1.6 cm H2O, showing a significant total pressure drop of 11 ± 1.6 cm H2O (difference between PINITIAL and PRECONNECTION) (P < .001). The PFINAL mean was 29.6 ± 1.3 cm H2O. Significant differences were found between manometers according to the time of measurement. A similar phenomenon was evidenced when analyzing different ETTs.
CONCLUSIONS: Significant pressure changes occur secondary to ETT cuff measurement, which has important implications for patient safety.
