Cuff Leak Test Research Articles

Cuff‐leak test for predicting postextubation airway complications: a systematic review

Postextubation problems such as laryngeal edema and reintubation are common complications after tracheal intubation. The cuff-leak test has been proposed as a method of identifying those patients at high risk in clinical practice, but its efficacy remains controversial. We searched electronic databases including PubMed, the Cochrane Controlled Trials Register, Web of Science, Ovid, and Embase. Studies were included if they were concerned with accuracy of the cuff-leak test and the effect of cuff-leak test screening on patient-important outcomes. Two reviewers independently assessed study quality with the QUADAS tool and extracted data. We compiled diagnostic two by two tables and pooled estimates of sensitivity and specificity, but refrained from pooling when there was considerable clinical or statistical heterogeneity. Sixteen diagnostic tests with 3172 participants and six clinical trials with 2500 patients were identified. The median diagnostic odds ratios for predicting postextubation laryngeal edema and reintubation were 18.16 (range, 3.54 to 356.00) and 10.80 (2.74 to 1665.00), respectively. The accuracy of the cuff-leak test varied with different methods, duration of intubation, and study population. An indirect comparison found significant differences in post-extubation incidence of laryngeal edema (OR = 2.09, 95% CI, 1.28 to 2.89) but not reintubation (OR = 0.94, 95% CI, 0.32 to 1.57) if using cuff-leak test screening. Our results suggest the cuff-leak test accurately predicts which adult patients are at high risk of postextubation airway complications, but randomized controlled trials are needed to further assess this diagnostic strategy.

Cuff Leak Test for the Diagnosis of Upper Airway Edema

Cuff Leak Test for the Diagnosis of Upper Airway Edema

Cuff-leak test predicts the severity of postextubation acute laryngeal lesions: a preliminary study

The objectives of the present study were to evaluate the relationships between the results of the cuff-leak test and the presence of laryngeal lesions; to assess whether lesions needing pharmacological treatment and surveillance can be predicted by the cuff-leak test; and to analyse the relationships between these lesions and postextubation stridor. The present study is a preliminary, prospective, clinical investigation set in an 11-bed ICU of a university hospital. We studied 50 consecutive adult patients admitted to the ICU and mechanically ventilated for more than 72 h. All patients underwent cuff-leak test before extubation. A laryngoscopic inspection was performed after extubation to evaluate the presence and degrees of laryngeal lesions. Laryngeal lesions were classified according to a 5-degree scale (0-4); patients with clinical manifestations were pharmacologically treated and monitored. A threshold cuff-leak value of 0.07 l (21% of tidal volume) was determined by visual inspection of the receiver-operating characteristic plot. Patients were divided into a positive and a negative cuff-leak test group. Comparing the severity of laryngeal lesions to the cuff-leak test, a relationship between higher degrees of lesions (degrees 3-4) and the positivity of the cuff-leak test (31.3% in the positive cuff-leak test group vs. 3.8% in the negative cuff-leak test group; P = 0.023) was observed. The positive and the negative predictive values were 25 and 96.1%, respectively. Only two cases of postextubation stridor were found, one in each group. There was no correlation between the results of the cuff-leak test and the occurrence of postextubation acute respiratory difficulties. Cuff-leak test is a simple, noninvasive tool, which may be useful to exclude, in patients with prolonged intubations, the presence of laryngeal injuries needing medical treatment and close monitoring. This occurs independently of postextubation stridor.

Post-extubation stridor in children : a case report and review of the literature

We describe a case of post-extubation stridor in a 3-year-old child who had suffered multiple trauma. Postextubation stridor is a not uncommon sequel of intubation in children. We review the literature on this complication and give recommendations on its prevention, prediction and management. Unplanned extubations, high ‘cuff’ pressures and movement of the tube in the trachea are the important risk factors. Although the ‘cuff-leak test’ has been proposed to predict post-extubation stridor, this test is unreliable in the younger child. Management has been by racemic adrenaline and steroids, but evidence to support this practice is lacking.

