Comparison of tracheal tube cuff pressure with two technique: fixed volume and minimal leak test techniques

The knowledge and skills of emergency department registered nursing staff at an academic hospital in South Africa, on endotracheal tube cuff manometry, before and after a training session

Introduction

Accurate management of endotracheal tube cuff pressure is essential to prevent patient morbidity and mortality. Due to increased length of stay of critically ill patients in emergency departments, it has become an increasingly important skill among Emergency Department nurses.

Methods

This prospective longitudinal interventional study was performed among registered nurses at the emergency departments in a Johannesburg Academic Hospital. The study aimed to determine their current knowledge and practical skills on endotracheal tube cuff manometry and assess the effectiveness of a training program. The training program was provided once, in the form of a narrated PowerPoint presentation developed by the researchers and involved theoretical and practical components. The participants' theoretical knowledge and practical skills were measured by using questionnaires and skill assessments. The theoretical and practical scores were compared pre- and post-training.

Results

Of the 63 registered nurses employed in the emergency departments, 95 % (60) participated in this study. 86 % reported having never received any formal training on endotracheal tube cuff manometry. Only 38.9 % used cuff manometry as standard practice and only 12.8 % checked it at appropriate 12-hourly intervals. The pre-training median score on theory was 4.5 (IQR=3.0) and improved to 7.0 (IQR=3.0) post-training. The maximum achievable score was 11 with a pre-training average of 41.8 % and post-training of 64.5 % (p = 0.001).The practical pre-training median score was 1.0 (IQR=8.0) and improved to 12.0 (IQR=2.0) post-training. The maximum achievable score was 12 with a pre-training average of 29.1 % and a post-training average of 93.3 % (p = 0.001).

Conclusion

This study showed inadequate knowledge and skills on endotracheal cuff pressure manometry among registered nurses in the emergency department. It also correlates with other evidence that supports the need for ongoing training programs. Our training program led to significant improvement among participants in both knowledge and practical skills. This training program was well received by participants and deemed to be practice changing. The recommendation after this study will be for South African emergency units to consider using this study and training material as a guide for annual in-service training.

Risk factor evaluation of cuff pressure of >30 cmH2O to stop air leakage during mechanical ventilation: A prospective observational study

AIM

The commonly recommended endotracheal tube cuff pressure is 20-30 cmH2O. However, some patients require a cuff pressure of >30 cmH2O to prevent air leakage. The study aims to determine the risk factors that contribute to the endotracheal tube cuff pressure of >30 cmH2O to prevent air leakage.

DESIGN

A multi-centre prospective observational study.

METHODS

Eligible patients undergoing mechanical ventilation in the intensive care unit of three hospitals between March 2020 and July 2022 were included. The endotracheal tube cuff pressure to prevent air leakage was determined using the minimal occlusive volume technique. The patient demographics and clinical information were collected.

RESULTS

A total of 284 patients were included. Among these patients, 55 (19.37%) patients required a cuff pressure of >30 cmH2O to prevent air leakage. The multivariate logistic regression results revealed that the surgical operation (odds ratio [OR]: 8.485, 95% confidence interval [CI]: 1.066-67.525, p = 0.043) was inversely associated with the endotracheal tube cuff pressure of >30 cmH2O, while the oral intubation route (OR: 0.127, 95% CI: 0.022-0.750, p = 0.023) and cuff inner diameter minus tracheal area (OR: 0.949, 95% CI: 0.933-0.966, p < 0.001) were negatively associated with the endotracheal tube cuff pressure of >30 cmH2O. Therefore, a significant number of patients require an endotracheal tube cuff pressure of ＞30 cmH2O to prevent air leakage. Several factors, including the surgical operation, intubation route, and difference between the cuff inner diameter and tracheal area at the T3 vertebra, should be considered when determining the appropriate cuff pressure during mechanical ventilation.

