Cuff Leak Test Research Articles

Development of postoperative laryngeal edema in patients undergoing craniotomy for elective intracranial tumor excision: a prospective, observational, preliminary study

BackgroundIntracranial tumor surgeries require different head and surgical positions as well as large fluid administration, which can cause laryngeal edema (LE) and increased morbidity. But there are no studies regarding its incidence in this patient population. As these patients often receive steroids for reducing peri-tumoral edema, which can also reduce LE, we hypothesized that incidence of LE in patients undergoing intracranial tumor resection in various positions might not be high. Thus, this prospective, observational study aimed to find LE incidence, as assessed by cuff leak test in these patients. MethodsASA I/ II, patients (18- 60 yrs) undergoing elective intracranial tumor resection were included after atraumatic tracheal intubation under standard general anesthetic technique. Cuff leak volume (CLV) was measured in supine position before start of surgery (CLVb) and completion (CLVc) of surgery. CLV ˂110 ml was considered to indicate LE. Important parameters were noted and patients were followed till discharge from the hospital. ResultsSeventy-three patients with male preponderance (58.9%) participated in study. Number of patients operated in supine, lateral, prone and sitting positions were 34, 16, 14 and 09, respectively. CLV decreased significantly in lateral and supine positions (p = 0.009 and 0.0002 respectively). Only, 02(2.74%) patients had CLVc <110 ml; both were male patients operated in supine position with head rotation. Anesthetic duration and intraoperative fluid administration were comparable across surgical positions. No PES was seen in any patient. ConclusionWe found that optimal intraoperative care of patients undergoing excision of intracranial tumors resulted in a low PLE incidence (2.74%) as detected by CLT at completion of surgery. However larger studies are required to further elaborate this issue.

Air leak test in the Paediatric Intensive Care Unit (ALTIPICU): rationale and protocol for a prospective multicentre observational study

IntroductionIn children, respiratory distress due to upper airway obstruction (UAO) is a common complication of extubation. The quantitative cuff-leak test (qtCLT) is a simple, rapid and non-invasive test that has...

A Case Series Reflecting Airway Difficulty Challenges: Insights into Intubation and Extubation for Large Retrosternal Goitres

Retrosternal goitres, often due to longstanding thyroid enlargement, can compress critical structures like the trachea and oesophagus, necessitating thyroidectomy. Managing the airway while ensuring patient safety presents a significant challenge for anaesthesiologists. This case series explores the complex airway management in three patients with large retrosternal goitres undergoing total thyroidectomy. The patients, aged 50, 60, and 73, presented with long-standing neck swelling, tracheal deviation and symptoms including breathlessness, dysphagia and hoarseness of voice. The goitres had progressively enlarged over many years, leading to significant tracheal compression and deviation, which posed a high-risk for airway obstruction during surgery. Given these challenges, Awake Fiberoptic Intubation (AFOI) was chosen to secure the airway while minimising the risk of airway loss. AFOI was performed under conscious sedation with dexmedetomidine and local anaesthesia, providing effective intubation with minimal discomfort and stable haemodynamics. This approach was critical in managing the anticipated difficult airway due to the retrosternal extension of the goitres and their impact on surrounding structures. Postoperatively, the patients were kept intubated to prevent tracheomalacia, a potential complication arising from prolonged tracheal compression. Tracheomalacia, characterised by the weakening of tracheal walls, can lead to airway collapse after extubation. To ensure airway stability, extubation was delayed until a satisfactory cuff-leak test was performed 24-36 hours after surgery. This case series emphasises the importance of careful preoperative planning and the use of AFOI in managing patients with large retrosternal goitres to avoid a ‘can’t intubate, can’t ventilate’ situation. The successful management of these cases highlights the effectiveness of AFOI in reducing perioperative risks and ensuring patient safety, particularly in scenarios where difficult airway management is anticipated. By implementing appropriate postoperative protocols, the risk of complications such as tracheomalacia can be significantly reduced, leading to improved surgical outcomes.