Cuff-leak test for the diagnosis of upper airway obstruction in adults: a systematic review and meta-analysis

To evaluate, in adults, the diagnostic accuracy of the cuff-leak test for the diagnosis of upper airway obstruction secondary to laryngeal edema and for reintubation secondary to upper airway obstruction. Systematic review without language restrictions based on electronic databases and manual review of the literature up to December 2008. When appropriate, a random-effects meta-analysis and meta-regression (Moses' method) were performed. Upper airway obstruction was the outcome in nine studies with an overall incidence of 6.9%. There was significant heterogeneity among studies. The pooled sensitivity was 0.56 (95% confidence interval: 0.48-0.63), the specificity was 0.92 (95% CI: 0.90-0.93), the positive likelihood ratio was 5.90 (95% CI: 4.00-8.69), the negative likelihood ratio was 0.48 (95% CI: 0.33-0.72), and the diagnostic odds ratio was 18.78 (95% CI: 7.36-47.92). The area under the curve of the summary receiver-operator characteristic (SROC) was 0.92 (95% CI: 0.89-0.94). Only three studies have evaluated the accuracy of the cuff-leak test for reintubation secondary to upper airway obstruction. Overall incidence was 7%. The pooled sensitivity was 0.63 (95% CI: 0.38-0.84), the specificity was 0.86 (95% CI: 0.81-0.90), the positive likelihood ratio was 4.04 (95% CI: 2.21-7.40), the negative likelihood ratio was 0.46 (95% CI: 0.26-0.82), and the diagnostic odds ratio was 10.37 (95% CI: 3.70-29.13). A positive cuff-leak test (absence of leak) should alert the clinician of a high risk of upper airway obstruction.

Steroids and Risk Factors for Airway Compromise in Multilevel Cervical Corpectomy Patients

Prospective, randomized, double-blind study. To evaluate intravenous corticosteroids in preventing delayed extubation after multilevel corpectomy and strut graft reconstructive procedures and to identify risk factors for delayed extubation in these patients. We performed a prospective, randomized double-blind study in patients undergoing multilevel cervical corpectomy procedures. Our hypothesis was that high-dose perioperative steroids would decrease edema and thus decrease the incidence of delayed extubation. We studied patients undergoing 2- or 3-level anterior cervical corpectomy procedures with anterior strut graft reconstruction. Sixty-six patients were randomized to receive 3 doses of either intravenous dexamethasone (n = 35) or saline (n = 31). The first dose was given before the incision, with subsequent doses given 8 and 16 hours later. Patients remained intubated until postoperative day 1, at which time a cuff leak test was performed by the anesthesiology attending. If a leak was present, the patient was extubated. If not, the test was repeated each postoperative day until a leak was present, indicating a patent airway. Five of 35 (14%) in the steroid group and 6 of 31 (19%) in the saline group required delayed extubation (P = 0.22). There were no statistical differences in preoperative parameters of age, gender, diagnosis, smoking history, BMI, number of operative levels, or preoperative American Society of Anesthesiologists rating between the 2 groups. Similarly there were no differences between the groups for duration of anesthesia, intraoperative colloids or crystalloids, intraoperative blood loss, or intraoperative urine output. The data for both groups were pooled to evaluate risk factors for delayed extubation. The only statistically significant risk factor for delayed extubation in this study was female gender (P = 0.0001). Based on our data, we cannot recommend intravenous dexamethasone for prevention of delayed extubation after multilevel anterior cervical corpectomy and strut grafting procedures.

Effects of steroids on reintubation and post-extubation stridor in adults: meta-analysis of randomised controlled trials

IntroductionThe efficacy of steroid administration before planned tracheal extubation in critical care patients remains controversial with respect to the selection of patients most likely to benefit from this treatment.MethodsWe performed an extensive literature search for adult trials testing steroids versus placebo to prevent reintubation or laryngeal dyspnoea. Studies were evaluated on a five-point scale based on randomisation, double-blinding and follow-up. Our analysis included trials having a score three or higher with patients mechanically ventilated for at least 24 hours and treated with steroids before extubation, taking into account the time of their administration (early vs late) and if the population selected was at risk or not.ResultsSeven prospective, randomised, double-blinded trials, including 1846 patients, (949 of which received steroids) were selected. Overall, steroids significantly decreased the risk of reintubation (relative risk (RR) = 0.58, 95% confidence interval (CI) = 0.41 to 0.81; number-needed-to-treat (NNT) = 28, 95% CI = 20 to 61) and stridor (RR = 0.48, 95% CI = 0.26 to 0.87; NNT = 11, 95% CI = 8 to 42). The effect of steroids on reintubation and stridor was more pronounced for selected high-risk patients, as determined by a reduced cuff leak volume (RR = 0.38, 95% CI = 0.21 to 0.72; NNT = 9, 95% CI = 7 to 19; and RR = 0.40, 95% CI = 0.25 to 0.63; NNT = 5, 95% CI = 4 to 8, respectively). In contrast, steroid benefit was unclear when trials did not select patients for their risk of reintubation (RR = 0.67, 95% CI = 0.45 to 1.00; NNT = 44, 95% CI ≥ 26 to infinity) or stridor (RR = 0.56, 95% CI = 0.20 to 1.55).ConclusionsThe efficacy of steroids to prevent stridor and reintubation was only observed in a high-risk population, as identified by the cuff-leak test and when it was administered at least four hours before extubation. The benefit of steroids remains unclear when patients at high risk are not selected.

