Effect of Adjusted Cuff Pressure of Endotracheal Tube During Thyroidectomy on Postoperative Airway Complications: Prospective, Randomized, and Controlled Trial

The impact of anesthesia instruments and drugs on the occurrence of vocal cord injury, systematic review and meta-analysis

OBJECTIVE

This study extensively examined common complications related to anesthesia drugs and equipment on vocal cords. It also delved into factors such as smoking, anesthesia duration and anesthesia induction methods. Overall, the research aimed to pinpoint influential factors for creating a general anesthesia protocol with minimal post-operative complications.

MATERIALS AND METHODS

We searched PubMed, Scopus, Web of Science, and Google Scholar for studies concerning the impact of anesthesia drugs and equipment on the vocal cord, until May 2023. after screening and reviewing of full text, the characteristics of the study including sample size, age, dosage or size of anesthesia drugs and equipment, Duration of intervention, Adverse effects, and Maintenance of adverse effects, were extracted. The quality assessment was done using the Newcastle-Ottawa scale and the Jadad Scale.

RESULTS

Our review included 39 studies from 1983 to 2023. The most frequent VCAEs were cough‎ (39.17%; CI = 9.84-68.51)‎, hoarseness (‎35.32%; CI = 25.04-45.60)‎, and erythema (35.09%; CI=-4.84-75.02). VC paralysis was relatively less frequent (‎4.16%; CI = 2.90-5.43)‎. Meta-regression showed no difference in the frequency of VCAEs with or without single-lung ventilation and smoking. However, the duration of procedure was shown to be affecting three outcomes; the duration shorter than 120 min is associated with lower rates of granuloma (2.74% vs. 44.30%; p < 0.05) and higher rates of cough (48.89% vs. 15.91%; p < 0.05) and VC paralysis (42.86% vs. 0.12%; p < 0.05). The overall outcomes were not affected.

CONCLUSIONS

The most common anesthesia-related VCAEs are cough, erythema, and dysphagia, while serious complications like vocal cord hematoma and paralysis are rare. Also surgery duration significantly influences VCAE occurrence.

Effect of continuous measurement and adjustment of endotracheal tube cuff pressure on postoperative sore throat in patients undergoing gynecological laparoscopic surgery: a randomized controlled trial

BACKGROUND

Postoperative sore throat (POST) is a common complication following endotracheal tube removal, and effective preventive strategies remain elusive. This trial aimed to determine whether actively regulating intraoperative cuff pressure below the tracheal capillary perfusion pressure threshold could effectively reduce POST incidence in patients undergoing gynecological laparoscopic procedures.

METHODS

This single-center, randomized controlled superiority trial allocated 60 patients scheduled for elective gynecological laparoscopic procedures into two groups: one designated for cuff pressure measurement and adjustment (CPMA) group, and a control group where only cuff pressure measurement was conducted without any subsequent adjustments. The primary outcome was POST incidence at rest within 24 h post-extubation. Secondary outcomes included cough, hoarseness, postoperative nausea and vomiting (PONV) incidence, and post-extubation pain severity.

RESULTS

The incidence of sore throat at rest within 24 h after extubation in the CPMA group was lower than in the control group, meeting the criteria for statistically significant superiority based on a one-sided test (3.3% vs. 26.7%, P < 0.025). No statistically significant differences were observed in cough, hoarseness, or pain scores within 24 h post-extubation between the two groups. However, the CPMA group had a higher incidence of PONV compared to the control group. Additionally, the control group reported higher sore throat severity scores within 24 h post-extubation.

CONCLUSIONS

Continuous monitoring and maintenance of tracheal tube cuff pressure at 18 mmHg were superior to merely monitoring without adjustment, effectively reducing the incidence of POST during quiet within 24 h after tracheal tube removal in gynecological laparoscopic surgery patients.

TRIAL REGISTRATION

The study was registered at www.chictr.org.cn (ChiCTR2200064792) on 18/10/2022.

The effect of different endotracheal tube cuff pressure monitoring systems on postoperative sore throat in patients undergoing tracheal intubation: a randomized clinical trial

BACKGROUND

Postoperative sore throat (POST) is an unpleasant outcome that can occur as a result of tracheal intubation in adults. Increased pressure from the endotracheal tube (ETT) cuff often leads to local mucosal injury, resulting in sore throat. The purpose of this study was to compare the effect of two different ETT cuff pressure monitoring systems vs. no cuff pressure monitoring on the incidence and severity of POST in adults.