Utilization of spontaneous breathing trial, objective cough test, and diaphragmatic ultrasound results to predict extubation success: COBRE-US trial

BackgroundThe results of clinical and weaning readiness tests and the spontaneous breathing trial (SBT) are used to predict the success of the weaning process and extubation.MethodsWe evaluated the capacity of the cuff leak test, rate of rapid and shallow breathing, cough intensity, and diaphragmatic contraction velocity (DCV) to predict the success of the SBT and extubation in a prospective, multicenter observational study with consecutive adult patients admitted to four intensive care units. We used receiver operating characteristic (ROC) curves to assess the tests’ predictive capacity and built predictive models using logistic regression.ResultsWe recruited 367 subjects who were receiving invasive mechanical ventilation and on whom 456 SBTs were performed, with a success rate of 76.5%. To predict the success of the SBT, we derived the following equation: (0.56 × Cough) − (0.13 × DCV) + 0.25. When the cutoff point was ≥ 0.83, the sensitivity was 91.5%, the specificity was 22.1%, and the overall accuracy was 76.2%. The area under the ROC curve (AUC-ROC) was 0.63. To predict extubation success, we derived the following equation: (5.7 × SBT) + (0.75 × Cough) − (0.25 × DCV) − 4.5. When the cutoff point was ≥ 1.25, the sensitivity was 96.8%, the specificity was 78.4%, and the overall accuracy was 91.5%. The AUC-ROC of this model was 0.91.ConclusionObjective measurement of cough and diaphragmatic contraction velocity could be used to predict SBT success. The equation for predicting successful extubation, which includes SBT, cough, and diaphragmatic contraction velocity values, showed excellent discriminative capacity.

Utilization of a Risk Stratification Tool and Volume-Based Cuff Leak Test to Assess Postextubation Stridor.

Postextubation stridor (PES) is an imminently life-threatening event. Maximizing patient safety requires a systematic approach to screen patients for PES risk factors and a standardized test to evaluate that risk. This retrospective study of adult subjects was based on quality assurance data including standardized surveillance screening criteria and a volume-based cuff leak test (CLT) to evaluate PES risk among predominantly surgical-trauma and neurotrauma subjects. Data characterizing PES subjects also were collected. Data were collected between May 2010-December 2017 for all intubated subjects in our surgical-trauma, neurotrauma, and medical ICUs. Respiratory therapists were trained in performing both PES risk assessment surveillance and a volume-based CLT. A pre hoc cutoff leak volume of < 110 mL defined a true positive test result when associated with PES, and a leak ≥ 110 mL defined a true negative test if PES was absent. Multiple comparisons were analyzed by Kruskal-Wallis tests and dichotomous variables assessed by Fisher exact tests. Alpha was set at 0.05. In 681 pre-extubation CLTs ∼85% produced true-negative results and 15% consisted of true-positive (∼4%), false-negative (∼5%), and false-positive (∼6%) results. Positive and negative predictive values were 0.42 (0.32-0.54) and 0.94 (0.92-0.96), respectively. The PES likelihood ratio was 7.0, and correct classification was 89%. Of the 115 PES incidences occurring in 112 PES cases, 67% were female and 48% had suffered acute brain injury. Among predominantly surgical-trauma and neurotrauma subjects with a CLT, leak volume of ≥ 110 mL was associated with a PES risk of ∼6%, whereas the risk of PES was 7 times greater when the leak volume was < 110 mL.

Frequency of Positive Cuff Leak Test Before Extubation in Robotic Surgeries Done in Steep Trendelenburg Position.

Anaesthesia for robotic surgeries done in steep trendelenburgposition are associated with risks such as facial oedema, conjunctival chemosis, raised intraocular pressure, laryngeal oedema, and delayed awakening. We proposed the use of the cuff leak test in them to record the frequency of laryngeal oedema at the end of surgery and attempted to find its correlation with probable risk factors. We conducted a prospective observational study of 100 patients aiming primarily to assess the frequency of positive cuff leak test in robotic abdominal surgeries performed in trendelenburg position. The secondary outcomes were to check its correlation with intravenous fluid administration, duration of pneumoperitoneum, and angle of trendelenburg position. We also recorded the frequency of chemosis, the frequency of post-extubation stridor in 24h post-operatively, and the frequency of reintubation. Out of 100 participants undergoing elective abdominal robotic surgery in trendelenburg position, ninety were analysed. Total 31.6% (n = 30) participants showed positive cuff leak test. Chemosis was observed in 31 (32.6%) participants. No patient experienced post-extubation stridor or required reintubation during post-operative follow up. There was a no correlation between cuff leak test and intravenous fluid, duration of pneumo-peritoneum, or with angle of trendelenburg. The frequency of positive cuff leak test was high in patients at the end of robotic surgery but none of these patients had post-extubation stridor or required reintubations. There was no correlation with the fluid, angle, or duration of surgery. Clinical Trials Registry of India (CTRI/2017/04/008289), ctri.nic.in.