Clinical review: Post-extubation laryngeal edema and extubation failure in critically ill adult patients

Laryngeal edema is a frequent complication of intubation. It often presents shortly after extubation as post-extubation stridor and results from damage to the mucosa of the larynx. Mucosal damage is caused by pressure and ischemia resulting in an inflammatory response. Laryngeal edema may compromise the airway necessitating reintubation. Several studies show that a positive cuff leak test combined with the presence of risk factors can identify patients with increased risk for laryngeal edema. Meta-analyses show that pre-emptive administration of a multiple-dose regimen of glucocorticosteroids can reduce the incidence of laryngeal edema and subsequent reintubation. If post-extubation edema occurs this may necessitate medical intervention. Parenteral administration of corticosteroids, epinephrine nebulization and inhalation of a helium/oxygen mixture are potentially effective, although this has not been confirmed by randomized controlled trials. The use of non-invasive positive pressure ventilation is not indicated since this will delay reintubation. Reintubation should be considered early after onset of laryngeal edema to adequately secure an airway. Reintubation leads to increased cost, morbidity and mortality.

The Cuff Leak Test is Not Predictive of Successful Extubation

In intubated patients the presence of a cuff leak (CL) is used as a predictor of successful extubation. CL is proposed to indicate laryngeal edema and predict which patients may develop complications such as postextubation stridor and eventual reintubation. Our objective was to evaluate the reliability of CL in our population of critically ill trauma patients. A retrospective chart review was performed of patients admitted to the trauma service who required mechanical ventilation. All patients undergo the CL test by a single respiratory therapist team before attempted extubation. Data collected included body mass index (BMI), endotracheal tube (ETT) size, length of time of mechanical ventilation, tidal volumes (Vt), and the size of the patient's trachea based on CT scan. The test is performed by the respiratory therapists and involves measuring expired Vt before and after the ETT cuff has been deflated and listening for an audible leak. A positive test result is defined as a CL greater than 10 per cent of Vt or, when volumes are not available, as audible air expired. From October 2005 to May 2006, 150 mechanically ventilated patients were identified and 49 charts were available for review. Forty-one patients had a cuff leak (+CL), whereas eight did not (-CL). The two cohorts were similar in age (+CL = 36.5 years, -CL = 38.1 years, P = 0.82), male gender (+CL = 70%, -CL = 50%, P = 0.25) ETT size (+CL = 7.4, -CL = 7.4, P = 0.57), and BMI (+CL = 28 kg/m2, -CL = 27 kg/m2, P = 0.71). The average tracheal diameter (+CL = 17.4 mm, -CL = 17.5 mm, P = 0.90) as well as the ratio of ETT and tracheal diameter was similar for the two cohorts (+CL = 0.65, -CL = 0.64, P = 0.73). Four patients (10%) in the +CL cohort failed extubation, whereas none of the -CL cohort failed (0%) (P = 0.40). The CL test does not reliably identify those patients who will require reintubation in our trauma population. In addition, the ratio of ETT and tracheal diameter is not predictive of successful extubation.

Titrated safe extubation: application of an original strategy for safe management of perioperative glottis edema with severe upper airway obstruction

