Endotracheal Cuff Inflation Research Articles

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.

Damage to endotracheal cuff inflation tube by harmonic scalpel in tonsillectomy leading to compromised airway

Use of harmonic scalpel has increased in the recent past for different surgical procedures. We report a case of damage to an endotracheal tube inflation line in a 47 year old female patient who underwent elective tonsillectomy due to harmonic scalpel. Pre-anaesthetic evaluation of the patient revealed no abnormalities. The patient’s trachea was intubated via nasal route with a cuffed north facing Ring, Adair and Elwyn tube of 7.0 mm internal diameter. The cuff was inflated after confirmation of tracheal placement of tube and pharyngeal packing was done. After 30 minutes of surgery, the bellows of the ventilator were collapsing. Suspecting a leak an attempt was made to inflate the cuff, which revealed high resistance in inflation tube. Surgeon was immediately asked to stop the surgery. Check laryngoscopy revealed damage to cuff inflation tube which was sealed by harmonic scalpel in semi-inflated condition. Anticipating that the tracheal extubation in that inflated position would result in vocal cord trauma, a 23 gauge spinal needle attached to 5ml syringe was introduced under direct laryngoscopic guidance. The cuff was punctured and air aspirated so as to deflate the cuff. The tube was taken out and was replaced. The surgery continued for next one hour, was uneventful and trachea extubated at completion.

Analysis on risk factors of endotracheal cuff under inflation in mechanically ventilated patients

To investigate the prevalent condition of endotracheal cuff pressure and risk factors for under inflation. A prospective cohort study was conducted. Patients admitted to the Department of Critical Care Medicine of Fuxing Hospital Affiliated to Capital Medical University, who were intubated with a high-volume low-pressure endotracheal tube, and had undergone mechanical ventilation for at least 48 hours, were enrolled. The endotracheal cuff pressure was determined every 8 hours by a manual manometer connected to the distal edge of the valve cuff at 07 : 00, 15 : 00, and 23 : 00. Measurement of the endotracheal cuff pressure was continued until the extubation of endotracheal or tracheostomy tube, or death of the patient. According to the incidence of under inflation of endotracheal cuff, patients were divided into the incidence of under inflation lower than 25% group (lower low cuff pressure group) and higher than 25% group (higher low cuff pressure group). The possible influencing factors were evaluated in the two groups, including body mass index (BMI), size of endotracheal tube, duration of intubation, use of sedative or analgesic, number of leaving from intensive care unit (ICU), the number of turning over the patients, and aspiration of sputum. Logistic regression analysis was used to determine risk factors for under-inflation of the endotracheal cuff. During the study period, 53 patients were enrolled. There were 812 measurements, and 46.3% of them was abnormal, and 204 times (25.1%) of under inflation of endotracheal cuff were found. There were 24 patients (45.3%) in whom the incidence of under inflation rate was higher than 25%. The average of under inflation was 7 (4, 10) times. Compared with the group with lower rate of low cuff pressure, a longer time for intubation was found in group with higher rate of low cuff pressure [hours: 162 (113, 225) vs. 118 (97, 168), Z=-2.034, P=0.042]. There were no differences between the two groups in other factors, including size of endotracheal tube, the time from intubation to first measurement of endotracheal cuff pressure, number of leaving from ICU during admission, use of sedative agent or analgesic, and the number of body turning and aspiration (all P>0.05). No risk factor was found resulting from under inflation of the endotracheal cuff by logistic regression analysis. No significant difference was found in the incidence of ventilator associated pneumonia, duration of mechanical ventilation, successful rate of weaning on 28th day, or 28-day mortality after weaning from mechanical ventilation, and ICU mortality between the two groups. However, patients in the group of higher rate of low cuff pressure had a longer ICU stay compared with that in the group of lower rate of low cuff pressure group [days: 13 (8, 21) vs. 10 (6, 18), Z=-2.120, P=0.034]. Abnormal endotracheal cuff pressure is common in critically ill patients with intratracheal intubation. Duration of intubation is associated with under inflation of the cuff, and it calls for strengthening monitoring and management.

