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Gu AN, Yu M. [The Effect of Intracuff Pressure Adjustment on Postoperative Sore Throat and Hoarseness after Nitrous Oxide and Air Anesthesia]. J Korean Acad Nurs 2019; 49:215-224. [PMID: 31064974 DOI: 10.4040/jkan.2019.49.2.215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 11/08/2018] [Accepted: 03/19/2019] [Indexed: 11/09/2022]
Abstract
PURPOSE To investigate the differences in postoperative sore throat and hoarseness by adjustment of endotracheal tube cuff pressure (CP) during nitrous oxide (N₂O) and air anesthesia. METHODS A one-equivalent control group pretest-posttest design was used. Data were collected from August 8 to October 19, 2017 and analyzed using the independent t-test and repeated measures ANOVA. Eighty-four participants were enrolled and divided into three groups: 28 in the Control Group (CP adjusted every 30 minutes using N₂O), 28 in Experimental Group 1 (CP adjusted every 10 minutes using N₂O), and 28 in Experimental Group 2 (non-adjusted CP using air), all of whom underwent urologic, gynecologic, and orthopedic surgeries at the G University hospital. Sore throat was assessed using a numeric rating scale; hoarseness was evaluate using the Stout classification at 1, 6, and 24 hours after surgery. RESULTS Scores for sore throat and hoarseness were significantly different between the groups at each measurement time, and scores were consistently higher in the control group. During subsequent measurements, sore throat and hoarseness scores were significantly lower at 6 hours. Cuff pressure changed significantly using air anesthesia (χ²=10.41, p=.015) up to 2 hours after induction. Severe sore throat and hoarseness was observed for up to 6 hours after surgery. CONCLUSION Cuff pressure adjustment at short time intervals would be helpful in reducing postoperative sore throat and hoarseness. Nursing intervention focused on prevention of sore throat and hoarseness should be required up to 6 hours postoperatively in patients undergoing endotracheal intubation.
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Affiliation(s)
- An Na Gu
- Department of Nursing, Gyeongsang National University Hospital, Jinju, Korea
| | - Mi Yu
- College of Nursing, Institute of Health Sciences, Gyeongsang National University, Jinju, Korea.
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2
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Su Z, Li S, Zhou Z, Chen X, Gu Y, Chen Y, Zhong C, Zhong M, Zhong N. A canine model of tracheal stenosis induced by cuffed endotracheal intubation. Sci Rep 2017; 7:45357. [PMID: 28349955 PMCID: PMC5368979 DOI: 10.1038/srep45357] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 02/23/2017] [Indexed: 01/14/2023] Open
Abstract
Postintubation tracheal stenosis is a complication of endotracheal intubation. The pathological mechanism and risk factors for endotracheal intubation-induced tracheal stenosis remain not fully understood. We aimed to establish an animal model and to investigate risk factors for postintubation tracheal stenosis. Beagles were intubated with 4 sized tubes (internal diameter 6.5 to 8.0 mm) and cuff pressures of 100 to 200 mmHg for 24 hr. The status of tracheal wall was evaluated by bronchoscopic and histological examinations. The model was successfully established by cuffed endotracheal intubation using an 8.0 mm tube and an intra-cuff pressure of 200 mmHg for 24 hr. When the intra-cuff pressures were kept constant, a larger sized tube would induce a larger tracheal wall pressure and more severe injury to the tracheal wall. The degree of tracheal stenosis ranged from 78% to 91% at 2 weeks postextubation. Histological examination demonstrated submucosal infiltration of inflammatory cells, hyperplasia of granulation tissue and collapse of tracheal cartilage. In summary, a novel animal model of tracheal stenosis was established by cuffed endotracheal intubation, whose histopathological feathers are similar to those of clinical cases of postintubation tracheal stenosis. Excessive cuff pressure and over-sized tube are the risk factors for postintubation tracheal stenosis.