METHODS

One hundred and fourteen ASA I-III patients of either gender, aged 18-65 years, and undergoing surgery requiring endotracheal intubation were included in this study. Patients were randomized into three groups: control (C), cuff pressure gauge (G), and automated cuff controller (A). The ETT cuff pressure was not monitored intraoperatively in group C but was monitored using a cuff pressure gauge and an automated cuff controller in groups G and A, respectively. Postoperatively, patients were assessed at 2, 24, and 48 h for the presence and severity of POST, hoarseness and cough.

RESULTS

One hundred and eleven patients completed the study. POST occurred in 40.5% of the patients in group G (n = 37) (p = 0.013) and 23.7% of the patients in group A (n = 38) (p < 0.001) within 48 h after surgery, compared to 69.4% in group C (n = 36). There were no significant differences in hoarseness, coughing, and dysphagia across the groups at any time. When comparing groups A and C, individuals in group A exhibited a lower occurrence of significant (grade ≥ 2) POST and hoarseness (10.5% vs. 41.7%, p = 0.002; 26.3% vs. 58.3%, p = 0.005). The incidence of significant cough and dysphagia did not differ substantially across the patient groups within 48 h after surgery. POST scores in group A at 2, 24 h postoperatively were both 0 (0-0), which was significantly lower than those in group C (1 (0-2) at 2 h, p < 0.001 ; 1 (0-1) at 24 h, p = 0.001). POST in group G at 2 h postoperatively was graded as 0 (0-1.5) which was milder than group C (P = 0.024). The severity of hoarseness in group A with scores of 0 (0-2) was superior to that in group C (2 (0-2), p = 0.006) at 2 h postoperatively.

CONCLUSIONS

In conclusion, the findings of this study indicated that the occurrence of POST can be reduced by using either the cuff pressure gauge approach or the automated cuff controller method. The automated cuff controller monitoring can potentially decrease the severity of POST and hoarseness.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, identifier: ChiCTR2100054089, Date: 08/12/2021.

A Neural Integrity Monitor Electromyography Endotracheal Tube Causes More Severe Postoperative Sore Throat Than a Standard Endotracheal Tube in Adults: A Prospective Cohort Study

BACKGROUND

This study aimed at figuring out the different effects of a neural integrity monitor electromyography endotracheal tube (NIM-EMG-ETT) and a standard endotracheal tube (ETT) on postoperative sore throat (POST).

METHODS

This prospective cohort study enrolled 143 patients scheduled to undergo general anesthesia with endotracheal intubation. Patients were allocated into three groups: Group A, non-thyroid surgery with a standard ETT; Group B, thyroid surgery with a standard ETT; Group C, thyroid surgery with a NIM-EMG-ETT. The incidence, the severity and visual analog scale (VAS) of POST were recorded. The incidence and the severity of POST were tested by χ2 test or Fisher's exact test. And VAS of POST was tested by Kruskal-Wallis test.

RESULTS

The incidences of POST in Group B and Group C were significantly higher than that of Group A at all the time points after extubation (P < 0.001). The incidences of POST in Group C was significantly higher than that in Group B at 8 h, 24 h and 48 h after extubation (89.4% vs. 68.8%, P = 0.014, relative risk (RR) 1.30, 95% confidence interval (CI) 1.05-1.61; 89.4% vs. 58.3%, P = 0.001, RR 1.53, 95% CI 1.18-1.98; 76.6% vs. 45.8%, P = 0.002, RR 1.67, 95% CI 1.18-2.36). Moreover, there was a significant higher VAS of POST and more serious POST with Group C than with Group B.

CONCLUSIONS

A NIM-EMG-ETT may induce higher incidence of POST and more serious POST than a standard ETT.

TRAIL REGISTRATION

Chinese Clinical Trail Registry ( http://www.chictr.org.cn/index.aspx , ChiCTR2200058896, 2022-4-18).