The incidence of oxygen desaturation during rapid sequence induction and intubation.

Rapid sequence induction and intubation (RSII) is an emergency airway management technique for patients with a risk of pulmonary aspiration. It involves preoxygenation, administration of predetermined doses of induction and paralytic drugs, avoidance of mask ventilation, and laryngoscopy followed by tracheal intubation and keeping cricoid pressure applied till endotracheal tube cuff be inflated. Oxygen desaturation has been seen during RSII. We assessed the incidence of oxygen desaturation during RSII. An institution-based observational study was conducted from March 3 to May 4, 2014 in our hospital. All patients who were operated upon under general anesthesia with RSII during the study period were included. A checklist was prepared for data collection. A total of 153 patients were included in this study with a response rate of 91.6%. Appropriate drugs for RSII, equipments for RSII, equipments for difficult intubation, suction machine with a catheter, a monitor and an oxygen backup such as ambu bag were not prepared for 41 (26.8%), 50 (32.7%), 51 (33.3%), 38 (24.8%) and 25 (16.3%) patients respectively. Cricoid pressure was not applied at all for 17 (11.1%) patients and 53 (34.6%) patients were ventilated after induction of anesthesia but before intubation and endotracheal cuff inflation. A total of 55 (35.9%) patients desaturated during RSII (SPO2<95%). The minimum, maximum and mean oxygen desaturations were 26%, 94% and 70.9% respectively. The oxygen desaturation was in the range of <50%, 50%-64%, 65%-74%, 75%-84%, 85%-89 % and 90%-94% for 6 (3.9%), 7 (4.6%), 5 (3.3%), 10 (6.5%), 13 (8.5%) and 14 (9.2%) patients respectively. The incidence of oxygen desaturation during RSII was high in our hospital. Preoperative patient optimization and training about the techniques of RSII should be emphasized.

Intubation‐Related Vocal Cord Palsy

Objective: 1) To review the incidence of intubation-related vocal cord palsy. 2) To analyze the risk factors of intubation-related vocal cord palsy and review literature. Method: Prospective study of patients who received general anesthesia by intubation from January 2010 to August 2011 in otolaryngology department. Patients who complained of hoarseness after operation will undergo flexible laryngoscopy to look for vocal palsy and will be included in this study. Results: A total of 2511 patients received general anesthesia by intubation in otolaryngology department. Six patients developed post-operative vocal palsy, including 5 men and 1 woman ages 47 to 67 years old. Time of endotracheal cuff inflation varies from 45 minutes to 1675 minutes. These 6 patients had neck hyperextension during operation. Recovery time of vocal palsy in each patient was less than 10 weeks. The incidence of intubation-related vocal palsy is around 0.2% in otolaryngology department, considerably higher than the literature reports. Prolonged endotracheal cuff inflation time and neck hyperextension could be the reasons for the higher incidence. Conclusion: The incidence of intubation-related vocal palsy in otolaryngology department is 0.2%. Risk factors are the same as the literature, including prolonged endotracheal cuff inflation time, and neck hyperextension position.

Tracheal-innominate artery fistula after repair of tracheal stenosis: Problem and prevention

Tracheal-innominate artery fistula was a lethal complication in 1 patient out of a series of 13 who have required tracheal resection and end-to-end anastomosis for symptomatic tracheal stenosis secondary to prolonged endotracheal cuff inflation. In 9 of these patients, the innominate artery was entrapped in the peritracheal fibrous tissue at the point where the innominate artery crossed the stenotic tracheal segment. In the first patient who developed this problem, we had placed only loose aerolar tissue between the innominate artery and the tracheal anastomosis at the time of tracheal repair. Ten days postoperatively he developed a fatal tracheal-innominate artery fistula. In the next 8 patients in whom the innominate artery was bound down to the tracheal scar, we have protected the thinned-out innominate artery from the tracheal repair site with a double-thickness pericardial flap. All these patients recovered and none developed a tracheal-innominate artery fistula.