Endotracheal Tube Cuff Inflation Research Articles

The Professional Experience of Anaesthesiologists in Proper Inflation of Laryngeal Mask and Endotracheal Tube Cuff.

Cuffs inflated to inappropriately high pressures cause ischemia, reducing tracheal mucosal blood flow, while cuffs inflated at lower pressure than necessary give rise to inadequate ventilation, aspiration of gastric contents, or extubation due to air leakage. In this study, we aimed to investigate the effect of the experience of anaesthesia staff on endotracheal tube and laryngeal mask airway cuff inflation. The study included 348 elective patients scheduled to undergo surgery under general anaesthesia, with 34 anaesthesia technicians, 16 anaesthesia residents, and 12 anaesthesiologists with different years of professional experience. The participants were told to inflate the cuff balloon with air to the level of the pressure that was appropriate for them. No information was provided to the participants about the values of the cuff pressure pending the completion of all measurements. After placement of the laryngeal mask airway and endotracheal tube, the success of the procedure was checked by monitoring square-wave capnograph tracing and thoracoabdominal motion. Each participant performed the procedures on three patients, and the mean cuff pressures were measured. There was no significant correlation between duration of experience of technicians, residents, and experts in using laryngeal mask airway pressure (r=-0.192/p=0.278, r=0.225/p=0.402, r=-0.476/p=0.118, respectively) and endotracheal tube (r=-0.306/p=0.079, r=-0.060/p=0.826, r=-0.478/0.116, respectively). It has been concluded that professional experience does not contribute to achieving normal cuff pressure without monitoring. Introduction of the cuff manometer into routine anaesthesia practice will be useful, irrespective of anaesthesiologists' experience.

Assessment of four methods of endotracheal tube cuff inflation in terms of optimal cuff sealing

Tsaousi, G.; Oloktsidou, I.; Tsiaousi, A.; Gkinas, D.; Vasilakos, D. Author Information

Endotracheal tube cuff inflation with and without a pressure gauge to minimise sevoflurane pollution during intermittent positive pressure ventilation

Editor,Possible health hazards from exposure to trace concentrations of inhalational anaesthetics cannot yet be definitively excluded.1 We have previously reported that the concentrations of the commonly used volatile anaesthetic sevoflurane were significantly higher in the proximity of the intubate

Tracheal tube cuff inflation guided by pressure volume loop closure associated with lower postoperative cuff-related complications: Prospective, randomized clinical trial.

Background:The main function of an endotracheal tube (ETT) cuff is to prevent aspiration. High cuff pressure is usually associated with postoperative complications. We tried to compare cuff inflation guided by pressure volume loop closure (PV-L) with those by just to seal technique (JS) and assess the postoperative incidence of sore throat, cough and hoarseness.Materials and Methods:In a prospective, randomized clinical trial, 100 patients’ tracheas were intubated. In the first group (n = 50), ETT cuff inflation was guided by PV-L, while in the second group (n. = 50) the ETT cuff was inflated using the JS technique. Intracuff pressures and volumes were measured. The incidence of postoperative cuff-related complications was reported.Results:Demographic data and durations of intubation were comparable between the groups. The use of PV-L was associated with a lesser amount of intracuff air [4.05 (3.7-4.5) vs 5 (4.8-5.5), P < 0.001] and lower cuff pressure than those in the JS group [18.25 (18-19) vs 33 (32-35), P ≤ 0.001]. The incidence of postextubation cuff-related complications was significantly less frequent among the PV-L group patients as compared with the JS group patients (P ≤ 0.009), except for hoarseness of voice, which was less frequent among the PV-L group, but not statistically significant (P ≤ 0.065). Multiple regression models for prediction of intra-cuff pressure after intubation and before extubation revealed a statistically significant association with the technique used for cuff inflation (P < 0.0001).Conclusions:The study confirms that PV-L-guided ETT cuff inflation is an effective way to seal the airway and associates with a lower ETT cuff pressure and lower incidence of cuff-related complications.

Do current methods for endotracheal tube cuff inflation create pressures above the recommended range? A review of the evidence

Inflation and measurement of endotracheal (ET) tube cuff pressure is often not seen as a critical aspect of care in surgical patients. The morbidity associated by an overinflated cuff has been regularly highlighted in literature, for example mucosal ulceration (Combes et al 2001) and vocal cord paralysis (Holley & Gildea 1971). This article will outline techniques for the methods of inflation based on the latest scientific evidence. The author will seek to examine if intraoperative cuff assessment and monitoring should become routine for the anaesthetic practitioner and if current practice for inflating cuffs creates pressures outside the safe range.