Sir: Usual approach to traumatic laryngeal oedema with glottis obstruction can be harmful. Long-term orotracheal intubation and a prolonged stay of airway exchange catheters (AECs) could make the patient suffer new lesions [1]; therefore bed immobility and ICU stay could be prolonged. Airway emergencies during tracheal extubation phase are still associated with death or brain damage, indicating that additional management strategies are required to improve patient safety [2]. We report the application of new approach to safe extubation in a case of iatrogenic upper airways obstruction. A 62-year-old woman (weight 75 kg, height 155 cm, BMI 31.2) was scheduled for an Heller’s extramucosal cardiomyotomy. An unexpected difficult intubation occurred. Successful orotracheal intubation with a 7.0 mm ID tube was reached at the third attempt by using a Frova introducer. Following the intubation, laceration of the oesophageal mucosa with massive glottis oedema was detected. Surgery was delayed and the patient was admitted to ICU in order to plan a safe extubation. Our goal was to remove the orotracheal tube from patient’s trachea and perform a fiberoptic diagnosis on a free glottis. If she was able to breath, a guidewire (Baxter , hidrophylic Teflon, J, O 0.035i, length 150 cm) would have been placed in her airway as a marker for re-intubation. But our patient was unable to breath spontaneously (a cuff-leak test [3] resulted positive, tirage and oxygen desaturation occurred during safe extubation) so a nasal re-intubation with a smaller and cuffless tube (Rusch , SilkoClear Flex, ID 4.5 mm, lenght 25 cm) (NT) was performed. It was under fiberoptic surveillance (video bronchoscope Pentax FB 18, O 6 mm) and local anaesthesia, over the guidewire and an AEC (Cook No. 11, OD 4 mm) (Fig. 1). The NT placement resolved

O uso do teste de escape do balonete como fator preditor de laringoespasmo

Weaning patients from mechanical ventilation is a challenge in the intensive care unit (ICU) practice and is related to some complications. One of these is the pos-extubation laryngospasm, an event that can be anticipated for the cuff leak test (CLT). The objective was demonstrate that the CLT is a simple, reliable and low costs method to available the presence of obstruction in high airway in patients under weaning ventilator. It was made a systematic review in databases MedLine, SciElo and LILACS with articles from 1995 to 2007. The selected studies focused the use of the CLT to predict laryngospasm and extubation failure. It was excluded studies with animals and others literature reviews. It was looked correlates the CLT with mechanical ventilation's days, age and specific groups that could beneficiates with the application of this technique. The CLT can be considerate a good index to predict laryngospasm pos-extubation, when considerate the studied population characteristics.

The cuff-leak test is a simple tool to verify severe laryngeal edema in patients undergoing long-term mechanical ventilation

The cuff-leak test is a simple tool to verify severe laryngeal edema in patients undergoing long-term mechanical ventilation

Risk Factors for Delayed Extubation After Single-stage, Multi-level Anterior Cervical Decompression and Posterior Fusion

Airway difficulties after single-stage, multilevel anterior and posterior cervical surgery are potentially life-threatening complications. Although extubation delays can occur, overnight intubation can reduce the risk of postoperative airway emergencies. Our protocol was as follows: all patients were kept intubated overnight in an intensive care unit and examined by the intensive care unit staff each morning. Readiness for extubation was based on the cuff-leak test, and extubation done on patients beyond the first postoperative day was considered delayed. Eleven patients were extubated on the first postoperative day (group 1), and 11 extubated beyond day 1 (group 2). No airway emergencies occurred. Patient factors-age, weight, smoking, medical comorbidities, American Society of Anesthesiologist class-were not significantly related to extubation delay. There were no differences between groups in the number of anterior and posterior levels or anterior and posterior operative times. Delayed extubation was significantly related to total operative time (8.2 hours vs. 10.6 hours), volume of crystalloid replacement (3,627 cm3 vs. 6,218 cm3) and intraoperative blood transfused (0.7 units vs. 3.1 units); approaching significance was increased blood loss (1,238 mL vs. 2,820 mL). We have found intraoperative factors-operative time, crystalloid volume, blood loss and replacement-rather than patient characteristics, to be risk factors for delayed extubation. Good communication with anesthesia staff and careful attention to postoperative airway management is essential after single-stage, multilevel anterior cervical decompression and posterior fusion.

The cuff-leak test is a simple tool to verify severe laryngeal edema in patients undergoing long-term mechanical ventilation