Effects of Endotracheal Tube with Adhesive Superficial Laryngeal Electrodes for Intraoperative Nerve Monitoring on Laryngopharyngeal Complications during Thyroidectomy

The endotracheal tube (ETT) with laryngeal adhesive electrodes for intraoperative neural monitoring (IONM) may be related to laryngopharyngeal complications, such as postoperative sore throat (POST), hoarseness, and coughing. We aimed to evaluate the effects of the ETT with laryngeal adhesive electrodes for IONM on the occurrence of laryngopharyngeal complications during thyroidectomy. In this retrospective study, we included 176 patients who underwent thyroidectomy for thyroid cancer between September 2020 and February 2021. The patients were categorized into control (n = 108) and IONM (n = 68) groups. Patients in the IONM group were intubated with the ETT with surface electrodes. Characteristics of the patients and surgery, perioperative variables, and laryngopharyngeal complications, including POST, hoarseness, and cough, were evaluated. The severity and incidence of POST were comparable between the two groups on postoperative days 0, 1, and 2 (p = 0.103, 0.386, and 0.056, respectively). Furthermore, no significant differences were observed in the occurrence of postoperative hoarseness and cough between the groups. The ETT with laryngeal adhesive electrodes for IONM during thyroidectomy did not affect the incidence and severity of postoperative laryngopharyngeal complications, including POST, hoarseness, and cough. Further prospective, double-blinded, randomized clinical trials are required to gain a clearer understanding.

Pressure changes in the endotracheal tube cuff in otorhinolaryngologic surgery: a prospective observational study

Objective

Inflation of the endotracheal tube cuff is needed for providing ventilation. Cuff pressure should be maintained inside the appropriate range to prevent critical airway complications. The purpose of this study is to evaluate the pressure changes in the endotracheal tube cuff during otorhinolaryngologic surgery.

Design and method

This single-center observational study was conducted at Severance Hospital in Korea between April 2020 and November 2020. Patients aged >20 years scheduled to undergo otorhinolaryngological surgical procedures were enrolled. Patients undergoing planned tracheostomy and those who were slated for uncuffed endotracheal tube use were excluded. Intubation was performed after the induction of general anesthesia. A pressure transducer was connected to the pilot balloon of the endotracheal tube, and cuff pressure was continuously monitored until extubation. If the cuff pressure was not appropriate for more than 5 min, it was adjusted to the appropriate range by injecting or removing air. The percentage of time for which the cuff pressure remained within the appropriate range was calculated and defined as the time in the therapeutic range (TTR). The presumed cause for the rise or fall in cuff pressure was identified.

Results

In total 199 patients, alterations in cuff pressure outside the appropriate range occurred in 191 patients (96.0%). The mean TTR was 79.7% (SD 25.0%), and head and neck surgery had the lowest mean TTR of 69.0% compared to ear and nose surgeries (94.2 and 82.1%, respectively). Sixty-eight patients (34.2%) demonstrated inadequate endotracheal tube cuff pressure for more than 20% of the total anesthesia time. Twenty-six patients (13.1%) demonstrated optimal endotracheal tube cuff pressure for less than 50% of the total anesthesia time. The causative factors inducing inappropriate cuff pressure were found to vary, including positional changes, surgical procedure, anatomical manipulation, and anesthetic procedure.

Conclusion

In otorhinolaryngologic surgery, cuff pressure increased or decreased outside the appropriate range due to various factors. Therefore, we suggest close continuous monitoring of cuff pressure during anesthesia for otorhinolaryngologic surgery.

Clinical trial registration

clinicaltrials.gov, identifier NCT03938493.

Effect of continuous measurement and adjustment of endotracheal tube cuff pressure on postoperative sore throat in patients undergoing gynecological laparoscopic surgery: study protocol for a randomized controlled trial

BACKGROUND

Postoperative sore throat (POST) is a common postoperative complication after endotracheal tube removal. There are still no effective preventive methods for POST. The aim of this trial is to confirm whether maintaining intraoperative cuff pressure below the tracheal capillary perfusion pressure could effectively reduce the incidence of POST among patients undergoing gynecological laparoscopic surgery.