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Affiliation(s)
- Zhuquan Su
- Sate Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Shiyue Li
- Sate Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Ziqing Zhou
- Sate Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xiaobo Chen
- Sate Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yingying Gu
- Pathology Department, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yu Chen
- Sate Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Changhao Zhong
- Sate Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Minglu Zhong
- Sate Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Nanshan Zhong
- Sate Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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Tennyson J, Ford-Webb T, Weisberg S, LeBlanc D. Endotracheal Tube Cuff Pressures in Patients Intubated Prior to Helicopter EMS Transport. West J Emerg Med 2016; 17:721-725. [PMID: 27833679 PMCID: PMC5102598 DOI: 10.5811/westjem.2016.8.30639] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Revised: 07/11/2016] [Accepted: 08/02/2016] [Indexed: 12/16/2022] Open
Abstract
Introduction Endotracheal intubation is a common intervention in critical care patients undergoing helicopter emergency medical services (HEMS) transportation. Measurement of endotracheal tube (ETT) cuff pressures is not common practice in patients referred to our service. Animal studies have demonstrated an association between the pressure of the ETT cuff on the tracheal mucosa and decreased blood flow leading to mucosal ischemia and scarring. Cuff pressures greater than 30 cmH2O impede mucosal capillary blood flow. Multiple prior studies have recommended 30 cmH2O as the maximum safe cuff inflation pressure. This study sought to evaluate the inflation pressures in ETT cuffs of patients presenting to HEMS. Methods We enrolled a convenience sample of patients presenting to UMass Memorial LifeFlight who were intubated by the sending facility or emergency medical services (EMS) agency. Flight crews measured the ETT cuff pressures using a commercially available device. Those patients intubated by the flight crew were excluded from this analysis as the cuff was inflated with the manometer to a standardized pressure. Crews logged the results on a research form, and we analyzed the data using Microsoft Excel and an online statistical analysis tool. Results We analyzed data for 55 patients. There was a mean age of 57 years (range 18–90). The mean ETT cuff pressure was 70 (95% CI= [61–80]) cmH2O. The mean lies 40 cmH2O above the maximum accepted value of 30 cmH2O (p<0.0001). Eighty-four percent (84%) of patients encountered had pressures above the recommended maximum. The most frequently recorded pressure was >120 cmH2O, the maximum pressure on the analog gauge. Conclusion Patients presenting to HEMS after intubation by the referral agency (EMS or hospital) have ETT cuffs inflated to pressures that are, on average, more than double the recommended maximum. These patients are at risk for tracheal mucosal injury and scarring from decreased mucosal capillary blood flow. Hospital and EMS providers should use ETT cuff manometry to ensure that they inflate ETT cuffs to safe pressures.
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Affiliation(s)
- Joseph Tennyson
- University of Massachusetts Medical School, Department of Emergency Medicine, Division of Emergency Medical Services, Worcester, Massachusetts
| | - Tucker Ford-Webb
- Lahey Hospital & Medical Center, Emergency Department, Burlington, Massachusetts
| | - Stacy Weisberg
- University of Massachusetts Medical School, Department of Emergency Medicine, Division of Emergency Medical Services, Worcester, Massachusetts
| | - Donald LeBlanc
- UMass Memorial LifeFlight, Emergency Medical Services, Worcester, Massachusetts
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Annoni R, Pires-Neto RC. Ineffectiveness of using the pressure relief valve technique during cuff inflation. Rev Bras Ter Intensiva 2016; 26:367-72. [PMID: 25607265 PMCID: PMC4304464 DOI: 10.5935/0103-507x.20140056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2014] [Accepted: 10/05/2014] [Indexed: 11/25/2022] Open
Abstract
Objective To test the effectiveness of using a cuff pressure relief valve technique to
maintain cuff pressure levels within the normal in vitro range (Phase 1) in
patients admitted to the intensive care unit (Phase 2) and to test the
reproducibility of the technique using different syringes. Methods In Phase 1, a tracheal tube was inserted into a trachea model. Ten- and 20mL
syringes were used to inflate the cuff through the tracheal tube. The cuff was
slowly and steadily inflated until the syringe plunger would move in the opposite
direction of the application. After the plunger stopped, the cuff pressures were
recorded. In Phase 2, the same maneuvers for inflating the cuff were performed on
20 patients using 5, 10, and 20mL syringes and were compared with manometer
measurements. The intraclass correlation coefficient and Bland-Altman analysis
were employed to determine the reproducibility and agreement between syringes.
