Endotracheal tube cuff pressure changes during manual cuff pressure control manoeuvres: An in-vitro assessment

The Effect of Perceptions of Evidence-Based Practice on Endotracheal Cuff Pressure Management in Critical Care Nurses: A Correlational Cross-Sectional Multicentre Study

AIMS

This correlational cross-sectional multicentre study aims to achieve two objectives. Firstly, to assess nurses' knowledge and practice of endotracheal cuff pressure management. Secondly, to examine the relationship between endotracheal cuff pressure management knowledge and evidence-based practice leadership and work environment.

DESIGN

A correlational cross-sectional multicentre study design.

METHODS

This study was conducted among 144 intensive care nurses in Turkey. Data collection included descriptive characteristics and cuff pressure management of nurses, the Evidence-Based Practice Leadership Scale and Evidence-Based Practice Work Environment Scale. Descriptive statistics, chi-square test, Pearson correlation and receiver operating characteristics analysis were conducted. A STROBE checklist was the reporting guide for this study.

RESULTS

The success status of nurses in terms of knowledge related to cuff pressure was found significantly different according to the type of intensive care unit working in and the status of receiving training on evidence-based practice. A positive, strong relationship was found between nurses' mean scores on the Evidence-Based Practice Leadership Scale and the Work Environment Scale. There was a very weak positive correlation between the mean scores of the Evidence-Based Practice Leadership Scale and the cuff pressure management.

CONCLUSION

Adherence by nurses to current evidence-based practice for cuff pressure monitoring is essential for safe patient care and improved quality of care. It is recommended to provide both a supportive working environment and training programmes for intensive care nurses to perform cuff pressure management in line with evidence-based practice.

RELEVANCE TO CLINICAL PRACTICE

Providing educational programs, an appropriate clinical environment, support from health managers and access to appropriate tools are important considerations in increasing the knowledge and skills of intensive care nurses to effectively monitor and manage cuff pressure.

REPORTING METHOD

Our study complies with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Checklist: cross-sectional studies.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Continuous Versus Intermittent Control Cuff Pressure for Preventing Ventilator-Associated Pneumonia: An Updated Meta-Analysis

OBJECTIVE

This study aimed to evaluate the effect of continuous control cuff pressure (CCCP) versus intermittent control cuff pressure (ICCP) for the prevention of ventilator-associated pneumonia (VAP) in critically ill patients.

METHODS

Relevant literature was searched in several databases, including PubMed, Embase, Web of Science, ProQuest, the Cochrane Library, Wanfang Database and China National Knowledge Infrastructure between inception and September 2022. Randomized controlled trials were considered eligible if they compared CCCP with ICCP for the prevention of VAP in critically ill patients. This meta-analysis was performed using the RevMan 5.3 and Trial Sequential Analysis 0.9 software packages. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework was used to assess the level of evidence.

RESULTS

We identified 14 randomized control trials with a total of 2080 patients. Meta-analysis revealed that CCCP was associated with a significantly lower incidence of VAP compared with ICCP (relative risk [RR] = 0.52; 95% confidence interval [CI]: 0.37-0.74; P < 0.001), although considerable heterogeneity was observed (I2 = 71%). Conducting trial sequential analysis confirmed the finding, and the GRADE level was moderate. Subgroup analysis demonstrated that CCCP combined with subglottic secretion drainage (SSD) had a more significant effect on reducing VAP (RR = 0.39; 95% CI = 0.29-0.52; P < 0.001). The effect of CCCP on ventilator-associated respiratory infection (VARI) incidence was uncertain (RR = 0.81; 95% CI = 0.53-1.24; P = 0.34; I2 = 61%). Additionally, CCCP significantly reduced the duration of mechanical ventilation (MV) (mean difference [MD] = -2.42 days; 95% CI = -4.71-0.12; P = 0.04; I2 = 87%). Descriptive analysis showed that CCCP improved the qualified rate of cuff pressure. However, no significant differences were found in the length of intensive care unit (ICU) stay (MD = 2.42 days; 95% CI = -1.84-6.68; P = 0.27) and ICU mortality (RR = 0.86; 95% CI = 0.74-1.00; P = 0.05).

