Automatic regulation of the endotracheal tube cuff pressure with a portable elastomeric device. A randomised controlled study

Continuous cuff pressure control on middle-aged and elderly patients undergoing endoscopic submucosal dissection of the esophagus effect of airway injury

OBJECTIVE

Assessment of the effect of continuous cuff pressure control on airway injury in middle-aged and elderly patients undergoing endoscopic submucosal dissection (ESD).

METHOD

A total of 104 eligible middle-aged and elderly patients requiring esophageal ESD from July 2022-September 2023 at the First Affiliated Hospital of Nanchang University were selected and randomly divided into two groups: the group undergoing general anesthesia tracheal intubation with continuous control of cuff pressure after intubation (Group A, n = 51) and the group undergoing general anesthesia tracheal intubation with continuous monitoring without control of cuff pressure (Group B, n = 53). After endotracheal intubation in Group A, under the guidance of an automatic cuff pressure controller, the air was used to inflate the tracheal cuff until the cuff pressure was 25-30cmH2O. The cuff pressure after intubation was recorded, and then the cuff pressure parameters were directly adjusted in the range of 25-30cmH2O until tracheal extubation after the operation. After endotracheal intubation, patients in Group B inflated the tracheal cuff with clinical experience, then monitored and recorded the cuff pressure with a handheld cuff manometer and instructed the cuff not to be loosened after being connected to the handheld cuff manometer-continuous monitoring until the tracheal extubation, but without any cuff pressure regulation. The patients of the two groups performed esophageal ESD. The left recumbent position was taken before the operation, and the cuff's pressure was recorded. Then, insert the gastrointestinal endoscope to find the lesion site and perform appropriate CO2 inflation to display the diseased esophageal wall for surgical operation fully. After determining the location, the cuff pressure of the two groups was recorded when the cuff pressure was stable. After the operation, the upper gastrointestinal endoscope was removed and the cuff pressure of the two groups was recorded. Postoperative airway injury assessment was performed in both groups, and the incidence of sore throat, hoarseness, cough, and blood in sputum was recorded. The incidence of postoperative airway mucosal injury was also observed and recorded in both groups: typical, episodic congestion spots and patchy local congestion.

RESULT

The incidence of normal airway mucosa in Group A was higher than that in Group B (P < 0.05). In comparison, the incidence of occasional hyperemia and local plaque congestion in Group A was lower than in Group B (P < 0.05).

CONCLUSION

Continuous cuff pressure control during operation can reduce airway injury in patients with esophageal ESD and accelerate their early recovery after the operation.

Continuous Versus Intermittent Control Cuff Pressure for Preventing Ventilator-Associated Pneumonia: An Updated Meta-Analysis

OBJECTIVE

This study aimed to evaluate the effect of continuous control cuff pressure (CCCP) versus intermittent control cuff pressure (ICCP) for the prevention of ventilator-associated pneumonia (VAP) in critically ill patients.

METHODS

Relevant literature was searched in several databases, including PubMed, Embase, Web of Science, ProQuest, the Cochrane Library, Wanfang Database and China National Knowledge Infrastructure between inception and September 2022. Randomized controlled trials were considered eligible if they compared CCCP with ICCP for the prevention of VAP in critically ill patients. This meta-analysis was performed using the RevMan 5.3 and Trial Sequential Analysis 0.9 software packages. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework was used to assess the level of evidence.

RESULTS

We identified 14 randomized control trials with a total of 2080 patients. Meta-analysis revealed that CCCP was associated with a significantly lower incidence of VAP compared with ICCP (relative risk [RR] = 0.52; 95% confidence interval [CI]: 0.37-0.74; P < 0.001), although considerable heterogeneity was observed (I2 = 71%). Conducting trial sequential analysis confirmed the finding, and the GRADE level was moderate. Subgroup analysis demonstrated that CCCP combined with subglottic secretion drainage (SSD) had a more significant effect on reducing VAP (RR = 0.39; 95% CI = 0.29-0.52; P < 0.001). The effect of CCCP on ventilator-associated respiratory infection (VARI) incidence was uncertain (RR = 0.81; 95% CI = 0.53-1.24; P = 0.34; I2 = 61%). Additionally, CCCP significantly reduced the duration of mechanical ventilation (MV) (mean difference [MD] = -2.42 days; 95% CI = -4.71-0.12; P = 0.04; I2 = 87%). Descriptive analysis showed that CCCP improved the qualified rate of cuff pressure. However, no significant differences were found in the length of intensive care unit (ICU) stay (MD = 2.42 days; 95% CI = -1.84-6.68; P = 0.27) and ICU mortality (RR = 0.86; 95% CI = 0.74-1.00; P = 0.05).