METHODS

This study is a single-center, randomized, parallel-controlled, superiority trial with a 1:1 allocation ratio. Sixty patients whose age is between 18 and 65 years and scheduled for gynecological laparoscopic surgery will be randomized to the cuff pressure measurement and adjustment (CPMA) group and the only cuff pressure measurement without adjustment group (control group). The primary endpoint is the incidence of sore throat at rest within 24 h after extubation. The secondary endpoints include the incidence of cough, the incidence of hoarseness, the incidence of postoperative nausea and vomiting (PONV), POST, and pain intensity within 24 h after extubation. Blocked randomization will be conducted with a computer-generated central randomization online service. The blind method will be applied to subjects, data collectors, outcome evaluators, and statisticians. Outcome assessments will be performed at 0 h and 24 h post-extubation.

DISCUSSION

This randomized controlled study hypothesizes that cuff pressure is the primary influencing factor of POST. By continuous monitoring of endotracheal tube cuff pressure and maintaining it within the range of 18-22 mmHg compared with only continuous measurement without adjustment, it aims to prove that continuous measurement and adjustment of endotracheal tube cuff pressure could be effective in reducing the incidence of POST in gynecological laparoscopic surgery patients. The result of this study could be used as a reference for future multicenter studies to confirm the effect of cuff pressure on POST and provides a scientific theoretical basis for preventing POST to further support comfort medicine.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2200064792. Registered on 18 October 2022. This protocol (version 1.0, 16 March 2022) was approved by the Ethics Committee of Beijing Chaoyang Hospital.

Evaluation of the endotracheal tube cuff pressure changes during cardiac operations under cardiopulmonary bypass

Introduction: Tracheal intubation is used for most operations under general anesthesia. Prolonged hyperinflation of the tube cuff can compromise tracheal mucosal perfusion, and low pressure of the cuff may cause some other complications. The aim of this study was the evaluation of changes in intra-cuff pressure in patients undergoing cardiac surgeries under cardiopulmonary bypass. Methods: In an observational study 120 patient's candidate to cardiac operations under cardiopulmonary bypass were enrolled. After induction of anesthesia and tracheal intubation by same tracheal tubes, tracheal tube cuff pressure was adjusted to 20-25 mm Hg (T0). Then the cuff pressure was measured at beginning of CPB (Cardio Pulmonary Bypass) (T1), at 30º hypothermia (T2) and after separation from CPB (T3). Results: The mean cuff pressure was 33.5±7.3, 28.9±5.4, 25.6±5.2 and 28.1±3.7 at T0, T1, T2 and T3 respectively. Intra- cuff pressure changed significantly during cardiopulmonary bypass. Conclusion: The mean intra-cuff pressure was decreased during hypothermic cardiopulmonary bypass. The decrease in cuff pressure may protect the tracheal mucosa against hypotensive ischemic injury in these patients.

Swallowing disorders after thyroidectomy: a systematic review and meta-analysis

PURPOSE

Swallowing disorders following thyroidectomy are common, even after surgery without confirmed complications. The purpose of the current systematic review is to investigate the prevalence of dysphagia at various time points after thyroidectomy, at the whole spectrum of it (total/partial, open/endoscopic, for benign/malignant disease).

METHODS

The literature available at PubMed, SciELO and Cochrane Library databases was reviewed, according to PRISMA guidelines, using the terms "dysphagia", "swallowing disorder", "deglutition disorder", "thyroidectomy" and "thyroid surgery" in the appropriate combinations. A quantitative synthesis of the results followed.

RESULTS

The systematic review of the literature resulted in 35 articles, which met the inclusion criteria and were analyzed regarding their type, sample, follow-up and results regarding post-thyroidectomy dysphagia in multiple follow-up times. A significant increase of swallowing impairment compared to baseline was recorded shortly after surgery. Dysphagia reverted to pre-operative levels 2-3 months later. Dysphagia continued to be reported in a significantly lower proportion of patients, even 1 year after surgery. No significant difference was noticed between open and endoscopic thyroid surgery at 2-3 months post-surgery.

CONCLUSIONS

The swallowing disorders reported after thyroidectomy should be expected, but are not always detectable through objective methods. This should not lead to underestimation of symptoms, since the patients' quality of life is negatively affected by the symptomatology.