CONCLUSION

Our findings suggest that the combination of CCCP and SSD can reduce the incidence of VAP and the duration of MV and maintain the stability of cuff pressure. A combination of CCCP and SSD applications is suggested for preventing VAP.

Endotracheal Cuff-pressure Monitoring in ICU: A Standard of Care Yet to be Standardized, and Often Neglected

How to cite this article: Kumar AKA. Endotracheal Cuff-pressure Monitoring in ICU: A Standard of Care Yet to be Standardized, and Often Neglected. Indian J Crit Care Med 2024;28(1):8-10.

Pre-hospital emergency cricothyrotomy in dogs part 2: Airway sealing and ventilation using cricothyrotomy tubes

Cricothyrotomy (CTT) has been recommended for use in the pre-hospital setting for military working dogs and Operational K9s during airway emergencies. Although the CTT can establish a patent airway for spontaneous ventilation, the ability to seal the airway and provide positive pressure ventilation (PPV) using tubes designed for humans has not been determined. Using various CTT tubes placed in cadaver dog airways, this study aimed to determine: (1) Whether the tube cuff could create a functional airway seal with safe intra-cuff pressures; (2) The magnitude of delivered tidal volume (TV) loss during a standard breath to assess the possibility of delivering an adequate tidal volume with a bag-valve device (BVM); (3) The best performing tubes for either test; (4) The reasons behind the findings using observations from upper airway endoscopy, dissection, and measurements. Cadaver dogs of similar weights to MWD and Operational K9 breeds had various CTT tubes placed including three from commercial kits, a standard endotracheal tube, and a tracheostomy tube. The minimum occlusive volume technique was used to inflate the tube cuff and a pressure ≤ 48 cm H₂O with an adequate seal was considered successful. Individual TVs were calculated for each dog and added to the volume lost during delivery of a standard breath from an ICU ventilator. Endoscopy and airway dissection were performed to assess the relationship between tubes cuffs and the airway. The tubes from the CTT kits performed poorly with regards to producing an airway seal with the H&H tube failing to seal the airway all tests. Tracheal dimensions were significantly associated with successful airway sealing (P = 0.0004). Tidal volume loss could be compensated using a BVM in 34/35 tests with the H&H tube in cadaver 8 the only to fail. Tracheal airway sealing is influenced by airway anatomy when tube cuffs are inflated to a target pressure and larger tubes do not always provide a better seal. The CTT tubes tested have the potential to facilitate ventilation with a BVM under the conditions set in this study. The 8.0 mm endotracheal tube performed the best and the H&H the worst in both tests.

The Effect of Intraoperative Transesophageal Echocardiography Probe Placement on the Endotracheal Tube Cuff Pressure in Adult Patients Undergoing On-Pump Cardiac Surgery

OBJECTIVES

The study was directed toward documentation of the effect of transesophageal echocardiography (TEE) probe insertion on the endotracheal tube cuff pressure (CP) in adult patients undergoing on-pump coronary bypass surgery. The primary objective of this study was to assess whether CP reaches supranormal pressures during the different stages of intraoperative TEE examination. The secondary objective was to observe the effect of TEE probe placement on the ventilation parameters.

DESIGN

A prospective observational study.

SETTING

At a tertiary care cardiac center.

PARTICIPANTS

Thirty-four cardiac surgical patients older than 18 years of age who required intraoperative TEE examination.

INTERVENTIONS

TEE probe insertion.

MEASUREMENTS AND MAIN RESULTS

Following the induction of general anesthesia and tracheal intubation, a TEE probe was introduced. The endotracheal tube CP was recorded at 5 time zones: Before TEE probe insertion, during the insertion of the probe, during probe manipulation, probe in the transgastric position, and during removal of the probe. A nonparametric test was used for comparing intracuff pressure between pairs of time zones. There was a statistically significant difference in CP values between the baseline and those during different time zones (chi-square test = 134.77, degrees of freedom = 4, p = 0.001). There was a statistically significant difference in the peak pressure between different time points compared to baseline (p = 0.0001).