Dexmedetomidine for Awake Intubation Procedure in Subtotal Thyroidectomy

Background: Giant struma makes airway management difficult for the anesthesiologist due to the risk of tracheal intubation failure. Awake fiberoptic intubation(AFOI) is the gold standard in the management of a predicted difficult airway. Giving analgesia and sedation can facilitate operator and patient comfort during the awake intubation procedure. Case: We report the case of a 63-year-old woman with a giant struma who was planned for a subtotal thyroidectomy. We provide ondansetron and dexamethasone premedication, analgesia and sedation using dexmedetomidine, propofol induction, muscle relaxant atracurium, with maintenance anesthetic sevoflurane. Dexmedetomidine was administered on loading dose 0.8 µg /kg/hour in the first 10 minutes then continue on analgesia dose 0.2 µg /kg. During the AFOI procedure, 100% oxygenation was given with the patient's hemodynamic range, namely systolic blood pressure of 110-131 mmHg, diastolic blood pressure of 75-93 mmHg, heart rate of 77-91 beats per minute, and SpO2 of 98-100%. Postoperatively the patient was transferred to the Intensive care unit (ICU) with an endotracheal tube intube. Monitoring of postoperative complications such as production of thyroid crisis drainage and extubation 24 hours after surgery was confirmed by the cuff leak test. Conclusion: Giving dexmedetomidine is better than opioids in the AFOI procedure because of its minimal respiratory depressant effect. Maintaining hemodynamic stability during the AFOI procedure is very important to avoid hemodynamic fluctuations so it can minimize the risk of perioperative complications.

A novel technique for assessment of post-extubation airway obstruction can successfully replace the conventional cuff leak test: a pilot study

BackgroundPost-extubation airway obstruction is an important complication of tracheal intubation. The cuff leak test is traditionally used to estimate the risk of this complication. However, the cuff leak test parameters are not constant and may depend on the respiratory system and ventilator settings. Furthermore, deflating the cuff also be a risk factor for patient-ventilator asynchrony and ventilator-associated pneumonia.Instead of using the cuff leak test, we measured the pressure of the leak to the upper airway through the gap between the tube and glottis with a constant low flow from the lumen above the cuff without deflating the cuff and called it "pressure above the cuff."The purpose of this study was to investigate whether pressure above the cuff can be used as an alternative to the cuff leak volume.MethodsThis prospective observational study was conducted at Kumamoto University Hospital after obtaining approval from the institutional review board. The pressure above the cuff was measured using an endotracheal tube with an evacuation lumen above the cuff and an automated cuff pressure modulation device. We pumped 0.16 L per minute of air and measured the steady-state pressure using an automated cuff pressure modulation device. Then, the cuff leak test was performed, and the cuff leak volume was recorded. The cuff leak volume was defined as the difference between the expiratory tidal volume with the cuff inflated and deflated. The relationship between the pressure above the cuff and cuff leak volume was evaluated. The patient-ventilator asynchrony during each measurement was also examined.ResultsThe pressure above the cuff was measured, and the cuff leak volume was assessed 27 times. The pressure above the cuff was significantly correlated with the cuff leak volume (r = -0.76, p < 0.001). Patient-ventilator asynchrony was detected in 37% of measurements during the cuff leak test, but not during the pressure above the cuff test.ConclusionsThis study suggests that pressure above the cuff measurement may be a less complicated alternative to the conventional cuff leak test for evaluation of the risk of post-extubation airway obstruction.Trial registrationUniversity Hospital Medical Information Network Clinical Trials Registry (UMIN000039987; March 30, 2020). https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000044604

The Effects of Combining Two Postures and Two Ventilator Flow Waveforms on the Cuff Leak Test.

