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

Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR) Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part II

The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factor, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.

The Effect of Topical Benzydamine Hydrochloride and Cuff Pressure Monitorization on Postoperative Sore Throat Due to Intubation

OBJECTIVE

Postoperative sore throat (POST) is the most common discomfort after endotracheal intubation. Damage to the tracheal mucosa caused by inappropriate endotracheal tube (ETT) cuff pressure has been shown as the major factor. Monitoring the ETT cuff pressure at a certain value reduces this damage. Benzydamine hydrochloride (BH) has proven to be effective on sore throat and studies have shown that it is also effective on POST. In this study, the efficacy of BH and ETT cuff pressure monitoring on POST was evaluated.

MATERIALS AND METHODS

After ethics committee approval 210 patients in the ASA (American Society of Anesthesiologists) I-III risk group undergoing elective surgery were included in the study. Routine anesthesia monitoring, induction, and maintenance were provided. Patients were randomly divided into three groups. Thirty minutes before surgery, the posterior pharyngeal wall was sprayed with BH in group 1 and distilled water in groups 2 and 3. Intraoperatively, the first and second groups were monitored to keep the ETT cuff pressure between 22 and 26 cmH2O, while no intervention was performed in the third group. The incidence and severity of postoperative dysphagia, hoarseness, and POST were questioned.

RESULTS

There was no difference between demographic data, and gender was not associated with POST. There was a statistically significant difference between the first and second groups and the third group in terms of all three symptoms questioned (p<0.01). No difference was observed between the first and second groups. Side effect rates were similar. Smoking was not found to be associated with symptoms.

CONCLUSION

The incidence and severity of POST, dysphagia, and hoarseness are reduced when the ETT cuff is inflated with a pressure of 22-26 cmH2O after intubation with a manometer and maintained at this pressure range throughout the operation. There was no beneficial effect of BH.

37-Year-Old Tracheostomized Woman With Overdistended Tracheostomy Cuff and Difficulty Ventilating

CASE PRESENTATION

A 37-year-old woman with a medical history of myasthenia gravis resulting in progressive respiratory failure requiring continuous mechanical ventilation via tracheostomy, as well as multiple cardiac arrests leading to severe anoxic brain injury, was brought to the hospital from a nursing home because of difficulties with ventilation and oxygenation. On presentation to the ED, the patient was found to be agitated and tachypneic on a ventilator, generating low tidal volumes despite elevated peak airway pressures. Before the current presentation, the patient had been mechanically ventilated at a long-term acute care facility for the past 5 years. More recently, staff has noted intermittent loss of tidal volumes, temporarily responding to overinflation of tracheostomy cuff. Additionally, the tracheostomy tube was exchanged for an extra-long tracheostomy tube to improve tidal volumes; however, the problem persisted, prompting the current presentation.

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.

Successful management of oesophageal atresia in Cameroon, Sub-Saharan Africa

Background

Oesophageal atresia (EA) is the most common congenital anomaly of the oesophagus. Despite improvement of survival observed over the previous two decades in developed countries, the mortality remains very high and the management greatly challenging in resource-poor settings such as Cameroon. We report our experience of management of EA in this environment, with a successful outcome.

Materials and Methods

We prospectively assessed patients diagnosed with EA and operated in January 2019, at the University Hospital Centre of Yaounde. Records were reviewed for demographics, history and physical examinations, radiological findings, surgical procedures and outcomes. The study has received approval from the Institutional Ethics Committees.

Results

In total, six patients (three males and three females, sex ratio, 0.5; mean age at diagnosis, 3.6 days; range, 1-7 days) were assessed. A past history of polyhydramnios was found in one patient (16.7%). All patients were classified Waterston Group A at diagnosis, with Ladd-Swenson type III atresia. Early primary repair was performed in four patients (66.7%) and delayed primary repair in two patients (33.3%). Operative repair mainly involved resection of the fistula, suture of trachea and oesophagus end-to-end anastomosis, followed by interposition of vascularised pleural flap. Patients were followed up 24 months. With one late death, the survival rate was 83.3%.

Conclusion

Improvement has been achieved in the outcomes of neonatal surgery in Africa in the past two decades, but EA-related mortality remains relatively too high. Using simple techniques and available, reproducible equipment can improve survival in resource-poor settings.

Complications secondary to endotracheal intubation in dogs and cats – A questionnaire-based survey among veterinary anaesthesiologists

OBJECTIVE

To investigate anaesthesiologists' attitudes towards endotracheal intubation and the perceived incidence of complications secondary to endotracheal intubation in dogs and cats.

STUDY DESIGN

A cross-sectional online questionnaire-based study.