CONCLUSIONS

TEE probe placement in patients with tracheal intubation may be associated with a significant increase in CP well above the baseline pressure. With the possibility of the mean arterial pressures during cardiopulmonary bypass being substantially lower than expected, the findings of the current study raised the concern of predisposing the tracheal mucosa to hypoperfusion, with subsequent temporary or permanent tracheal damage. Hence, at least a baseline estimation of the endotracheal tube CP at the time of tracheal intubation, with the help of a pressure gauge in the operating room, may be considered as a safe practice.

The Relationship between Cuff Pressure and Air Injection Volume of Endotracheal Tube: A Study with Sheep Trachea Ex Vivo

Background

Endotracheal intubation is a widely used treatment. Excessive pressure of the endotracheal tube cuff leads to a series of complications. Here, we used tracheae of sheep to analyze the relationship between the air injection volume and endotracheal tube cuff pressure so as to guide the doctors and nurses in controlling the pressure of the endotracheal tube cuff during clinical work and minimise the risk of complications.

Materials and Methods

Forty sheep tracheae were utilised and were divided into five groups according to their diameters. Different sizes of endotracheal tubes were inserted into each trachea, and the cuff pressure with the increase of air injection volume was recorded. The formulas that reflect the relationship between air injection volume and cuff pressure were obtained. Then, sheep tracheae were randomly selected; different types of tubes were inserted, and the stipulated volume of air was injected. The actual pressure was measured and compared with the pressure predicted from the formulas. Statistical analysis was conducted to verify whether the formulas obtained from the first part of the experiment were in accordance with the expert evaluation table, which consists of opinions of several experts.

Results

After obtaining 15 formulas, we collected the differences between the theoretical cuff pressure and the actual cuff pressure that satisfied the expert evaluation. Relying on the formulas, the medical turntable was obtained, which is a tool that consists of two round cards with data on them. The top card has a notch. The two cards are stacked together, and as the top card rotates, the data on the bottom card can be easily seen in a one-to-one relationship.

Conclusion

The formulas are capable of showing the relationship between the cuff air injection volume and pressure of endotracheal tube cuff. The medical turntable can estimate the air injection volume to ensure that the pressure stays in an acceptable range.

A Tapered Cuff Tracheal Tube Decreases the Need for Cuff Pressure Adjustment After Surgical Retraction During Anterior Cervical Spine Surgery: A Randomized Controlled, Double-Blind Trial

Background

Surgical retraction to expose the vertebrae during anterior cervical spine surgery increases tracheal tube cuff pressure and may worsen postoperative sore throat and dysphonia. This randomized double-blind study investigated the effect of cuff shape on intraoperative cuff pressure and postoperative sore throat and dysphonia.

Methods

Eighty patients were randomized to tracheal intubation with a tapered cuff or a conventional cylindrical high-volume low-pressure cuff (control) during anesthesia. Intraoperative cuff pressures were compared. The primary outcome was the incidence of pressure adjustment needed when the cuff pressure increased to &gt; 25 mm Hg after surgical retraction. The secondary outcome was the incidence of postoperative sore throat and dysphonia.

Results

The incidence of pressure adjustment after surgical retraction was significantly lower in the tapered group than in the control group (13% vs. 48%; P = 0.001; relative risk reduction, 74%). The median [interquartile range (IQR)] cuff pressure (mm Hg) was significantly lower for the tapered cuff than for the control cuff before surgical retraction [9 (7–12) vs. 12 (10–15); P &lt; 0.001] and after retraction [18 (15–23) vs. 25 (18–31); P = 0.007]. The median (IQR) postoperative dysphonia score assessed by a single speech-language pathologist was lower in the tapered group than in the control group [4 (3–6) vs. 5.5 (5–7); P = 0.008].

Conclusion

A tapered cuff tracheal tube decreased the need for the adjustment of cuff pressure after surgical retraction during anterior cervical spine surgery, thereby avoiding intraoperative pressure increase. It also has a better outcome in terms of dysphonia.

Clinical Trial Registration

[www.clinicaltrials.gov], identifier [NCT04591769].

Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update

The purpose of this document is to highlight practical recommendations to assist acute care hospitals to prioritize and implement strategies to prevent ventilator-associated pneumonia (VAP), ventilator-associated events (VAE), and non-ventilator hospital-acquired pneumonia (NV-HAP) in adults, children, and neonates. This document updates the Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology (SHEA), and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America, the American Hospital Association, the Association for Professionals in Infection Control and Epidemiology, and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.

Automatic Continuous Control of Cuff Pressure and Subglottic Secretion Suction Used Together to Prevent Pneumonia in Ventilated Patients-A Retrospective and Prospective Cohort Study

The ventilator bundle consists of multiple methods to reduce ventilator-associated pneumonia (VAP) rates in Intensive Care Units (ICU). The aim of the study was to evaluate how the continuous automatic pressure control in tapered cuffs of endotracheal/tracheostomy tubes applied along with continuous automatic subglottic secretion suction affect the incidence of VAP. In the prospective cohort (n = 198), the standard VAP bundle was modified by continuous automatic pressure control in taper-shaped cuff of endotracheal/tracheostomy tubes and subglottic secretion suction. VAP incidence, time to VAP onset, invasive mechanical ventilation days/free days, length of ICU stay, ICU mortality, and multidrug-resistant bacteria were assessed and compared to the retrospective cohort (n = 173) with the standard bundle (intermittent cuff pressure of standard cuff, lack of subglottic secretion suction). A smaller incidence of VAP (9.6% vs. 19.1%) and early onset VAP (1.5% vs. 8.1%) was found in the prospective compared to the retrospective cohort (p < 0.01). Patients in the prospective cohort were less likely to develop VAP (RR = 0.50; 95% CI: 0.29 to 0.85) and early-onset VAP (RR = 0.19; 95% CI: 0.05 to 0.64) and had longer time to onset VAP (median 9 vs. 5 days; p = 0.03). There was no significant difference (p > 0.05) between both cohorts in terms of invasive mechanical ventilation days/free days, length of ICU stay, ICU mortality and multidrug-resistant bacteria. Modification of the bundle for prevention of VAP can reduce early-onset VAP and total incidence of VAP and delay the time of VAP occurrence.

Effects of Head and Neck Position on Nasotracheal Tube Intracuff Pressure: A Prospective Observational Study

To prevent endotracheal tube-related barotrauma or leakage, the intracuff pressure should be adjusted to 20-30 cm H₂O. However, changes in the nasotracheal tube intracuff pressure relative to neck posture are unclear. In this study, we investigated the effect of head and neck positioning on nasotracheal tube intracuff pressure. Fifty adult patients with nasotracheal tubes who were scheduled for surgery under general anesthesia were enrolled. Following intubation, intracuff pressure was measured by connecting the pilot balloon to a device that continuously monitors the intracuff pressure. Subsequently, the intracuff pressure was set to 24.48 cm H₂O (=18 mmHg) for the neutral position. We recorded the intracuff pressures based on the patients' position during head flexion, extension, and rotation. The initial intracuff pressure was 42.2 cm H₂O [29.6-73.1] in the neutral position. After pressure adjustment in the neutral position, the intracuff pressure was significantly different from the neutral to flexed (p < 0.001), extended (p = 0.003), or rotated (p < 0.001) positions. Although the median change in intracuff pressure was <3 cm H₂O when each patient's position was changed, overinflation to >30 cm H₂O occurred in 12% of patients. Therefore, it is necessary to adjust the intracuff pressure after tracheal intubation and each positional change.

Could clinical nursing procedures lead to tracheal cuff pressure drop? A prospective observational study

AIM

To evaluate the dynamic changes in tracheal cuff pressure before and after four clinical nursing procedures including sputum suction, oral care, atomisation inhalation, and turning over, and thus provide references for the adjustment time of cuff pressure in clinical practice.

BACKGROUND

Cuff pressure must be kept within the range of 25-30 cmH₂ O to ensure effective ventilation and prevent aspiration, while maintaining tracheal blood flow perfusion.

DESIGN

A prospective observational study.