The cuff-leak test has been proposed as a simple tool to clinically predict stridor or respiratory distress secondary to laryngeal edema following extubation. However, the true incidence of laryngeal edema in patients on long-term mechanical ventilation is uncertain. The relationship between upper airway obstruction (detected by video bronchoscopy) and the cuff-leak test value for patients with prolonged translaryngeal intubation during percutaneous dilatational tracheostomy (PDT) was investigated. Prospective, clinical investigation. Intensive care unit of a university hospital. Ninety-five patients with prolonged translaryngeal intubation requiring PDT were enrolled during a 12-month period. Cuff-leak test, PDT, video bronchoscopy. The average duration of translaryngeal intubation was 28.1 +/- 17.6 days. The incidence of severe laryngeal edema was 36.8% (35/95). We chose 140 mL as the threshold cuff-leak volume below which edema is indicated. The rate of cuff-leak test positivity was 38.9% (37/95). The sensitivity and the specificity of the test were 88.6% and 90.0%, respectively. The positive and negative predictive values were 83.8% and 93.1%, respectively. Patients who developed severe laryngeal edema had a smaller leak volume than those who did not, expressed in absolute values (53.9 +/- 56.2 vs. 287.9 +/- 120.0 mL; p < .001) or in relative values (10.1 +/- 10.2 vs. 55.3 +/- 22.7%, p < .001). The occurrence of severe laryngeal edema was not associated with age, gender, body weight, respiratory failure due to pneumonia, duration of translaryngeal intubation, endotracheal tube diameter, Acute Physiology and Chronic Health Evaluation II score, or history of self-extubation. A reduced cuff-leak volume measured before PDT may signal the presence of severe laryngeal edema in patients on long-term mechanical ventilation.

Laryngeal ultrasound: a useful method in predicting post-extubation stridor. A pilot study

The cuff-leak test was widely used for the prediction of post-extubation stridor, but controversial results limit its clinical application. The current study used real-time ultrasonography to evaluate the air-leak and hypothesised that the air-column width, measured by ultrasonography, may be correlated to the development of post-extubation stridor. From June 1, 2001 to March 1, 2002, a total of 51 planned extubations in 51 consecutively intubated patients were included. All of the patients received ultrasonographical examinations of their vocal cords and larynx in addition to an air-column width measurement within 24 h prior to extubation. The overall post-extubation stridor rate was 7.8%. The air-leak volume presented as median (interquartile range) were 300 (350) mL and 25 (20) mL, respectively, for the nonstridor and stridor groups. The air-column width during cuff deflation was 6.4 (2) mm and 4.5 (0.8) mm, respectively. They were found to be statistically significant. In conclusion, the authors demonstrated that laryngeal ultrasonography could be a reliable, noninvasive method, in the evaluation of vocal cords, laryngeal morphology and the ease of airflow, which passed through vocal cords or subglottic area due to laryngeal oedema. The air-column width during cuff deflation was a potential predictor of post-extubation stridor.

Risk Factors of Extubation Failure and Analysis of Cuff Leak Test as a Predictor for Postextubation Stridor

Background: Extubation failure was associated with poor prognosis and high hospital mortality. Cuff leak test (CLT) has been proposed as a relatively simple method for detecting laryngeal obstruction that predispose toward postextubation stridor (PES) and reintubation. We examined the risk factors of extubation failure and evaluated the usefulness and limitation of CLT for predicting PES and reintubation. Methods: Thirty-four consecutive patients intubated more than 24 hours were examined. The subjects were evaluated daily for extubation readiness, and CLT was performed prior to extubation. Several parameters in the extubation success and failure group were compared. The accuracy and limitation of CLT were evaluated after choosing the thresholds values of the cuff leak volume (CLV) and percentage (CLP). Results: Of the 34 patients studied, 6 (17.6%) developed extubation failure and 3 (8.8%) were accompanied by PES. The patients who had extubation failure were more likely to have a longer duration of intubation and more severe illness. The patients who developed PES had a smaller cuff leak than the others: according to the CLV (22.5±23.8 vs 233.3±147.1ml, p=0.020) or CLP (6.2±7.3 vs 44.3±24.7%, p=0.013). The best cut off values for the CLV and CLP were 50ml and 14.7%, respectively. The sensitivity, negative predictive value, and specificity of CLT were relatively high, but the positive predictive value was low. Conclusion: The likelihood of developing extubation failure increases with increasing severity of illness and duration of intubation. A low CLV or CLP (<50ml or 14.7%) is useful in identifying patients at risk of PES, but the CLT is not an absolute predictor and should not be used an indicator for delaying extubation. (Tuberc Respir Dis 2006; 61: 34-40)

High Body Mass Index and Long Duration of Intubation Increase Post-Extubation Stridor in Patients with Mechanical Ventilation

