Experienced paramedics cannot inflate or estimate endotracheal tube cuff pressure using standard techniques

Abstract

Study objectives: Tracheal necrosis and stenosis may result from an overinflated endotracheal tube cuff. Safe, appropriate pressure in endotracheal tube cuffs is considered to be between 15 and 25 cm H2O, which are pressures below normal capillary perfusion pressure. We sought to determine the ability of practicing paramedics to inflate an endotracheal tube cuff to appropriate pressure using standard syringe technique and to assess appropriateness of pressure of previously inflated endotracheal tube cuffs by palpating the pilot balloon. Methods: This institutional review board–approved descriptive survey of 54 paramedics from various base stations licensed and practicing in New York City used a previously tested, tracheal simulation model with a 7.5 endotracheal tube with a high-volume low-pressure cuff (Mallinkrodt, St. Louis, MO). Using their choice of a 5-mL or 10-mL plastic syringe with standard luer lock (Beckton-Dickson, Franklin Lakes, NJ), participants inflated the endotracheal tube cuff by standard method of injecting air as they deemed appropriate in conjunction with palpating the pilot balloon to estimate cuff pressure. Subsequently, the endotracheal tube cuff pressure was measured using a highly sensitive and accurate analog manometer (Boehringer Laboratories, Norristown, PA). Later, participants palpated the pilot balloon of 9 endotracheal tubes with cuffs previously inflated to know pressures ranging from 0 to 120 cm H2O and reported whether the pressure was low, appropriate, or high. Results: No participants inflated the endotracheal tube cuff to a safe pressure. The average cuff pressure generated was greater than 105 cm H2O. The true mean could not be determined because 65% (n=35) of participants inflated to pressures greater than the upper limit of manometer sensitivity (>120 cm H2O). Using palpation, participants had an overall sensitivity judging appropriateness of endotracheal tube cuff pressure of 30%, and they were only 13% sensitive in detecting overinflated endotracheal tube cuffs. Experience as a licensed paramedic ranged from 1 to 18 years, with average of 10 years. Conclusion: This group of experienced paramedics had no ability to inflate an endotracheal tube cuff to safe pressure, little ability to accurately estimate pressure of a previously inflated cuff using standard technique, and minimal ability to detect overinflated endotracheal tube cuffs. Nearly all inflated the cuff to dangerously high pressures. Clinicians should consider using devices that permit safe and accurate inflation and measurement of endotracheal tube cuff pressure rather than relying on standard palpation technique, which is potentially unsafe and highly inaccurate. Study objectives: Tracheal necrosis and stenosis may result from an overinflated endotracheal tube cuff. Safe, appropriate pressure in endotracheal tube cuffs is considered to be between 15 and 25 cm H2O, which are pressures below normal capillary perfusion pressure. We sought to determine the ability of practicing paramedics to inflate an endotracheal tube cuff to appropriate pressure using standard syringe technique and to assess appropriateness of pressure of previously inflated endotracheal tube cuffs by palpating the pilot balloon. Methods: This institutional review board–approved descriptive survey of 54 paramedics from various base stations licensed and practicing in New York City used a previously tested, tracheal simulation model with a 7.5 endotracheal tube with a high-volume low-pressure cuff (Mallinkrodt, St. Louis, MO). Using their choice of a 5-mL or 10-mL plastic syringe with standard luer lock (Beckton-Dickson, Franklin Lakes, NJ), participants inflated the endotracheal tube cuff by standard method of injecting air as they deemed appropriate in conjunction with palpating the pilot balloon to estimate cuff pressure. Subsequently, the endotracheal tube cuff pressure was measured using a highly sensitive and accurate analog manometer (Boehringer Laboratories, Norristown, PA). Later, participants palpated the pilot balloon of 9 endotracheal tubes with cuffs previously inflated to know pressures ranging from 0 to 120 cm H2O and reported whether the pressure was low, appropriate, or high. Results: No participants inflated the endotracheal tube cuff to a safe pressure. The average cuff pressure generated was greater than 105 cm H2O. The true mean could not be determined because 65% (n=35) of participants inflated to pressures greater than the upper limit of manometer sensitivity (>120 cm H2O). Using palpation, participants had an overall sensitivity judging appropriateness of endotracheal tube cuff pressure of 30%, and they were only 13% sensitive in detecting overinflated endotracheal tube cuffs. Experience as a licensed paramedic ranged from 1 to 18 years, with average of 10 years. Conclusion: This group of experienced paramedics had no ability to inflate an endotracheal tube cuff to safe pressure, little ability to accurately estimate pressure of a previously inflated cuff using standard technique, and minimal ability to detect overinflated endotracheal tube cuffs. Nearly all inflated the cuff to dangerously high pressures. Clinicians should consider using devices that permit safe and accurate inflation and measurement of endotracheal tube cuff pressure rather than relying on standard palpation technique, which is potentially unsafe and highly inaccurate.