METHODS

The cuff pressure of 56 intubated patients was adjusted to 28-30 cmH₂ O. A cuff pressure monitor was used to continuously monitor cuff pressure changes before and after four clinical nursing procedures (sputum suction, oral care, atomisation inhalation, and turning over) and the cuff pressures at various time points were compared. The semi-quantitative cough strength score (SCSS) was used to evaluate cough strength during sputum suction and the effect of cough strength on cuff pressure during sputum suction. This study followed the STROBE checklist for cross-sectional studies.

RESULTS

The cuff pressures during the four clinical nursing procedures of sputum suction, atomisation inhalation, turning over, and oral care, all temporarily increased (p < 0.001) and decreased to varying degrees 20 min later (p < 0.001). Among them, the cuff pressure rose the highest under a state of moderate or strong coughing during sputum suction (78.38 ± 12.13 cmH₂ O) and dropped the most at 20 min after the procedure (21.71 ± 4.80 cmH₂ O).

CONCLUSIONS

The four clinical nursing procedures of sputum suction, atomisation inhalation, turning over, and oral care can all cause different degrees of cuff pressure drop. The decision on whether the cuff pressure needs to be corrected depends on the specific situation.

RELEVANCE TO CLINICAL PRACTICE

During clinical practice, the cuff pressure can be individually corrected according to different clinical nursing procedures, which can increase the qualified rate of cuff pressure and reduce the workload of nurses.

Establishing changes in endotracheal cuff pressure with continuous monitoring in patients undergoing laparoscopic surgery in Trende- lenburg position

Background : After endotracheal intubation, the endotracheal cuff gets inflated to a sufficiently high pressure to prevent air leaking. Placing a patient in Trendelenburg position and establishing a pneumoperitoneum affects the endotracheal cuff pressure. Objectives : Determine the impact of these factors on the endotracheal cuff pressure. Design and setting : This prospective, observational study was conducted in the Catharina Hospital (Eindhoven, the Netherlands). Methods : This study included adult patients undergoing laparoscopic surgery. A routine endotracheal tube was inserted, in which the cuff pressure was continuously monitored. Main outcome measures : The outcome of interest was a change in endotracheal cuff pressure after establishment of a pneumoperitoneum and/ or placing a patient in a Trendelenburg position. Results : 39 patients were included. Cuff pressures in- creased significantly from the moment of pneumo-peritoneum, placing a patient into a Trendelenburg position increased endotracheal cuff pressure and peak pressures even more. The highest endotracheal cuff pressure was 67 cm H2O, the highest registered peak pressure was 35 cm H2O. Conclusion : Both endotracheal cuff pressure and peak pressure increased during laparoscopic surgical procedures with a pneumoperitoneum and the patient placed in Trendelenburg position. Measuring the endo-tracheal cuff pressure only after endotracheal intubation is insufficient and should be repeated during surgery on fixed moments.

Automatic regulation of the endotracheal tube cuff pressure with a portable elastomeric device. A randomised controlled study

BACKGROUND

Intermittent manual correction of the endotracheal tube cuff pressure (P_cuff) may delay the detection of underinflation (source of contaminated oropharyngeal content microaspiration) or overinflation (exposing to airway damage). Devices for automated continuous correction of P_cuff are appealing but some are inconvenient, expensive or even harmful. This prospective randomised controlled study tested whether the tracoe Smart Cuff Manager™ reduced the rate of patients undergoing≥1 episode of underinflation (P_cuff<20 cmH₂O), as compared with routine manual P_cuff correction. The rate of patients with≥1 overinflation episode (P_cuff>30 cmH₂O) and the incidence of under/overinflation were also compared.

METHODS

Patients with acute brain injury and likely to receive invasive mechanical ventilation for>48h were randomly allocated to receive, during 48h, automated P_cuff correction (combined with manual correction) or manual correction alone. P_cuff was measured with a dedicated manual manometer, at least every 8h.