Data were expressed as medians (interquartile range). Results There was no reproducibility between syringes with an intraclass correlation
coefficient ranging between -0.33 and 0.8 (p>0.05). The pressures generated
with the syringes were higher than the pressures generated using a standard
manometer: the 5mL syringe pressure was 105cmH2O
(82.5-120cmH2O), the 10mL syringe pressure was 69cmH2O
(47.5-111.3cmH2O), and the 20mL syringe pressure was
45cmH2O (35-59.5cmH2O). The Bland-Altman analysis
confirmed the large bias and variability between the syringes used, compared with
the manometer. Conclusion The use of syringes is not an effective technique for determining the cuff
pressure in patients admitted to the intensive care unit.
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Affiliation(s)
- Raquel Annoni
- Departamento de Patologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Ruy Camargo Pires-Neto
- Departamento de Patologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
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El-Orbany M, Salem MR. Endotracheal tube cuff leaks: causes, consequences, and management. Anesth Analg 2013; 117:428-34. [PMID: 23744958 DOI: 10.1213/ane.0b013e318292ee21] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The consequences of endotracheal tube (ETT) cuff leak may range from a bubbling noise to a life-threatening ventilatory failure. Although the definitive solution is ETT replacement, this is often neither needed nor safe to perform. Frequently, the leak is not caused by a structural defect in the ETT. Cuff underinflation, cephalad migration of the ETT (partial tracheal extubation), misplaced orogastric or nasogastric tubes, wide discrepancy between ETT and tracheal diameters, or increased peak airway pressure can cause leaks around intact cuffs. Correction of these problems will stop the leak without ETT replacement. Alternatively, ETT cuff, pilot balloon, and inflation system damage due to inadvertent trauma or manufacturing defects may be responsible. Conservative management ideas (management without ETT replacement) were previously published to solve the problem. However, when a large structural defect is identified or conservative measures fail, ETT replacement becomes necessary. This can be performed with direct laryngoscopy if laryngeal visualization is adequate. A difficult exchange with possible airway loss should be anticipated, and prepared for, when there are signs and/or history of difficult intubation. A risk/benefit analysis of each individual situation is warranted before decisions are made on how best to proceed. Alternative back-up ventilation plans should be preformulated and the necessary equipment ready before the exchange. In this review, various management concerns and plans are discussed, and a simple algorithm to manage leaky ETT cuff situations is presented.
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Affiliation(s)
- Mohammad El-Orbany
- Department of Anesthesiology, Medical College of Wisconsin, 9200 W Wisconsin Ave., Milwaukee, WI 53226, USA.
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Kumar RDC, Hirsch NP. Clinical evaluation of stethoscope-guided inflation of tracheal tube cuffs. Anaesthesia 2011; 66:1012-6. [PMID: 21851343 DOI: 10.1111/j.1365-2044.2011.06853.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Tracheal tube cuffs are commonly inflated to pressures exceeding the recommended upper limit of 30 cmH(2)O. We evaluated whether a stethoscope-guided method of cuff inflation results in pressures within the recommended range. Patients were randomly assigned to receive one of two methods of cuff inflation. In the standard 'just seal' group, air was introduced into the tracheal cuff until the audible leak at the mouth disappeared. In the stethoscope-guided group, air was introduced into the cuff until a change from harsh to soft breath sounds occurred, whilst listening with a stethoscope bell placed over the thyroid cartilage. Twenty-five patients were recruited to each group. The median (IQR [range]) cuff pressure in the 'just seal' group was 34 (28-40 [18-49]) cmH(2)O, and in the stethoscope-guided group was 20 (20-26 [16-28]) cmH(2)O, p < 0.0001. The stethoscope-guided method of tracheal tube cuff inflation is a novel, simple technique that reliably results in acceptable tracheal cuff pressures.