Approximately 20% of mechanically ventilated patients experience post-extubation stridor (PES) and reintubation, which subsequently may lead to an increased risk of morbidity and mortality. The risk of PES development is significantly higher in obese patients. Low air leakage between the endotracheal tube and the trachea, following cuff deflation, may indicate a higher risk for the development of PES. The aim of this study is to identify the relationship between body mass index (BMI) and PES using the cuff-leak test in patients intubated in the respiratory intensive care unit. A total of 67 consecutive intubations on 56 different ventilated patients were included in this study. The mean age was 63.6 +/- 12.1 years and 84% of the patients were male. PES developed in seven patients (10.4%). The mean cuff-leak volume was 395 +/- 187 ml in non-PES patients and 240 +/- 93 ml in PES patients (p = 0.023). The mean BMI was 36 +/- 13 kg/m2 in PES patients and 24 +/- 7 kg/m2 in non-PES patients (p = 0.046). BMI > 26.5 kg/m2 (OR: 1.2), low cuff-leak volume (< 283 ml) and mechanical ventilation required for more than 5 days (OR: 0.9) were independent variables for PES occurrence. We therefore suggest that non-obese patients, short-term intubated patients and those having a high air leakage around the endotracheal tube could be extubated without much difficulty.

Determinants of the cuff-leak test: a physiological study

IntroductionThe cuff-leak test has been proposed as a simple method to predict the occurrence of post-extubation stridor. The test is performed by cuff deflation and measuring the expired tidal volume a few breaths later (VT). The leak is calculated as the difference between VT with and without a deflated cuff. However, because the cuff remains deflated throughout the respiratory cycle a volume of gas may also leak during inspiration and therefore this method (conventional) measures the total leak consisting of an inspiratory and expiratory component. The aims of this physiological study were, first, to examine the effects of various variables on total leak and, second, to compare the total leak with that obtained when the inspiratory component was eliminated, leaving only the expiratory leak.MethodsIn 15 critically ill patients mechanically ventilated on volume control mode, the cuff-leak volume was measured randomly either by the conventional method (Leakconv) or by deflating the cuff at the end of inspiration and measuring the VT of the following expiration (Leakpause). To investigate the effects of respiratory system mechanics and inspiratory flow, cuff-leak volume was studied by using a lung model, varying the cross-sectional area around the endotracheal tube and model mechanics.ResultsIn patients Leakconv was significantly higher than Leakpause, averaging 188 ± 159 ml (mean ± SD) and 61 ± 75 ml, respectively. In the model study Leakconv increased significantly with decreasing inspiratory flow and model compliance. Leakpause and Leakconv increased slightly with increasing model resistance, the difference being significant only for Leakpause. The difference between Leakconv and Leakpause increased significantly with decreasing inspiratory flow (V'I) and model compliance and increasing cross-sectional area around the tube.ConclusionWe conclude that the cross-sectional area around the endotracheal tube is not the only determinant of the cuff-leak test. System compliance and inspiratory flow significantly affect the test, mainly through an effect on the inspiratory component of the total leak. The expiratory component is slightly influenced by respiratory system resistance.

How to identify patients with no risk for postextubation stridor?

The aim of this study was first, to evaluate the value of cough following tracheal tube cuff deflation, and second, to reassess the value of the cuff-leak test to predict postextubation stridor (PES). In spontaneously breathing patients, immediately before extubation, the tracheal tube was deflated and the absence of cough was monitored. The tube was then obstructed with a finger, and the absence of leak was monitored. Extubation was then performed. Four PESs were observed after 115 extubations (incidence: 3.5%). The absence of cough was more frequently observed when PES occurred than when it did not (75% v 21%, P = .04). The absence of leak was observed in 100% of PES and in 20% of PES free extubations ( P = .01). The absence of both leak and cough was more frequently observed in PES (75% v 7%, P < .0001). In the absence of leak, the likelihood ratio of developing PES was 5.04 and rose to 10.4 when cough was also absent. The likelihood ratio of not developing PES in the absence of leak alone was 0. We conclude that in a population of medical intensive care unit spontaneously breathing patients, just before extubation, the presence of leaking around the endotracheal tube rules out PES, whereas the absence of cough and of leak are good predictors of PES.

The cuff-leak test: what are we measuring?

Stridor is one of the most frequent causes of early extubation failure. The cuff-leak test may help to identify patients at risk to develop post-extubation laryngeal edema. However the discrimination power of the cuff-leak test is highly variable and can be use, at best, to detect patients at risk to develop edema but should not be used to postpone extubation as tracheal extubation can still be successful in many patients with a positive test. In this editorial, the author discuss the factors influencing the leak and hence its predictive value.