The cuff leak test (CLT) has been shown to have excellent specificity and moderate sensitivity for predicting postextubation stridor (PES). However, the ventilator flow waveform and the subject position are not uniform in current clinical practice. We conducted a prospective cohort study in the respiratory ICU of the Beijing Chaoyang Hospital, Capital Medical University. Prior to extubation, 4 CLTs, combining 2 different postures and ventilator flow waveforms, were conducted, and the diagnostic performance of each test was assessed. Of the 143 included subjects, PES occurred in 13 (9.1%), and 10 (7%) subjects required re-intubation. Initially, an air leak volume of 110 mL was used as the standard to judge performance. The test that involved the square waveform and the subject in semi-recumbent position (test 4) had the best diagnostic performance, with a specificity of 80% and a sensitivity of 67% for predicting PES. After analyzing the receiver operating characteristic curve, an optimal diagnostic threshold of 116 mL for air leak volume was found to result in a specificity of 92% and a sensitivity of 63% for test 4. Additionally, when the air leak ratio of test 4 was 0.32, the area under the curve was 0.76, the specificity was 92%, and the sensitivity was 62%. In this study, performing the CLT with the subject in semi-recumbent position using the square waveform appeared to allow for the best prediction of PES.

Prediction of Endotracheal Tube Size in Pediatric Population Using Ultrasonographic Subglottic Diameter and Age-Related Formulas: A Comparative Study.

Background:Choosing the correct Endotracheal tube (ETT) size is important in paediatric patients because an inappropriately large and small sized tube has its own disadvantages and chances of re-intubation with different size tube is high. The currently available modalities do not reflect the actual tracheal diameter for selection of endotracheal tube. Ultrasonography (USG) guided evaluation of transverse diameter at subglottic region may be helpful to estimate the proper size of ETT. We tested the hypothesis that Ultrasound guided subglottic diameter better predicts optimal ETT size than existing methods.Aims:To predict the appropriate size of ETT in pediatric patients to avoid multiple attempts of intubation and airway edema using simple noninvasive USG-guided methods.Settings and Design:Design: Prospective studySettings:Tertiary care hospital.Materials and Methods:Institutional ethical committee clearance no. BMCRI/PS/138/2020-21 was taken. Laryngoscopy and endotracheal intubation were done in 27 pediatric patients of age 2-15 years using a predetermined-sized ETT, estimated by ultrasonography. ETT size was considered optimal when the cuff leak test was negative. If there was resistance to ETT passage into the trachea, the tube was exchanged with one that was 0.5 mm smaller. If the cuff leak test was positive, then the ETT was exchanged for one with the 0.5-mm larger tube. The comparison was done between the size of ETT calculated by USG-guided subglottic diameter, age, height-related formulas, and clinical methods to look for accuracy of prediction for proper ETT size after cuff leak test.Statistical Analysis:The data collected were entered into Microsoft Excel and analyzed using SPSS version 22. IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp. Appropriate parametric and nonparametric tests were applied wherever necessary.Categorical data:Represented in the form of frequencies and proportions. Continuous data: Represented as mean and standard deviation. Paired sample test: Test to identify the mean difference between two quantitative variables. Kappa statistics: To measure the level of agreement.Results:A total of 27 children of age between 2 and 15 years were selected, out of which 15 were male and 12 were female. The accuracy of predicting appropriate ETT size is greater in ultrasound-guided subglottic diameter when compared to conventional clinical assessment and age- and height-related formula and almost the same accuracy as the clinical method.Conclusion:Ultrasound-guided subglottic diameter is an easy, effective, and noninvasive way of predicting accurate ETT size in the pediatric population.

Abstract No.: ABS2336: Ultra-sound-guided laryngeal air column width ratio as a predictor of post-extubation stridor in paediatric trauma patients: A prospective, observational study.