Do Current Methods for Endotracheal Tube Cuff Inflation Create Pressures above the Recommended Range? A Review of the Evidence

Inflation and measurement of endotracheal (ET) tube cuff pressure is often not seen as a critical aspect of care in surgical patients. The morbidity associated by an overinflated cuff has been regularly highlighted in literature, for example mucosal ulceration (Combes et al 2001) and vocal cord paralysis (Holley & Gildea 1971). This article will outline techniques for the methods of inflation based on the latest scientific evidence. The author will seek to examine if intra-operative cuff assessment and monitoring should become routine for the anaesthetic practitioner and if current practice for inflating cuffs creates pressures outside the safe range.

Design and In Vitro Testing of a Pressure-Sensing Syringe for Endotracheal Tube Cuffs

Endotracheal intubation is a frequently performed procedure in the prehospital setting, intensive care unit, and for patients undergoing surgery. The endotracheal tube cuff must be inflated to a pressure that prevents air leaks without compromising tracheal mucosal blood flow. For simultaneous endotracheal tube cuff inflation and measurement, we designed and tested a novel pressure-sensing syringe in vitro. The prototype was developed using a standard 10-mL polycarbonate syringe body that houses a plunger and a silicone rubber bellows, the pressure-sensing element. Bellow feasibility was determined and modeled using finite element analysis. Repeatability testing at each pressure measurement for each bellows (pressure versus deflection) was within an average standard deviation of 0.3 cm to 1.61 cm (1%-5% error). Using an aneroid manometer for comparison, there was excellent linear correlation with a Spearman rank of 0.99 (P < 0.001), up to 30 cm H(2)O.

Is sealing cuff pressure, easy, reliable and safe technique for endotracheal tube cuff inflation?: A comparative study

Objective:To compare the three common methods of endotracheal tube cuff inflation (sealing pressure, precise standard pressure or finger estimation) regarding the effective tracheal seal and the incidence of post-intubation airway complications.Methods:Seventy-five adult patients scheduled for N2 O free general anesthesia were enrolled in this study. After induction of anesthesia, endotracheal tubes size 7.5 mm for female and 8.0 mm for male were used. Patients were randomly assigned into one of three groups. Control group (n=25), the cuff was inflated to a pressure of 25 cm H2O; sealing group (n=25), the cuff was inflated to prevent air leaks at airway pressure of 20 cm H2O and finger group (n=25), the cuff was inflated using finger estimation. Tracheal leaks, incidence of sore throat, hoarseness and dysphagia were tested.Results:Although cuff pressure was significantly low in the sealing group compared to the control group (P<0.001), the incidence of sore throat was similar in both groups. On the other hand, cuff pressure as well as the incidence of sore throat were significantly higher in the finger group compared to both the control and the sealing group (P<0.001 and P=0.008). The incidence of dysphagia and hoarseness were similar in the three groups. None of the patients in the three groups developed air leak around the endotracheal tube cuff..Conclusions:In N2O, free anesthesia sealing cuff pressure is an easy, undemanding and safe alternative to the standard technique, regarding effective sealing and low incidence of sore throat.

Part 14: Pediatric Advanced Life Support

In contrast to adults, cardiac arrest in infants and children does not usually result from a primary cardiac cause. More often it is the terminal result of progressive respiratory failure or shock, also called an asphyxial arrest. Asphyxia begins with a variable period of systemic hypoxemia, hypercapnea, and acidosis, progresses to bradycardia and hypotension, and culminates with cardiac arrest.1 Another mechanism of cardiac arrest, ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), is the initial cardiac rhythm in approximately 5% to 15% of pediatric in-hospital and out-of-hospital cardiac arrests;2,–,9 it is reported in up to 27% of pediatric in-hospital arrests at some point during the resuscitation.6 The incidence of VF/pulseless VT cardiac arrest rises with age.2,4 Increasing evidence suggests that sudden unexpected death in young people can be associated with genetic abnormalities in myocyte ion channels resulting in abnormalities in ion flow (see “Sudden Unexplained Deaths,” below). Since 2010 marks the 50th anniversary of the introduction of cardiopulmonary resuscitation (CPR),10 it seems appropriate to review the progressive improvement in outcome of pediatric resuscitation from cardiac arrest. Survival from in-hospital cardiac arrest in infants and children in the 1980s was around 9%.11,12 Approximately 20 years later, that figure had increased to 17%,13,14 and by 2006, to 27%.15,–,17 In contrast to those favorable results from in-hospital cardiac arrest, overall survival to discharge from out-of-hospital cardiac arrest in infants and children has not changed substantially in 20 years and remains at about 6% (3% for infants and 9% for children and adolescents).7,9 It is unclear why the improvement in outcome from in-hospital cardiac arrest has occurred, although earlier recognition and management of at-risk patients on general inpatient units …