METHODS

Using an online questionnaire distributed via electronic mail, the perceived incidence of complications secondary to endotracheal intubation in dogs and cats was investigated. Attitudes towards endotracheal intubation, average caseload and percentage of animals intubated were examined. The study population consisted of Diplomates, Residents, and residency trained members of the American and European Colleges of Veterinary An(a)esthesia and Analgesia. Univariate descriptive statistics were calculated. For each complication, a mean incidence score (MIS) was calculated, ranging from 1 (never) to 5 (always). Additionally, a Wilcoxon signed-rank test and binary regression analyses were performed. A p value ≤ 0.05 was considered significant.

RESULTS

The overall response rate was 35.1%, with a completion rate of 26.6%. Most dogs and cats undergoing general anaesthesia were intubated. Endotracheal intubation was viewed as an integral part of modern anaesthesia. Significant differences were found in the incidence of 16 of the 24 examined complications between dogs and cats (p ≤ 0.001). The most frequently perceived complications were reported to be cuff leak (MIS 3.20) and coughing during intubation (MIS 3.10) in dogs, and coughing (MIS 3.01) and laryngeal spasm during intubation (MIS 2.91) in cats. Sociodemographic and practice-specific aspects did not appear to play a significant role in the reported incidence of complications.

CONCLUSIONS AND CLINICAL RELEVANCE

Endotracheal intubation was considered a state-of-the-art technique by the respondents. It was associated with a perceived low incidence of major complications and more frequent minor ones. Differences between dogs and cats need to be accounted for. Considering the retrospective and self-reporting nature of this survey, true incidences might differ.

Disposable Airway Pressure Manometers for Endotracheal Tube Cuff Inflation

This study aimed to assess the performance, accuracy, precision and repeatability of two single-use airway pressure manometers as a cost-effective alternative for inflation of endotracheal tubes with high-volume, low-pressure cuffs. The manometers were tested in a bench top model against a U-tube manometer. Eighteen units of each device were tested. Three consecutive measurements were performed at pressures of 20, 25 and 30 cmH₂O each. The mean ± SD of the recorded pressures and maximum deviation from the target pressures were calculated for each device and each target pressure. For device A, the mean ± SD pressures were 19.6 ± 0.7, 23.6 ± 0.8 and 28.3 ± 0.8 cmH₂O; for device B, the mean ± SD pressures were 19.3 ± 0.6, 24.3 ± 0.9 and 29.2 ± 0.67 cmH₂O for target pressures of 20, 25 and 30 cmH₂O, respectively. The bias for device A was -0.4, -1.4, and -1.7 cmH₂O and for device B, -0.7, -0.7, and -0.8 cmH₂O for target pressures of 20, 25, and 30 cmH₂O, respectively. Both devices showed results comparable to those reported for commercial cuff manometers. They represent inexpensive tools that provide clinically sufficient accuracy, precision and repeatability for ETT cuff inflation between pressures of 20 and 30 cmH₂O.

Methods Used for Endotracheal Tube Cuff Inflation and Pressure Verification in Veterinary Medicine: A Questionnaire on Current Practice

Endotracheal intubation is a routine procedure in veterinary anaesthesia, yet no consensus guidelines exist for endotracheal tube (ETT) cuff inflation and pressure measurement. The aim of this study was to assess current practice of ETT cuff inflation and seal verification in veterinary medicine. An online questionnaire was distributed among veterinary professionals who administer anaesthesia, comprising six demographic and twelve ETT cuff-related questions per species. N = 348 questionnaires were completed. Cuff pressure was measured by 30% of respondents in cats, 32% in dogs and 9% in both farm animals and horses. Anaesthesia diplomates were not more likely to measure cuff pressure than others, except in cats (OR: 1.8; 95% CI: 1.1−2.9). The most frequently selected recommended range of cuff pressure was 20−30 cm H2O, regardless of species, although >30 cm H2O was selected significantly more often in horses compared to dogs, cats and farm animals. The preferred technique to verify cuff seal was minimal occlusive volume in dogs, cats and farm animals, whereas in horses, the preferred method was verification of normal capnogram waveform. ETT cuff pressure measurement remains uncommon in veterinary anaesthesia. The development of consensus recommendations for cuff inflation, including evidence-based target cuff pressure ranges for various species and different ETT models or materials, can help to improve practice.

The impact of esophageal device insertion on cuff pressure of endotracheal tube: a literature review and meta-analysis

The impact of intraoperative esophageal device insertion (EDI) on endotracheal tube (ET) cuff inflation pressure remains unclear. Electronic databases including Medline, Embase, Google scholar, Web of Science™ and Cochrane Central Register of Controlled Trials were searched for studies involving EDI after placement of ETs from inception to July 7, 2022. The primary outcome was risk of high cuff pressure, while the secondary outcomes were increases in cuff pressure following EDI. Difference between adults and children was investigated with subgroup analysis. There were ten eligible studies (observation study, n = 9, randomized controlled study, n = 1) involving a total of 468 participants. EDI notably increased the risk of high cuff pressure (n = 7, risk ratio: 12.82, 95% confidence interval: 4.9 to 33.52, subgroup analysis: p = 0.008). There were significant elevations in cuff pressure in adults and children both during (13.42 and 7.88 cmH₂O, respectively, subgroup analysis: p = 0.15) and after (10.09 and 3.99 cmH₂O, respectively, subgroup analysis: p = 0.0003) EDI. Our results revealed an over 12-fold increase in the risk of high endotracheal tube cuff pressure in patients, especially adults, receiving EDI under endotracheal anesthesia. There were significant increases in both adults and children despite a higher increase in the former after device insertion.