CONCLUSION

Our findings suggest that the combination of CCCP and SSD can reduce the incidence of VAP and the duration of MV and maintain the stability of cuff pressure. A combination of CCCP and SSD applications is suggested for preventing VAP.

The effect of different endotracheal tube cuff pressure monitoring systems on postoperative sore throat in patients undergoing tracheal intubation: a randomized clinical trial

BACKGROUND

Postoperative sore throat (POST) is an unpleasant outcome that can occur as a result of tracheal intubation in adults. Increased pressure from the endotracheal tube (ETT) cuff often leads to local mucosal injury, resulting in sore throat. The purpose of this study was to compare the effect of two different ETT cuff pressure monitoring systems vs. no cuff pressure monitoring on the incidence and severity of POST in adults.

METHODS

One hundred and fourteen ASA I-III patients of either gender, aged 18-65 years, and undergoing surgery requiring endotracheal intubation were included in this study. Patients were randomized into three groups: control (C), cuff pressure gauge (G), and automated cuff controller (A). The ETT cuff pressure was not monitored intraoperatively in group C but was monitored using a cuff pressure gauge and an automated cuff controller in groups G and A, respectively. Postoperatively, patients were assessed at 2, 24, and 48 h for the presence and severity of POST, hoarseness and cough.

RESULTS

One hundred and eleven patients completed the study. POST occurred in 40.5% of the patients in group G (n = 37) (p = 0.013) and 23.7% of the patients in group A (n = 38) (p < 0.001) within 48 h after surgery, compared to 69.4% in group C (n = 36). There were no significant differences in hoarseness, coughing, and dysphagia across the groups at any time. When comparing groups A and C, individuals in group A exhibited a lower occurrence of significant (grade ≥ 2) POST and hoarseness (10.5% vs. 41.7%, p = 0.002; 26.3% vs. 58.3%, p = 0.005). The incidence of significant cough and dysphagia did not differ substantially across the patient groups within 48 h after surgery. POST scores in group A at 2, 24 h postoperatively were both 0 (0-0), which was significantly lower than those in group C (1 (0-2) at 2 h, p < 0.001 ; 1 (0-1) at 24 h, p = 0.001). POST in group G at 2 h postoperatively was graded as 0 (0-1.5) which was milder than group C (P = 0.024). The severity of hoarseness in group A with scores of 0 (0-2) was superior to that in group C (2 (0-2), p = 0.006) at 2 h postoperatively.

CONCLUSIONS

In conclusion, the findings of this study indicated that the occurrence of POST can be reduced by using either the cuff pressure gauge approach or the automated cuff controller method. The automated cuff controller monitoring can potentially decrease the severity of POST and hoarseness.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, identifier: ChiCTR2100054089, Date: 08/12/2021.

Ten Issues to Update in Nosocomial or Hospital-Acquired Pneumonia: An Expert Review

Nosocomial pneumonia, or hospital-acquired pneumonia (HAP), and ventilator-associated pneumonia (VAP) are important health problems worldwide, with both being associated with substantial morbidity and mortality. HAP is currently the main cause of death from nosocomial infection in critically ill patients. Although guidelines for the approach to this infection model are widely implemented in international health systems and clinical teams, information continually emerges that generates debate or requires updating in its management. This scientific manuscript, written by a multidisciplinary team of specialists, reviews the most important issues in the approach to this important infectious respiratory syndrome, and it updates various topics, such as a renewed etiological perspective for updating the use of new molecular platforms or imaging techniques, including the microbiological diagnostic stewardship in different clinical settings and using appropriate rapid techniques on invasive respiratory specimens. It also reviews both Intensive Care Unit admission criteria and those of clinical stability to discharge, as well as those of therapeutic failure and rescue treatment options. An update on antibiotic therapy in the context of bacterial multiresistance, in aerosol inhaled treatment options, oxygen therapy, or ventilatory support, is presented. It also analyzes the out-of-hospital management of nosocomial pneumonia requiring complete antibiotic therapy externally on an outpatient basis, as well as the main factors for readmission and an approach to management in the emergency department. Finally, the main strategies for prevention and prophylactic measures, many of them still controversial, on fragile and vulnerable hosts are reviewed.