Background and Aims:Paediatric trauma patients need prolonged ventilation leading to post-extubation laryngeal oedema and stridor. Air-column width change reflects air leak and airflow around the endotracheal tube and vocal cords. Laryngeal air column width difference and ratio (LACWD and LACWR) are non-invasive methods for predicting the post-extubation stridor (PES).Methods:All children aged 1–14 years admitted to the trauma intensive care unit (TICU) for mechanical ventilation for >24 hours were included over 1 year. For intubated patients, if the size of the endotracheal tube was too large or too small, it was appropriate, whereas with an inappropriate size, the tube was changed. Cuff pressures were monitored and kept at or <20 cm of H2O. Dexamethasone was administered at 0.3 mg/kg/8 hours for 48 hours prior to planned extubation. LACW was measured on the day of receiving in TICU, immediately following intubation, prior to steroid therapy and before extubation. The Cuff leak test was used prior to the start of steroid therapy and before extubation.Results:A total of 50 patients were included, out of which 11 (22%) patients developed PES. Of the total number of patients, seven were intubated in TICU, whereas 43 patients were received intubation from outside. The positive predictive value cut-off of ultra-sound-guided LACWR to diagnose PES was <0.93 with a sensitivity of 90.91 and a specificity of 84.62.Conclusion:Ultra-sound-guided LACWD and LACWR are non-invasive methods of predicting PES in paediatric trauma patients.

Effectiveness of the cuff-leak test for assessing changes of resistance of the upper respiratory tract

Effectiveness of the cuff-leak test for assessing changes of resistance of the upper respiratory tract

Predictors of post-extubation stridor in patients on mechanical ventilation: a prospective observational study

The cuff leak test (CLT) has been widely accepted as a simple and noninvasive method for predicting post-extubation stridor (PES). However, its accuracy and clinical impact remain uncertain. We aimed to evaluate the reliability of CLT and to assess the impact of pre-extubation variables on the incidence of PES. A prospective observational study was performed on adult critically ill patients who required mechanical ventilation for more than 24 h. Patients were extubated after the successful spontaneous breathing trial, and CLT was conducted before extubation. Of the 191 patients studied, 26 (13.6%) were deemed positive through CLT. PES developed in 19 patients (9.9%) and resulted in a higher reintubation rate (8.1% vs. 52.6%, p < 0.001) and longer intensive care unit stay (8 [4.5–14] vs. 12 [8–30.5] days, p = 0.01) than patients without PES. The incidence of PES and post-extubation outcomes were similar in patients with both positive and negative CLT results. Compared with patients without PES, patients with PES had longer durations of endotracheal intubation and required endotracheal suctioning more frequently during the 24-h period prior to extubation. After adjusting for confounding factors, frequent endotracheal suctioning more than 15 times per day was associated with an adjusted odds ratio of 2.97 (95% confidence interval, 1.01–8.77) for PES. In conclusion, frequent endotracheal suctioning before extubation was a significant PES predictor in critically ill patients. Further investigations of its impact on the incidence of PES and patient outcomes are warranted.

Laryngeal air column width ratio in predicting postextubation stridor

Abstract Background Cuff leak test (CLT) has been used widely to assess upper airway patency before extubation but with low positive predictive value. Aim To assess the diagnostic accuracy of the airway column width ratio (ACWR) in predicting postextubation stridor (PES). Patients and methods 50 Patients who intubated &amp;gt;24 hours were observed for postextubation stridor and reintubation. Laryngeal ultrasound was done to measure the ACW with ETT cuff deflated immediately after intubation and 3–4 h before extubation. Cuff leak test was done. Results Fifty patients were included with mean age 58 ± 14.71 years, 68% were males and 32% were females. PES developed in 8% of patients. There was highly statistically significant difference between both groups regarding ACW before extubation and ACW ratio (p-value =0.006 and 0.000 respectively). The mean ACW ratio in stridor group (0.79 ± 0.03) was significantly lower than in non-stridor group (0.94 ± 0.04). Reintubation was higher in stridor group (100%) than non-stridor group (23.9%), P = 0.001. There was statistically significant higher duration of mechanical ventilation in stridor group (7.50 ± 0.58 vs. 4.23 ± 2.50 days, P = 0.013). A cut off point of ACW ratio ≤0.81 has a sensitivity 100% and Specificity 100%. Conclusion ACW showed excellent utility in prediction of patients with PES. Air column width ratio of ≤ 0.81 was a good predictor of PES.