Intracuff buffered lidocaine versus saline or air—A comparative study for smooth extubation in patients with hyperactive airways undergoing eye surgery

ABSTRACTBackground: Increased cough and restlessness during emergence from general anaesthesia in patients undergoing ophthalmologic surgical procedures might result in increased intraocular pressure, ruptured sutures and suprachoroidal haemorrhage, which can be detrimental to the outcome of surgery. In hyperactive airway patients, as the cough receptors are in the hypersensitised stage, the patients tend to cough more frequently and violently during extubation. Hence, in such patients, we sought to determine the benefits of filling the endotracheal tube cuff with either buffered lidocaine, saline or air, so as to prevent endotracheal tube-induced coughing during emergence from general anaesthesia.Methods: Seventy five patients either with a history of chronic smoking or recently treated upper respiratory tract infections were randomly assigned into three groups (n = 25), based on the type of endotracheal tube cuff inflation, as follows: Group A (air), Group B (6 ml normal saline) and Group C (6 ml 2% lid...

Usefulness of new technique using a disposable syringe for endotracheal tube cuff inflation.

Risk for injuries resulting from overinflated or underinflated endotracheal tube cuff warrants adequate cuff inflation technique. Thus, this study was designed to measure the actual intracuff pressures obtained by new estimation techniques. 95 adult surgical patients requiring tracheal intubation were randomized to two groups with respect to the endotracheal tube model: Portex(R) (n = 55) and Euromedical(R) (n = 40). After induction of anesthesia, the cuff was inflated using new estimation techniques with two different syringes: PR10 or PR20 (passive release technique using a 10-ml or 20-ml syringe, respectively). Subsequently, an aneroid manometer was used to measure the actual intracuff pressures. These inflation techniques were repeated two times. A direct cuff measurement range of 25 to 40 cmH2O was used as a reference for optimal intracuff pressure. Size 7.0 mm internal diameter (ID) tubes were used for women and size 7.5 mm ID for men. 88 eligible patients were studied: Portex group (n = 50) and Euromedical group (n = 38). With respect to the rate of optimal cuff inflation, PR10 was significantly higher than PR20 in both groups (56% vs. 10% in Portex group; 63.2% vs. 0% in Euromedical group, respectively) (P < 0.05). When direct intracuff measurement is not available, a new method, named "passive release technique" using a 10-ml syringe, is a useful alternative cuff inflation method.

87: Do Endotracheal Tube Cuff Pressure and Volume Have a Linear or Nonlinear Relationship?

Standard methods of endotracheal tube (ETT) cuff inflation may result in high intracuff pressure. If a logarithmic relationship between ETTc cuff pressures and ETTc volumes exists, addition of small volumes of air may result in dramatic increases in pressure after a threshold volume is reached. If a linear relationship exists, no such precipitous increase in pressure with additional volume would occur. We sought to determine if there is a linear or logarithmic relationship between ETTc pressure and ETTc volume.

The effects of two endotracheal tube cuff inflation pressures on liquid aspiration and tracheal wall damage in horses