Methods Used for Endotracheal Tube Cuff Inflation and Pressure Verification in Veterinary Medicine: A Questionnaire on Current Practice

Endotracheal intubation is a routine procedure in veterinary anaesthesia, yet no consensus guidelines exist for endotracheal tube (ETT) cuff inflation and pressure measurement. The aim of this study was to assess current practice of ETT cuff inflation and seal verification in veterinary medicine. An online questionnaire was distributed among veterinary professionals who administer anaesthesia, comprising six demographic and twelve ETT cuff-related questions per species. N = 348 questionnaires were completed. Cuff pressure was measured by 30% of respondents in cats, 32% in dogs and 9% in both farm animals and horses. Anaesthesia diplomates were not more likely to measure cuff pressure than others, except in cats (OR: 1.8; 95% CI: 1.1−2.9). The most frequently selected recommended range of cuff pressure was 20−30 cm H2O, regardless of species, although >30 cm H2O was selected significantly more often in horses compared to dogs, cats and farm animals. The preferred technique to verify cuff seal was minimal occlusive volume in dogs, cats and farm animals, whereas in horses, the preferred method was verification of normal capnogram waveform. ETT cuff pressure measurement remains uncommon in veterinary anaesthesia. The development of consensus recommendations for cuff inflation, including evidence-based target cuff pressure ranges for various species and different ETT models or materials, can help to improve practice.

Endotracheal Tube Overinflation Leading to Hypoxic Cardiac Arrest: A Case Report and Review of the Literature

Endotracheal tube cuff overinflation has been shown to produce airway obstruction and subsequent ventilatory and hemodynamic compromise. Although rare, this complication is reversible and its prompt identification is paramount. We describe a case of a 68-year-old woman undergoing microlaryngoscopy and vocal cord lesion biopsy, who developed ventilatory failure and cardiac arrest following endotracheal tube overinflation intraoperatively. The patient was successfully resuscitated and was able to be ventilated after endotracheal tube replacement. We present a literature review and evidence-based management insights for endotracheal tube obstruction due to cuff overinflation.

Effectiveness of Continuous Cuff Pressure Control in Preventing Ventilator-Associated Pneumonia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVES

Microaspiration of subglottic secretions is the main pathogenic mechanism for ventilator-associated pneumonia (VAP). Adequate inflation of the endotracheal cuff is pivotal to providing an optimal seal of the extraluminal airway. However, cuff pressure substantially fluctuates due to patient or tube movements, which can induce microaspiration. Therefore, devices for continuous cuff pressure control (CCPC) have been developed in recent years. The purpose of this systematic review and meta-analysis is to assess the effectiveness of CCPC in VAP prevention.

DATA SOURCES

A systematic search of Embase, the Cochrane Central Register of Controlled Trials, and the International Clinical Trials Registry Platform was conducted up to February 2022.

STUDY SELECTION

Eligible studies were randomized controlled trials (RCTs) and quasi-RCTs comparing the impact of CCPC versus intermittent cuff pressure control on the occurrence of VAP.

DATA EXTRACTION

Random-effects meta-analysis was used to calculate odds ratio (OR) and 95% CI for VAP incidence between groups. Secondary outcome measures included mortality and duration of mechanical ventilation (MV) and ICU stay. The certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach.

DATA SYNTHESIS

Eleven RCTs with 2,092 adult intubated patients were included. The use of CCPC was associated with a reduced risk of VAP (OR, 0.51). Meta-analyses of secondary endpoints showed no significant difference in mortality but significant differences in durations of MV (mean difference, -1.07 d) and ICU stay (mean difference, -3.41 d) in favor of CCPC. However, the risk of both reporting and individual study bias was considered important. The main issues were the lack of blinding, potential commercial conflicts of interest of study authors and high heterogeneity due to methodological differences between studies, differences in devices used for CCPC and in applied baseline preventive measures. Certainty of the evidence was considered "very low."