Difficult Airway Management in Pediatric with a Large Cystic Hygroma Colli Undergoing One-Stage Excision Surgery

Background: A large cystic hygroma colli is a complicating factor in airway management in pediatric. Proper preparation, planning, and anticipation can reduce the risk of complications, morbidity, and mortality during difficult airway management. The fundamental principle of difficult airway management is to maintain adequate oxygenation and avoid hypoxemia by maintaining spontaneous ventilation. Case: A 22-month-old girl, weighing 9 kg, diagnosed with a large cystic hygroma colli who underwent single-stage excision surgery. Cystic hygroma was experienced since birth and with age, the cysts enlarge to a size of 25 x 17 x 12 cm which extends towards the face and shoulders. The patient did not experience stridor and symptoms of airway obstruction. The chest x-ray reveals no expansion of the cyst into the chest cavity and showed minimal tracheal deviation to the right. The difficult airway management was accomplished while maintaining the patient's spontaneous breathing. Sedation and analgesia obtained with intravenous administration of dexmedetomidine, ketamine, and nebulized lidocaine. A video laryngoscope is used to facilitate intubation. Awake extubation was performed after confirming that there was no risk of complications of laryngeal edema, laryngeal nerve injury, and tracheomalacia using a cuff-leak test. Conclusion: Maintaining spontaneous breathing, optimal levels of sedation and analgesia by administering dexmedetomidine, ketamine, and nebulizing lidocaine, and the use of a video laryngoscope can provide successful management of difficult airways due to a large cystic hygroma colli in pediatric patients.

The Effect of Goal-Directed Fluid Therapy versus Standard Fluid Therapy on the Cuff Leak Gradient in Patients Undergoing Complex Spine Surgery in Prone Position.

Objective Cuff leak test is an effective and established maneuver to predict airway edema. Standard fluid therapy (SFT) based on conventional monitoring is often associated with postoperative airway edema after complex spine surgeries. We conducted this prospective randomized controlled study to compare the effect of SFT versus goal-directed fluid therapy (GDFT) on the cuff leak gradient (CLG) in patients undergoing complex spine surgery in prone position. Our secondary objectives were to compare the effect of SFT and GDFT on sore throat, hoarseness, and length of intensive care unit (ICU) and hospital stay. Materials and Methods Thirty consecutive American Society of Anesthesiologists physical status I and II patients (18–60 years), of either sex, scheduled for spine surgery in prone position with expected duration of surgery more than 5 hours were included. The patients were randomized into two groups of 15 each. Group S patients ( n = 15) served as control group and received SFT intraoperatively, while patients in group G ( n = 15) received GDFT. Standard anesthetic protocol was followed in both the groups. The CLG was defined as the difference between the cuff leak volume (CLV) after intubation (CLV AI ) and before extubation (CLV BE ). Statistical Analysis and Results CLG was significantly less in group G (group S, 137.12 mL; group G, 65.52 mL; p -value <0.001). Intravenous fluids, blood loss, and postoperative sore throat were comparatively lesser in group G, though not statistically significant. Postoperative hoarseness was significantly lower in group G ( p -value = 0.003). Duration of ICU stay in group G (19.43 hours) was significantly lower ( p -value = 0.009) than group S (24.64 hours), but length of hospital stay was comparable. Conclusion GDFT significantly reduces airway edema and consequently reduces CLG as compared with SFT in patients undergoing complex spine surgery in prone position. Postoperatively, it also reduces sore throat, hoarseness of voice, and duration of ICU stay.

Cuff Leak Test and Airway Obstruction in Mechanically Ventilated Intensive Care Unit Patients: A Pilot Randomized Controlled Clinical Trial.