Examination of the frequency of upward and downward fluctuations in the pressure obtained from the cuff pressure-time curve by continuous measurement of endotracheal tube cuff pressure during thyroid surgery: a case series

Background

Few studies examined time-to-time changes of cuff pressure of an endotracheal tube during surgery. We retrospectively analyzed the changes of cuff pressure during thyroid surgery and examined its relationships with postoperative airway complications.

Case presentation

Cuff pressure was initially adjusted at 26 cmH₂O and continuously measured in 61 patients. The cuff pressure-time curve dynamically fluctuated, and exceeded 30 cmH₂O in all patients, whereas decreased to ≤ 20 cmH₂0 in 42 (69%) patients. Ratio of the period with such an increase and decrease of cuff pressure to the total duration of surgery were 40% (28–66%) and 9% (0–21%), respectively (median, interquartile range). No patients showed symptoms of airway stenosis requiring treatment except one who developed recurrent laryngeal nerve palsy. No patients had lower respiratory tract infection.

Conclusions

Cuff pressure dynamically fluctuated during thyroid surgery. Preventing an increase as well as decrease of cuff pressure is required.

Patient Perception of Swallowing after Thyroidectomy in the Absence of Laryngeal Nerve Injury

INTRODUCTION

Swallowing and voice alterations may manifest in patients with thyroid disease, especially after thyroidectomy.

OBJECTIVE

To identify the prevalence of patients with complaints of swallowing disorders after thyroidectomy and to evaluate patients' perceptions regarding swallowing before and after the procedure.

METHODS

A prospective longitudinal study was performed with 26 consecutive patients undergoing a private service thyroidectomy, in which the presence of swallowing dysfunction was evaluated using validated questionnaires that addressed the perception of swallowing by patients before (on the day of surgery) and after the surgery (on the first postoperative day).

RESULTS

Of the 26 patients, 18 (69.2%) were subjected to total thyroidectomy and 8 to partial thyroidectomy. Analysis of the domains of the Swallowing Handicap Index questionnaire showed higher scores when evaluated on the first postoperative day, demonstrating a significant worsening in swallowing after the procedure. The same result was demonstrated for the final score of swallowing perception, with 15.3 and 30.8% of patients reporting moderate alterations before and after the thyroidectomy, respectively, and 11.5% reporting the alterations as severe. Swallowing and vocal symptoms on the first postoperative day were more prevalent in the procedure than previously mentioned. Eight patients (30.8%) noted swallowing alterations before the procedure, compared with 80.8% (21 cases) after thyroidectomy.

CONCLUSION

There was a prevalence of 42.3% in swallowing complaints on the first postoperative day, regardless of the lesion in the laryngeal innervation, and this prevalence was significantly higher than that prior to the procedure.

Thyroidectomy-related Swallowing Difficulties: Review of the Literature

This study aims to provide insight into the etiology and frequency of swallowing complications that arise after thyroidectomy and to outline the available diagnostic procedures by revising the existing literature on this topic. We conducted a bibliographic search using the electronic database MEDLINE/PubMed to identify all relevant articles and 44 studies were included in the review out of a total of 218 published articles. Dysphagia after thyroid surgery is a common postoperative complication which, in the short- or long-term, significantly affects patient life quality. There is no standard diagnostic protocol for thyroidectomy-related swallowing impairment. Among the reviewed studies, 8 questionnaires and 12 instrumental diagnostic tools were used to identify swallowing difficulties related to thyroid surgery. The Swallowing Impairment Index (SIS-6) was the most-used questionnaire. Fiberoptic endoscopy is a standard diagnostic tool performed prior and after thyroid surgery, primarily to identify changes in vocal fold mobility. Although instrumental findings usually reveal non-specific alterations of swallowing; swallowing videofluoroscopy and esophageal manometry can be the most helpful tools in further management of thyroidectomy dysphagia. In patients with thyroidectomy-related swallowing difficulties and suspected laryngopharyngeal reflux, 24-hour MII-pH metry should be performed.

Detrimental Effects of Filling Laryngotracheal Airways To Excessive Pressure (DEFLATE-P): a quality improvement initiative

Background

This quality improvement (QI) project was performed at a single center to determine the incidence of postoperative complications associated with use of cuffed airway devices. An educational program was then completed that involved training our anesthesia providers about complications related to excessive cuff pressure and how to utilize a quantitative cuff pressure measurement device (manometer). The impact of this educational initiative was assessed by comparing the incidence of postoperative complications associated with the use of airway devices before and after the training period.