CONCLUSIONS

The use of CCPC was associated with a reduction in VAP incidence; however, this was based on very low certainty of evidence due to concerns related to risk of bias and inconsistency.

The Relationship between Cuff Pressure and Air Injection Volume of Endotracheal Tube: A Study with Sheep Trachea Ex Vivo

Background

Endotracheal intubation is a widely used treatment. Excessive pressure of the endotracheal tube cuff leads to a series of complications. Here, we used tracheae of sheep to analyze the relationship between the air injection volume and endotracheal tube cuff pressure so as to guide the doctors and nurses in controlling the pressure of the endotracheal tube cuff during clinical work and minimise the risk of complications.

Materials and Methods

Forty sheep tracheae were utilised and were divided into five groups according to their diameters. Different sizes of endotracheal tubes were inserted into each trachea, and the cuff pressure with the increase of air injection volume was recorded. The formulas that reflect the relationship between air injection volume and cuff pressure were obtained. Then, sheep tracheae were randomly selected; different types of tubes were inserted, and the stipulated volume of air was injected. The actual pressure was measured and compared with the pressure predicted from the formulas. Statistical analysis was conducted to verify whether the formulas obtained from the first part of the experiment were in accordance with the expert evaluation table, which consists of opinions of several experts.

Results

After obtaining 15 formulas, we collected the differences between the theoretical cuff pressure and the actual cuff pressure that satisfied the expert evaluation. Relying on the formulas, the medical turntable was obtained, which is a tool that consists of two round cards with data on them. The top card has a notch. The two cards are stacked together, and as the top card rotates, the data on the bottom card can be easily seen in a one-to-one relationship.

Conclusion

The formulas are capable of showing the relationship between the cuff air injection volume and pressure of endotracheal tube cuff. The medical turntable can estimate the air injection volume to ensure that the pressure stays in an acceptable range.

Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update

The purpose of this document is to highlight practical recommendations to assist acute care hospitals to prioritize and implement strategies to prevent ventilator-associated pneumonia (VAP), ventilator-associated events (VAE), and non-ventilator hospital-acquired pneumonia (NV-HAP) in adults, children, and neonates. This document updates the Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology (SHEA), and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America, the American Hospital Association, the Association for Professionals in Infection Control and Epidemiology, and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.

Knowledge and practice of tracheal tube cuff pressure monitoring: a multicenter survey of anaesthesia and critical care providers in a developing country

BACKGROUND

Tracheal tubes are routinely used during anaesthesia and in the intensive care unit. Subjective monitoring of cuff pressures have been reported to produce consistently inappropriate cuffs pressures, with attendant morbidity. But this practice of unsafe care remains widespread. With the proliferation of intensive care units in Nigeria and increasing access to surgery, morbidity relating to improper tracheal cuff pressure may assume a greater toll. We aimed to evaluate current knowledge and practice of tracheal cuff pressure monitoring among anaesthesia and critical care providers in Nigeria.

METHODS

This was a multicenter cross-sectional study conducted from March 18 to April 30, 2021. The first part (A) was conducted at 4 tertiary referral hospitals in Nigeria by means of a self-administered questionnaire on the various cadre of anaesthesia and critical care providers. The second part (B) was a nation-wide telephone survey of anaesthesia faculty fellows affiliated to 13 tertiary hospitals in Nigeria, selected by stratified random sampling.

RESULTS

Only 3.1% (6/196) of the care providers admitted having ever used a tracheal cuff manometer, while 31.1% knew the recommended tracheal cuff pressure. The nationwide telephone survey of anaesthesia faculty fellows revealed that tracheal cuff manometer is neither available, nor has it ever been used in any of the 13 tertiary hospitals surveyed. The 'Pilot balloon palpation method' and 'fixed volume of air from a syringe' were the most commonly utilized method of cuff pressure estimation by the care providers, at 64.3% and 28.1% respectively in part A survey (84.6% and 15.4% respectively, in the part B survey).

CONCLUSION

The use of tracheal cuff manometer is very limited among the care providers surveyed in this study. Knowledge regarding tracheal cuff management among the providers is adjudged to be fair, despite the poor practice and unsafe care.