Objective To investigate the effect of endotracheal tube cuff inflation pressure on the occurrence of liquid aspiration and tracheal wall damage.Study design Prospective, randomized experimental study.Animals Ten healthy horses, weighing 535 ± 55 kg.Methods Horses were anesthetized, orotracheally intubated, placed in dorsal recumbency, and maintained on isoflurane in oxygen with controlled ventilation for 175 ± 15 minutes. The horses were randomly assigned to an endotracheal cuff pressure of 80–100 or 120 cm H2O. The cuff pressure was continuously monitored and maintained at a constant pressure. Methylene blue in saline was instilled proximal to the cuff. After euthanasia, the trachea was opened distal to the endotracheal tube tip to check for evidence of dye leaking past the cuff. The cervical trachea was then resected and opened longitudinally for gross and histologic examinations.Results No blue staining was found distal to the cuff in any horse. Visual examination of the tracheal mucosa revealed hyperemic and hemorrhagic lesions at the site of the cuff contact. Histologic changes included epithelium attenuation or erosion, submucosal neutrophilic infiltration, and submucosal hemorrhages. Lesions were absent or less extensive in the lower cuff pressure group as compared to the high cuff pressure group.Conclusions The endotracheal tube cuff produced a seal sufficient to prevent leakage in both groups. Tracheal wall damage was more severe and occurred more frequently in the higher cuff pressure group.Clinical relevance Tracheal mucosal damage induced by cuff inflation is pressure-dependent. Cuff pressure monitoring is recommended.

The Effect of Sevoflurane and Desflurane on Upper Airway Reactivity

Although bronchial reactivity can be assessed by changes in airway resistance, there is no well-accepted measure of upper airway reactivity during anesthesia. The authors used the stimulus of endotracheal tube cuff inflation and deflation to assess changes in airway reactivity in patients anesthetized with sevoflurane and desflurane. Sixty-four patients classified as American Society of Anesthesiologists physical status I or II participated in this randomized, double-blind study. Patients were anesthetized with either sevoflurane or desflurane at 1.0 and 1.8 minimum alveolar concentration (MAC). The trachea was stimulated by inflating the endotracheal tube cuff. A blinded observer assessed the severity of patient response to the stimulus and changes in hemodynamic variables. The process was repeated at the second MAC treatment condition. At 1.0 MAC, patients anesthetized with desflurane had a more intense response and a greater likelihood of significant coughing and associated hemodynamic changes (both at P < 0.05). At 1.8 MAC, sevoflurane and desflurane both suppressed clinically significant responses to tracheal stimulation. Interrater reliability was excellent for this measure of upper airway reactivity (P < 0.001). The assessment of the cough response to tracheal stimulation by endotracheal tube cuff inflation is a reliable and clinically meaningful measure of upper airway reactivity. At 1.0 MAC, sevoflurane is superior to desflurane for suppressing moderate and severe responses to this stimulus.

Foreign Body Removal: Tracheal Backflow Air or Rigid Bronchoscopy?

To the Editor: We read the interesting report of Fung et al (1), which describes the removal of a foreign body (FB) by tracheal backflow air. However, this technique does not exclude the possibility of failure of FB expulsion (and subsequent FB aspiration into the right mainstem bronchus) caused by FB impact on the right vocal cord; the FB dimensions were approximately 4 × 8 mm (1), whereas the maximal space between a 7.5 endotracheal tube (ETT) (outer diameter = 10–10.5 mm) and the vocal cords [maximal width of relaxed glottis = 12 mm (2)] is 2 mm. Furthermore, even in the case of successful FB expulsion (1), the FB might traumatize the right vocal cord. We would therefore recommend an alternative technique (3) of FB removal: 1) after ventilation with 100% O2, simultaneous insertion of a fiberoptic bronchoscope (FOB) and a 7F Fogarty catheter (FC) into the ETT, FC balloon inflation between the carina and the ETT tip under fiberoptic visualization, and simultaneous ETT and FOB removal (Fig. 1A), 2) insertion of a rigid bronchoscope into the trachea (aside the FC) and FB removal (Fig. 1B), and 3) reintubation of the trachea with a 7.5–8.5 ETT, ETT cuff inflation (Fig. 1C), deflation of the FC balloon and FC removal (Fig. 1C), and resumption of patient ventilation.Figure 1: The proposed technique of aspirated foreign body (FB) removal in the case of FB-location above the inflated cuff of an endotracheal tube (ETT). A, A fiberoptic bronchoscope (FOB) and a Fogarty catheter (FC) are simultaneously introduced into the ETT, and the FC cuff is inflated just above the carina under fiberoptic visualization; the ETT and the FOB are then simultaneously withdrawn (see arrows). B, a rigid bronchoscope (RB) is inserted into the trachea aside the FC and the FB is removed (see arrow). C, after the withdrawal of the RB, an ETT is introduced into the trachea aside the FC; after the ETT cuff inflation, the FC balloon is deflated and the FC is removed (see arrows).Maria J. Tzoufi MD Spyros D. Mentzelopoulos MD