Methods

After approval by our institution’s Institutional Review Board, a pre-intervention (baseline) survey was obtained from 259 adult patients after having undergone surgery with general anesthesia with the use of an endotracheal tube (ETT) or laryngeal mask airway (LMA). Survey responses were used to determine the baseline incidence of sore throat, hoarseness, and dysphagia. Once these results were obtained, education was provided to the anesthesia department members addressing the complications associated with excessive cuff pressures, appropriate cuff pressures based on manufacturer recommendations, and instructions on the use of a quantitative monitor to determine cuff pressure (manometry). Clinical care was then changed by requiring intraoperative cuff pressure monitoring throughout our institution for all surgical patients. After this educational period, 299 patients completed the same survey describing postoperative airway complications.

Results

The use of manometry reduced the incidence of moderate-to-severe postoperative sore throat in the pre- vs. post-intervention groups (35 patients vs 31 patients, p = 0.045), moderate to severe hoarseness (30 patients vs 13, patients p = 0.0001), and moderate-to-severe dysphagia (13 patients vs 5 patients, p = 0.03).

Conclusion

Caring for patients in the perioperative setting frequently entails placement of an airway device. This procedure is associated with several potential complications, including sore throat, coughing, and vocal cord damage. Our quality improvement initiative has shown that intraoperative management of intra-cuff pressure based on manometry is feasible to implement in clinical practice and can reduce postoperative airway complications.

The Effect of Adjustment of Endotracheal Tube Cuff Pressure during Scarless Remote Access Endoscopic and Robotic Thyroidectomy on Laryngo-Pharyngeal Complications: Prospective Randomized and Controlled Trial

Scarless remote access endoscopic and robotic thyroidectomy has been recently performed as a safe and feasible method. However, little is known about the laryngo-pharyngeal complications after surgery and the effect of adjusting the endotracheal tube cuff pressure during surgery on laryngo-pharyngeal complications. Patients were randomized into two groups: the control group (n = 52) and adjusted group (n = 52). The initial cuff pressure was set to 25 mmHg and then monitored without adjustment (control group) or with adjustment at approximately 25 mmHg (adjusted group) throughout surgery. The incidences and severity of postoperative sore throat (POST), hoarseness, dysphagia, and cough were recorded at 1, 6, 24, and 48 h after surgery. Cuff pressures of the control group changed significantly over time and were higher than those of the adjusted group. The incidence of POST was lower in the adjusted group at 24 h postoperatively (p = 0.035), and there was a significant difference in the severity of POST at 6 and 24 h postoperatively between the two groups. There were no differences in the incidence of hoarseness, dysphagia, and cough between the two groups, except dysphagia and cough at 6 h postoperatively. Therefore, intraoperative monitoring and adjustment of the cuff pressure can reduce the incidence of laryngo-pharyngeal complications.

Effects of Luo Han Guo on throat complications associated with tracheal intubation: a randomized controlled trial

Objectives

Conventional treatment for throat complications after surgery involves the use of hormone therapy, which has variable effects. This study was performed to investigate the effects of oral administration of Luo Han Guo decoction for throat complications after tracheal intubation during general anesthesia for laparoscopic radical hysterectomy.

Methods

Beginning at 6 h after surgery, patients in the experimental group were administered 30 mL of a Luo Han Guo decoction; the control group received black tea. Patients in both groups were evaluated using a Visual Analogue Scale for the degree of throat soreness at 2, 12, 24, and 48 h after surgery; coughing and expectoration were evaluated at 48 h after surgery.

Results

This study included 203 patients: 102 in the experimental group and 101 in the control group. Compared with controls, the experimental group had significantly lower evaluation scores at 12, 24, and 48 hours postoperatively. Moreover, at 48 hours postoperatively, coughing and expectoration were significantly reduced in the experimental group, compared with in the control group.

Conclusions

Administration of a Luo Han Guo decoction can effectively reduce throat pain, hoarseness, throat swelling, cough, and sputum after tracheal intubation during general anesthesia.