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Affiliation(s)
- R D C Kumar
- National Hospital for Neurology and Neurosurgery, London, UK
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7
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Janossy KM, Pullen J, Young D, Bell G. The effect of pilot balloon design on estimation of safe tracheal tube cuff pressure. Anaesthesia 2010; 65:785-91. [DOI: 10.1111/j.1365-2044.2010.06413.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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8
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Huh J, Yoon TG, Kwon WK, Joo Y, Kim DK. Usefulness of new technique using a disposable syringe for endotracheal tube cuff inflation. Korean J Anesthesiol 2009; 56:513-518. [DOI: 10.4097/kjae.2009.56.5.513] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Jin Huh
- Department of Anesthesiology and Pain Medicine, Boramae Municipal Hospital, Seoul, Korea
| | - Tae Gyoon Yoon
- Department of Anesthesiology and Pain Medicine, Konkuk University Hospital, Konkuk University School of Medicine, Seoul, Korea
| | - Won Kyoung Kwon
- Department of Anesthesiology and Pain Medicine, Konkuk University Hospital, Konkuk University School of Medicine, Seoul, Korea
| | - Young Joo
- Department of Anesthesiology and Pain Medicine, National Police Hospital, Seoul, Korea
| | - Duk Kyung Kim
- Department of Anesthesiology and Pain Medicine, Konkuk University Hospital, Konkuk University School of Medicine, Seoul, Korea
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10
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Munsterman MEJ. Cuffdrukmeting van levensbelang. Crit Care 2007. [DOI: 10.1007/bf03063191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Hoffman RJ, Parwani V, Hahn IH. Experienced emergency medicine physicians cannot safely inflate or estimate endotracheal tube cuff pressure using standard techniques. Am J Emerg Med 2006; 24:139-43. [PMID: 16490640 DOI: 10.1016/j.ajem.2005.07.016] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2005] [Revised: 07/27/2005] [Accepted: 07/29/2005] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Tracheal necrosis, stenosis, and rupture may result from overinflated endotracheal tube cuffs (ETTcs). We sought to determine the ability of faculty emergency medicine (EM) physicians to safely inflate ETTc as well as to estimate pressure of previously inflated ETTc. METHODS Using a previously tested tracheal simulation model, we assessed EM physician inflation of ETTc pilot balloons. Participants also palpated the pilot balloon of 9 ETTc inflated to pressures ranging from extremely low to extremely high in a random order and reported their estimate of pressure. RESULTS We sampled 41 faculty EM physicians from 5 EM residency programs. Using palpation, participants were only 22% sensitive detecting overinflated ETTc. The average ETTc pressure produced by inflation was more than 93 cm H(2)O (normal, 15-25 cm H(2)O). CONCLUSIONS Participants were unable to inflate ETTc to safe pressures or estimate pressure of ETTc by palpation. Clinicians should consider using devices to facilitate safe inflation and accurate measurement of ETTc pressure.
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Affiliation(s)
- Robert J Hoffman
- Department of Emergency Medicine, Beth Israel Medical Center, New York, NY 10003, USA.
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12
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Mac Murdo SD, Buffington CW. Brand and size matter when choosing a syringe to relieve pressure in a tracheal tube cuff. Anesth Analg 2004; 99:1445-1449. [PMID: 15502046 DOI: 10.1213/01.ane.0000134799.36294.e5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We studied the use of an inline syringe as a pressure relief valve for tracheal tube cuffs during exposure to nitrous oxide to see if the technique works. Bench testing was done to determine the stick and slip characteristics of syringes of different brands and sizes. Cuffs were inflated with 20 mL of air, producing a cuff pressure of 100-120 mm Hg. Then the plunger of the syringe was allowed to passively rebound to a steady pressure at which the plunger stopped ("stick pressure"). After several minutes, pressure in the syringe was forcibly increased with a second syringe until the plunger started moving again ("slip pressure"). Stick pressure varied from 18 to 82 mm Hg depending on the brand and size of syringe used. Slip pressures exceeded stick pressures by 20-120 mm Hg. Cuff pressure increased in a linear fashion during nitrous oxide exposure, and no syringe demonstrated automatic pressure reduction. We conclude that a syringe attached to the pilot balloon connector can be used to control tracheal tube cuff pressure during nitrous oxide anesthesia. However, not all syringes are suitable for this purpose: large syringes are better than small syringes, and the Terumo brand is more suitable than BD or Monoject. The system does not work automatically, and intermittent compression of the syringe plunger to overcome static friction is required to avoid overdistension.
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Affiliation(s)
- Stanley D Mac Murdo
- Department of Anesthesiology, University of Pittsburgh, Pittsburgh, Pennsylvania
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