Endotracheal Tube Cuff Pressures in the Operating Room of a Pediatric Hospital: A Quality Improvement Initiative

Endotracheal tube (ETT) cuff pressures are frequently out of the recommended range of 20-30 cm H₂O. This can lead to multiple iatrogenic complications ranging from cough, sore throat, and tracheal edema to more serious medical issues such as tracheal stenosis, aspiration, nerve injuries, and tracheal rupture. Additionally, current methods to inflate ETT cuffs vary between anesthesia providers and are not consistent in the recommended range. The objective of this quality improvement project was to increase the percentage of cuff pressures between 20 and 30 cm H₂O.

METHODS

Four plan-do-study-act (PDSA) cycles were completed in the operating rooms at Nationwide Children's Hospital over 9 months to assess ways to improve the accuracy of obtaining recommended ETT cuff pressures. Control charts were used to evaluate the primary outcome measure.

RESULTS

Preimplementation, ETT cuff pressures were out of the recommended range 76% of the time. Cuff pressures were out of the recommended range 64% of the time with the addition of the air method, 84% of the time in the tidal volume ratio cycle, and 50% of the time using the removal of air technique. The removal of air method was the most effective in achieving cuff pressures within the recommended pressure range (P < 0.001).

CONCLUSIONS

Using quality improvement methodology, the percentage of ETT cuff pressures falling within the recommended pressure range increased using the removal of air technique. This approach is a simple and practical method that can be easily implemented in the clinical setting and would provide additional safety in the anesthetic management of pediatric patients.

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.

Comparative evaluation of three methods of endotracheal tube cuff inflation for adequacy of seal

Background and Aims

Intubation with cuffed endotracheal tube (ETT) is common in operation rooms, critical care, and emergency rooms. The pressure exerted by the cuff on the tracheal mucosa can lead to a reduction in blood flow to the tracheal wall and result in mucosal ischemia. There are many methods for ETT cuff inflation. Aim of the study was to compare the cuff pressures and volumes between the three methods of ETT cuff inflation.

Material and Methods

One hundred and twenty patients were randomized into three groups: Group SG (stethescope guided), group AL (audible leak), and group P (palpation). In group SG, the cuff was inflated by auscultating with the bell of the stethoscope over the thyroid cartilage for leak around cuff. In group AL, the cuff was inflated by listening for an audible leak around the cuff with observer's ear 5 cm away from the mouth of the patient. In group P, the cuff was inflated by palpating for a leak over the cricoid and trachea. The adequacy of the cuff seal was compared between the groups by assessing the volumes of additional air needed to stop the leak around the cuff as confirmed by supraglottic capnometry.

Results

The initial volumes needed to inflate the cuff were significantly more in the stethoscope (SG) and hearing (AL) groups than in the palpation (P) group (SG = 5.1 ± 1.4 ml, AL = 4.6 ± 1.6 ml, P = 3.1 ± 0.9 ml; SG and AL vs. P, P < 0.001). Additional cuff volumes required to achieve zero leak around cuff by supraglottic capnometry were 0.85 ± 1 ml in group SG, 1.3 ± 1.1 ml in group AL, and 2.237 ± 0.8 ml in group P (SG vs. P and AL vs. P; P < 0.001).

Conclusion

Out of the auscultation-guided, audible leak-guided, and palpation-guided methods of ETT cuff inflation, the auscultation-guided and audible leak-guided methods achieve significantly better tracheal seal than the palpation-guided method.

Establishing changes in endotracheal cuff pressure with continuous monitoring in patients undergoing laparoscopic surgery in Trende- lenburg position

Background : After endotracheal intubation, the endotracheal cuff gets inflated to a sufficiently high pressure to prevent air leaking. Placing a patient in Trendelenburg position and establishing a pneumoperitoneum affects the endotracheal cuff pressure. Objectives : Determine the impact of these factors on the endotracheal cuff pressure. Design and setting : This prospective, observational study was conducted in the Catharina Hospital (Eindhoven, the Netherlands). Methods : This study included adult patients undergoing laparoscopic surgery. A routine endotracheal tube was inserted, in which the cuff pressure was continuously monitored. Main outcome measures : The outcome of interest was a change in endotracheal cuff pressure after establishment of a pneumoperitoneum and/ or placing a patient in a Trendelenburg position. Results : 39 patients were included. Cuff pressures in- creased significantly from the moment of pneumo-peritoneum, placing a patient into a Trendelenburg position increased endotracheal cuff pressure and peak pressures even more. The highest endotracheal cuff pressure was 67 cm H2O, the highest registered peak pressure was 35 cm H2O. Conclusion : Both endotracheal cuff pressure and peak pressure increased during laparoscopic surgical procedures with a pneumoperitoneum and the patient placed in Trendelenburg position. Measuring the endo-tracheal cuff pressure only after endotracheal intubation is insufficient and should be repeated during surgery on fixed moments.