Does objective measurement of tracheal tube cuff pressures minimise adverse effects and maintain accurate cuff pressures? A systematic review and meta-analysis

Correct inflation pressures of the tracheal cuff are recommended to ensure adequate ventilation and prevent aspiration and adverse events. However there are conflicting views on which measurement to employ. The aim of this review was to examine whether adjustment of cuff pressure guided by objective measurement, compared with subjective measurement or observation of the pressure value alone, was able to prevent patient-related adverse effects and maintain accurate cuff pressures. A search of PubMed, Web of Science, Embase, CINAHL and ScienceDirect was conducted using keywords 'cuff pressure' and 'measure*' and related synonyms. Included studies were randomised or pseudo-randomised controlled trials investigating mechanically ventilated patients both in the intensive care unit and during surgery. Outcomes included adverse effects and the comparison of pressure measurements. Pooled analyses were performed to calculate risk ratios, effect sizes and 95% confidence intervals. Meta-analysis found preliminary evidence that adjustment of cuff pressure guided by objective measurement as compared with subjective measurement or observation of the pressure value alone, has benefit in preventing adverse effects. These included cough at two hours (odds ratio [OR] 0.42, confidence interval [CI] 0.23 to 0.79, P=0.007), hoarseness at 24 hours (OR 0.49, CI 0.31 to 0.76, P <0.002), sore throat (OR 0.73, CI 0.54 to 0.97, P <0.03), lesions of the trachea and incidences of silent aspiration (P=0.001), as well as maintaining accurate cuff pressures (Hedges' g 1.61, CI 2.69 to 0.53, P=0.003). Subjective measurement to guide adjustment or observation of the pressure value alone may lead to patient-related adverse effects and inaccuracies. It is recommended that an objective form of measurement be used.

Lesão de mucosa laringotraqueal e fatores associados após extubação endotraqueal: estudo piloto

Resumo Objetivo Descrever os sinais clínicos de lesão de mucosa laringotraqueal e seus fatores associados. Métodos Estudo observacional, longitudinal, em pacientes intubados por ocasião da anestesia geral. Foram realizadas avaliações no pré-operatório, transoperatório, e nas 24, 48 e 72 horas após extubação. Para análise, utilizaram-se estatísticas descritiva e exploratória, e também foi verificada a razão de chances. Resultados Dentre os pacientes, 53,3% apresentaram pelo menos um sinal clínico de lesão de mucosa laringotraqueal, sendo predominantes: rouquidão (43,3%), disfagia (40%) e odinofagia (33,3%). Estiveram associados aos seguintes fatores: pressão intra-cuff acima de 25cmH2O, intubação por mais de 120 minutos e uso de tubos maiores que 7,5mm. Conclusão Os sinais clínicos de lesão de mucosa laringotraqueal mais frequentes na população deste estudo foram rouquidão, disfagia e odinofagia, associados à pressão do cuff acima de 25 cmH2O, seguido do tempo de intubação e tamanho inadequado de tubos endotraqueais.

The effect of ketorolac and dexamethasone on the incidence of sore throat in women after thyroidectomy: a prospective double-blinded randomized trial

Background

We evaluated the effect of two drugs with anti-inflammatory action, dexamethasone and ketorolac, on reduction of postoperative sore throat (POST) after general anesthesia with endotracheal intubation in patients undergoing thyroidectomy.

Methods

One hundred and ninety-two female patients scheduled to undergo general anesthesia with endotracheal intubation for thyroidectomy were enrolled in this prospective study. Participants were randomly allocated to receive intravenous medication; placebo (Group C, n = 45), ketorolac 30 mg immediately before intubation (Group Kpre, n = 47), ketorolac 30 mg at the end of surgery (Group Kpost, n = 45) and dexamethasone 10 mg (Group D, n = 43). The incidence and severity of POST and hoarseness were evaluated at 1, 6 and 24 hours after surgery.

Results

Incidences and severities of POST at rest and during swallowing in first 6 hours after extubation were comparable among 4 groups. At 24 hours postextubation, the incidence (P = 0.002, 95% CI of proportion differences; 0.05–0.39) and severity (P = 0.008) of POST during swallowing were significantly lower in group D than in group C. Kpre and Kpost groups did not show a greater reduction in POST than group C, despite lower rescue analgesic requirement at 1 hour after extubation in group Kpre (P = 0.006; 95% CI of proportion differences; 0.07–0.38). No intergroup differences were observed in incidences of hoarseness or adverse events.