Anesthesia for Tracheal Resection: A New Technique of Airway Management in a Patient with Severe Stenosis of the Midtrachea

Anesthesia for Tracheal Resection: A New Technique of Airway Management in a Patient with Severe Stenosis of the Midtrachea

Anesthesia for Tracheal Resection: A New Technique of Airway Management in a Patient with Severe Stenosis of the Midtrachea

We report the combined use of a Fogarty catheter (FC), a 3.5-mm fiberoptic bronchoscope (FOB), and a 6.0 endotracheal tube (ETT) to intubate the lower trachea of a patient with a primary upper- and midtracheal tumor causing a 66% stenosis of the tracheal lumen at the level of the thoracic inlet. Initially, the 6.0 ETT, with the FOB and the FC fed to its tip, was placed above the tumor and rotated 90° counterclockwise. The FOB and the FC were advanced through the stenosis, and the FC cuff was inflated just above the carina. The ETT was advanced over the FOB toward the FC cuff, and the ETT cuff was inflated below the tumor and above the FC cuff. After inspection for blood and tumor debris through the FOB’s eyepiece, the FC cuff was deflated, both the FOB and FC were withdrawn, and intermittent positive pressure ventilation (IPPV) was begun.

Utility of portable chest radiographs as a predictor of endotracheal tube cuff pressure

Increased endotracheal tube cuff pressure causes mucosal ischemia that can lead to necrosis, infection, and, eventually, tracheomalacia or tracheal stenosis. Endotracheally intubated patients frequently undergo portable chest radiography. In this study we explored the relationship of endotracheal tube cuff pressure and the appearance on the tracheal air columns on the portable chest radiograph. We measured the endotracheal tube cuff pressure of intensive care unit patients 124 times immediately before portable chest radiography. On 64 of these radiographs we measured the width of the tracheal air column below the tip of the endotracheal tube and at the maximal diameter of the endotracheal tube balloon. We then analyzed the relationship of cuff pressure to tracheal dilation. The results of ANOVA of tracheal dilation for three groups (safe, borderline, and unsafe cuff pressures) were significant. Large overlapping ranges existed in each group. Regression analysis confirmed a linear relationship between cuff pressure and tracheal dilation ( r = 0.435, p < 0.001). Predicted tracheal expansion at 20 mm Hg was a poor screen for endotracheal tube cuff inflation safety; the sensitivity was only 56% and specificity only 71%. The differences in the capacity for tracheal distension between patients make these findings not unexpected. The portable chest radiograph is a poor screening tool for unsafe endotracheal tube cuff pressure. (Otolaryngol Head Neck Surg 1999;120:51-6.)

Capnography-Guided Nasotracheal Intubation of a Patient with a Difficult Airway and Unwanted Respiratory Depression

Capnography-Guided Nasotracheal Intubation of a Patient with a Difficult Airway and Unwanted Respiratory Depression

The self-inflating bulb to detect esophageal intubation during emergency airway management.

The negative-pressure test using a self-inflating bulb (SIB) during emergency intubation was studied to determine its reliability and predictive value in this setting. The endotracheal tube (ETT) position was tested in 300 consecutive patients undergoing in-hospital emergency endotracheal intubation. Immediately after intubation and before ETT cuff inflation, the following protocol was strictly followed: (1) an SIB was compressed, connected to the ETT, and released. A 10-s period was allowed for the bulb to inflate. (2) The ETT cuff was inflated, and the ETT position was confirmed using colorimetric or infrared carbon dioxide detection, or both, combined with clinical evaluation. There were 19 esophageal intubations (6% incidence). The SIB correctly identified all patients with esophageal intubation (sensitivity, 100%) and correctly identified all but three ETTs placed in the trachea (specificity, 99%). The three tracheally placed tubes that were misidentified by the bulb syringe occurred during one case each of chronic obstructive pulmonary disease, copious secretions, and obesity; of note were three tracheally placed tubes that were misidentified by the carbon dioxide analyzers during cardiopulmonary resuscitation. The SIB proved to be a sensitive and specific test for esophageal intubation in the emergency setting when used according to the protocol described, and it is complementary to carbon dioxide detection. The predictive value of the bulb syringe appears to be improved when a prolonged period for reinflation is allowed. It holds particular promise because of its low cost and portability.