Endotracheal Tube Cuff Pressure Monitor: A Fancy Gadget or Necessary Tool in Intensivist's Armamentarium

How to cite this article: Bhowmick R. Endotracheal Tube Cuff Pressure Monitor: A Fancy Gadget or Necessary Tool in Intensivist's Armamentarium. Indian J Crit Care Med 2021;25(2):121-122.

Improving nurses' knowledge of managing endotracheal tube cuff pressure in intensive care units: A quasi-experimental study

BACKGROUND

Previous studies conducted on nurses' knowledge regarding endotracheal tube cuff pressure revealed that there were differences in intensive care nurses' knowledge, leading to varying practices.

AIM

This study aimed to evaluate how an educational intervention based on the existing evidence-based guidelines, using both passive and active implementation strategies, could improve the knowledge of nurses regarding managing endotracheal tube cuff pressures in Malawian intensive care units.

SETTING

Six functional ICUs (four public and two private) in Malawi.

METHODS

The study followed a quasi-experimental, pre- and post-test design using an educational intervention. Intensive care nurses of six functional intensive care units in Malawi were randomly assigned to two intervention groups. Both groups received a half-day educational session, a printed version of the evidence-based guidelines, a printed and laminated summary of the guidelines and a related algorithm. Additionally, Intervention 2 group received four monitoring visits. Pre- and post-test questionnaires were conducted between February and August 2016. Descriptive and inferential data analyses (a chi-square test and t-test) were utilised.

RESULTS

An improvement in knowledge was observed on the nursing care practices for the management of endotracheal tube cuff pressure for both groups following the educational intervention, although only the results comparing Intervention 2 group participants indicate that the level of knowledge was significant (t[df = 48] = 2.08, p = 0.043, d = 0.59).

CONCLUSION

Implementation of a formal training and mentorship programme for Malawian intensive care nurses would be of great benefit to enhance the knowledge and skills managing endotracheal tube cuff pressure. Follow-up studies would also assist in understanding how guidelines could be implemented most effectively to achieve better knowledge outcomes.

Effects of anesthesiologists awareness on the control of cuff pressure in patients submitted to cardiac surgery

INTRODUCTION

Sedatives applied to cardiac surgery patients can act on the respiratory tract, creating a demand for a tracheal prosthesis in the artificial route, whose distal part (cuff) has a recommended pressure of 20 to 25 mm Hg. The professional's lack of knowledge about procedures and adequate pressure can pose risks to patients' health.

OBJECTIVE

To analyze the effect of anesthesiologists awareness on the control of cuff pressure.

METHODOLOGY

A prospective cohort study. At the beginning of the research, cuff pressures were consecutively measured immediately after the patient's admission to the intensive care unit (ICU). After this period, anesthesiologists were trained by the responsible researchers for 1 month. In the final 2.5 months of the research, cuff pressure was again measured immediately after the patient's admission to the ICU.

RESULTS

A total of 70 patients were evaluated, 37 of whom were pre-awareness and 33 were post-awareness. Male sex was the most prevalent with 46 (66%) patients and the mean age was 58 ± 10 years. There was a reduction from 76 ± 14 to 28 ± 9 in cuff pressure (P < .01).

CONCLUSION

The training of anesthesiologists who assist cardiac surgery patients allowed a reduction in cuff pressure abnormalities.

Measuring endotracheal tube intracuff pressure: no room for complacency

Tracheal intubation constitutes a routine part in the care of critically ill and anaesthetised patients. Prolonged use of endotracheal with inflated cuff is one of the major multifactorial causes of complications. Both under-inflation and over-inflation of cuff are associated with complications. Despite known problems, regular measurement of cuff pressure is not routine, and it is performed on an ad hoc basis.