Rationale: Laryngeal edema is a known complication of endotracheal intubation that may cause airway obstruction upon extubation. The only test available to predict this complication is the cuff leak test (CLT). Objectives: Given the uncertainty of the CLT's clinical utility, we conducted the COMIC (Cuff Leak Test and Airway Obstruction in Mechanically Ventilated ICU Patients) pilot study to examine the feasibility of undertaking a larger trial. Methods: COMIC is a multicentered, parallel-group randomized trial performed in Canada, Saudi Arabia, and Poland. We enrolled mechanically ventilated adults admitted to the intensive care unit who were deemed ready for extubation. Those allocated to the intervention arm had the results of their CLT communicated to the healthcare team, who then decided to proceed with extubation or not. In those randomized to the control arm, the CLT results were not communicated to the healthcare team and patients were extubated, regardless of the CLT result. The primary outcomes focused on feasibility. Results: One hundred patients (56 in the intervention and 44 in the control arm) were enrolled. All feasibility criteria were met, including 1) recruitment rate of 7.6 patients/month, 2) consent rate of 88.3% (95% confidence interval [CI], 82.1-94.5%), and 3) protocol adherence of 98% (95% CI, 95-100%). There were two episodes of clinically significant stridor in the intervention group and four patients who required reintubation in each group. Conclusions: The results of the COMIC pilot trial support the feasibility of a larger trial to determine the effect of the CLT on reintubation and clinically important stridor.Clinical trial registered with www.clinicaltrials.gov (NCT03372707).

Comparison of Laryngeal Ultrasound and Cuff Leak Test to Predict Post-Extubation Stridor in Total Thyroidectomy.

Prediction of post-extubation stridor (PES) after thyroid surgeries has been challenging, and many criteria such as preoperative clinical parameters and intraoperative cuff leak test (CLT) have been used with variable results. The application of laryngeal ultrasound in predicting PES is a relatively new and non-invasive technique. Measurement of the air column width difference (ACWD) by laryngeal ultrasonography can predict PES. This study aimed to evaluate the efficacy of laryngeal ultrasound in the prediction of PES in patients after thyroidectomy and compare it with that of the CLT. A total of 200 patients who had undergone total thyroidectomy under general anaesthesia in a tertiary healthcare hospital were enrolled in the study. At the end of the surgery, air column widths (ACWs) were measured during endotracheal cuff inflation and deflation using laryngeal ultrasound in patients with spontaneous breathing. ACWD was measured and compared with that of the CLT at the time of extubation to predict PES. A total of 12 (6%) patients developed PES. ACWD using laryngeal ultrasound and CLT showed high sensitivity (91.7% and 92.6%, respectively), specificity (91.7% and 90.4%, respectively) and negative predictive value (99.43% and 99.42%, respectively) with low positive predictive value (44% and 37.93%, respectively) for both the diagnostic tests. Application of laryngeal ultrasound in combination with CLT can help the anaesthesiologist in decision making with the extubation plan after thyroid surgeries.

The cuff leak test in critically ill patients: An international survey of intensivists.

The cuff leak test (CLT) is used to assess laryngeal edema prior to extubation. There is limited evidence for its diagnostic accuracy and conflicting guidelines surrounding its use in critically ill patients who do not have risk factors for laryngeal edema. The primary study aim was to describe intensivists' beliefs, attitudes, and practice regarding the use of the CLT. A 13-item survey was developed, pilot-tested, and subjected to clinical sensibility testing. The survey was distributed electronically through MetaClinician®. Descriptive statistics and multivariable regression analysis were performed to examine associations between participant demographics and survey responses. 1184 practicing intensivists from 17 countries in North and South America, Europe, Oceania, and Asia participated. The majority (59%) of respondents reported rarely or never perform the CLT prior to extubating patients not at high risk of laryngeal edema, which correlated with 54% of respondents reporting they believed a failed CLT did not predict reintubation. Intensivists from the Middle East were 2.4 times more likely to request a CLT compared to those from North America. Intensivists with base training in medicine or emergency medicine were more likely to request a CLT prior to extubation compared to those with base training in anesthesiology. Use of the CLT prior to extubating patients not at high risk of laryngeal edema in the intensive care unit is highly variable. Practice appears to be influenced by country of practice and base specialty training.

Cuff Leak Test for Predicting Post Extubation Stridor in Intubated Adult Patients- A Prospective Observational Study

Cuff Leak Test for Predicting Post Extubation Stridor in Intubated Adult Patients- A Prospective Observational Study