Conclusions

Intravenous administration of dexamethasone 10 mg, but not ketorolac, before induction of anesthesia reduces the incidence and severity of POST during swallowing at 24 hours after thyroidectomy.

Comparison of the endotracheal tube cuff pressure between a tapered- versus a cylindrical-shaped cuff after changing from the supine to the lateral flank position

PURPOSE

Positional change can displace an endotracheal tube (ETT) and change the ETT cuff pressure in a tracheally intubated patient. Endotracheal tubes with different cuff shapes may lead to different cuff pressures after positional change. We hypothesized that the intracuff pressure in the TaperGuard™ ETT with a tapered-shaped cuff would be higher than that in the conventional ETT with a cylindrical-shaped cuff after a change from the supine to the lateral flank position.

METHODS

Fifty-eight patients scheduled for open urological procedures in the lateral flank position were randomly allocated to receive either a TaperGuard ETT (group T) or conventional ETT (group C). The ETT cuff pressure was initially set at 20 cm H2O in the supine position and was measured after the change to the lateral flank position. The distance from the ETT tip to the carina was measured in both the supine and the lateral flank positions.

RESULTS

Two patients, one from each group, were excluded from the data analysis. The mean (SD) ETT cuff pressure was significantly higher in group T (n = 28) than in group C (n = 28) after the change in position [31 (7) cm H2O vs 25 (4) cm H2O, respectively; mean difference, 6 cm; 95% confidence intervals [CI], 3 to 9; P < 0.001]. The mean (SD) proximal migration of the ETT tip was comparable between the two groups [8 (18) mm vs 4 (14) mm, respectively; P = 0.367].

CONCLUSIONS

After the change from the supine to the lateral flank position, the ETT cuff pressure was significantly higher in the TaperGuard ETT than in the conventional ETT, although the extent of cephalad displacement of the ETT was comparable between the two groups. This trial was registered at Clinicaltrials.gov: NCT02165319.

Dysphagia, hoarseness, and globus in a postoperative patient

Sore throat, hoarseness, and dysphagia are known and recognized postoperative complications of laryngeal mask airway use during operative procedures. The patient's symptoms, present immediately after surgery, are thought related to airway manipulation. Airway foreign bodies, although low on the differential, can cause similar symptoms. We present a case of a single patient who presented to a tertiary care center after an elective outpatient procedure with postoperative sore throat, hoarseness, and dysphagia. A foreign body was found lodged in the patient's hypopharynx. The differential diagnosis of sore throat, hoarseness, and dysphagia in the postoperative patient is explored in further detail.

Continuous control of tracheal cuff pressure for the prevention of ventilator-associated pneumonia in critically ill patients: where is the evidence?

PURPOSE OF REVIEW

Ventilator-associated pneumonia (VAP) is a major cause of death, morbidity and costs in ICUs. Several evidence-based clinical interventions have been increasingly described for its prevention. However, continuous control of tracheal cuff pressure (Pcuff) is rarely mentioned in the latest clinical guidelines. This review focuses on the available data about the management of Pcuff in the ICU, including discontinuous and continuous control, and its impact on the prevention of VAP.

RECENT FINDINGS

Current discontinuous monitoring and adjustment of Pcuff, even well performed, is inaccurate in maintaining Pcuff in the target range. Underinflation (Pcuff<20 cmH2O) of tracheal cuff is an independent risk factor for VAP through microaspiration of contaminated subglottic secretions into the lower respiratory tract. Two main types of devices, electronic and pneumatic, have been developed for the continuous control of Pcuff. Both have shown effectiveness in maintaining Pcuff in recommended range in ICU patients, but only the pneumatic device has provided a reduction in microaspiration and VAP incidence.

SUMMARY

Continuous controllers of Pcuff represent effective, easy to use and timesaving devices in today's busy ICU environment. However, further studies are required to determine the impact of continuous control of Pcuff on VAP incidence, patient outcomes, antimicrobial consumption and to compare pneumatic and electronic devices, before generalizing their use in routine practice.