RESULTS

Sixty patients were included and randomised (32 patients with manual and 28 with automated P_cuff correction) for 506 measurements of P_cuff (269 and 237, respectively). Automated correction of P_cuff was associated with a lower rate of patients with≥1 episode of underinflation (63% and 18%, respectively, P<0.001), a lower incidence of underinflation episodes (15% vs. 2%; P<0.001), a lower rate of manual corrections (77% vs. 58%; P<0.001). For overinflation, there were no significant between-groups differences (2% vs. 2%). The incidence of early respiratory infections was similar in both groups (29% vs. 25%, P=0.78).

CONCLUSIONS

The adjunction of continuous P_cuff control with the Tracoe Smart Cuff Manager™ to routine manual intermittent correction reduced the incidence of P_cuff underinflation episodes without provoking overinflation.

TRIAL REGISTRATION

ClinicalTrials NCT03330379. Registered 6 November 2017, https://clinicaltrials.gov/ct2/show/NCT03330379.

The Changes of Endotracheal Tube Cuff Pressure during Manual and Intermittent Controlling in Intensive Care Units

BACKGROUND

Usually, the endotracheal tube cuff pressure is controlled by cuff pressure monitoring. However, the intermittent pilot-manometer connection and disconnection may cause a change in the adjusted pressure. This study aimed to investigate changes in the endotracheal tube cuff pressure using both manual and intermittent controls.

MATERIALS AND METHODS

A semi-experimental within-subject design was conducted. Fifty-nine intubated patients in the Mazandaran Intensive Care Units (ICUs) participated through convenience sampling in 2018. In the control condition, first, the cuff pressure was adjusted in 25 cm H2O then it was measured without manometer-pilot disconnection at 1 and 5 min intervals. In the intervention condition, cuff pressure was immediately adjusted in 25 cm H2O then it was measured with manometer-pilot disconnection in the 1st and 5th minutes. Data analysis was performed using Independent t-test, Chi-square test, and Phi coefficient.

RESULTS

The mean and Standard Deviation (SD) change of cuff pressure after 1 minute, from 25 cm H2O, in the intervention condition was 20.22 (3.53) cm H2O. The mean (SD) of this change in the control condition was 25.22 (3.39) cm H2O. This difference was significant (t 116 = 7.83, p < 0.001, d = 1.44). The mean (SD) change of cuff pressure after 5 minutes, from 25 cm H2O, in the intervention condition was 19.11 (2.98) cm H2O. The mean (SD) of this change in the control condition was 25.47 (4.53) cm H2O. This difference was significant (t 116 = 9.24, p < 0.001, d = 1.70).

CONCLUSIONS

The tracheal tube cuff pressure has been significantly reduced during manual intermittent measuring. Therefore, it is suggested that continuous cuff pressure monitoring and regulation should be used.

Bi-national survey of intraoperative cuff pressure monitoring of endotracheal tubes and supraglottic airway devices in operating theatres

Correct intracuff pressure of endotracheal tubes and supraglottic airway devices is required to avoid complications such as sore throat, dysphagia and dysphonia, while maintaining an adequate airway seal. However, intracuff pressure monitoring of airway devices during general anaesthesia may not receive the attention it deserves. The aim of this survey was to investigate the current practice regarding intraoperative cuff pressure monitoring in hospitals across Australia and New Zealand. An online ten-question survey was disseminated by the Australian and New Zealand College of Anaesthetists Clinical Trials Network to a randomised selection of 1000 Australian and New Zealand College of Anaesthetists Fellows working in private and public hospitals of varying sizes. There were 305 respondents in total, but not all respondents answered all questions. In total, 67 of 304 respondents (22.0%) did not have access to a cuff pressure manometer at their main site of work, and of these, 30 (9.9%) expressed that they would like access to one in their daily practice. Of 288 respondents, 122 (40.0%) reported that they used cuff pressure monitoring as part of their routine practice, but 95 (33.0%) measured the cuff pressure at induction only. For supraglottic airway devices, only 44 of 250 respondents (17.6%) aimed for a cuff pressure of 40–60 cmH2O. Of 255 respondents, 101 (39.6%) aimed for a cuff pressure of 20–30 cmH2O for endotracheal tubes. These findings indicate that educational programmes are required to increase the availability and use of cuff pressure monitoring devices for both endotracheal tubes and supraglottic airway devices across Australia and New Zealand.