Effects of bevel direction of endotracheal tube on the postoperative sore throat when performing fiberoptic-guided tracheal intubation: A randomized controlled trial

BACKGROUND

During fiberoptic-guided tracheal intubation, impingement between the distal tip of the endotracheal tube and the airway tissue can cause difficulties in tube insertion or tissue damage during the tube advancement over the bronchoscope. This randomized controlled study aimed to investigate the effects of the endotracheal tube's bevel direction on the complications associated with airway injury when performing fiberoptic-guided tracheal intubation.

METHODS

The study subjects were divided into 2 groups: L (control) and D (study). When advancing the tube over the bronchoscope, the tube's bevel was facing the patients' left in Group L and the dorsal direction in Group D. According to the degree of resistance at the time of tube advancement, the insertion score was graded in 3 stages; the severity of the patients' sore throat and hoarseness was evaluated and recorded postoperatively.

RESULTS

The severity of postoperative sore throat was higher in Group L than in Group D 3 hours and 24 hours after surgery. (P = .008, P = .023, respectively). The tube insertion score was comparable between the groups. The severity of postoperative hoarseness did not vary significantly between the groups.

CONCLUSION

Endotracheal tube insertion with the bevel facing the dorsal direction of the patient during fiberoptic-guided tracheal intubation reduced the severity of postoperative sore throat in patients undergoing laparoscopic gynecologic surgery.

Anterior servikal omurga cerrahisi sonrası farklı endotrakeal tüp kaf basınçlarının disfajı üzerine etkileri

Amaç: Bu çalışmada, anterior servikal omurga cerrahisinde iki farklı endotrakeal kaf basıncının postoperatif disfaji, boğaz ağrısı, disfoni ve hastanede kalış üzerindeki etkilerinin karşılaştırılması amaçlanmıştır. Gereç ve Yöntem: Cerrahi planlanan 70 hasta rastgele iki gruba ayrıldı. Entübasyondan sonra endotrakeal kaf basıncı Grup I'de (n=35) ve Grup II'de (n=35) sırasıyla 20 cmH2O ve 25 cmH2O'ya şişirildi. Disfajinin derecesi Bazaz disfaji skoru ile değerlendirildi. Boğaz ağrısı Görsel Analog Skala ile değerlendirildi. Operasyon bölgesine ilişkin toplam ağrı skoru VAS kullanılarak değerlendirildi (. Ses kısıklığı, seste herhangi bir değişiklik olup olmamasına göre sert veya gergin olarak değerlendirildi. Disfaji, disfoni ve boğaz ağrısı ameliyat sonrası 1. ve 24. saatlerde değerlendirildi. Bulgular: Gruplar arasında demografik verilerde farklılık yoktu. Ameliyat sonrası 1. ve 24. saatlerde yutma güçlüğü ve boğaz ağrısı Grup I'de Grup II'ye göre anlamlı olarak daha azdı. Disfoni sıklığı Grup I'de Grup II'ye kıyasla sadece cerrahi sonrası 1. saatte anlamlı olarak daha azdı. Gruplar arasında ameliyat sonrası 1. ve 24. saatlerde VAS skorlarında fark yoktu. Sonuç: Bu çalışmada, 25 cmH2O'ya kıyasla endotrakeal kaf basıncı 20 cmH2O ile cerrahi sonrası disfaji gelişme riskinin önemli ölçüde azalttığı gösterilmiştir. Ayrıca, daha düşük kaf basıncı, daha hafif bir boğaz ağrısı, ameliyat sonrası 1. saatte daha az ses kısıklığı ve daha kısa hastanede kalış süresi ile ilişkilendirildi.

Postoperative Nursing Care of a Deceased Donor Tracheal Transplant Recipient

INTRODUCTION

Certain airway disorders, such as tracheal stenosis, can severely affect the ability to breathe, reduce quality of life, and increase morbidity and mortality. Treatment options for long-segment tracheal stenosis include multistage tracheal replacement with biosynthetic material, autotransplantation, and allotransplantation. These interventions have not demonstrated long-term dependable results because of lack of adequate blood supply to the organ and ciliated epithelium. A new transplant program featuring single-stage long-segment tracheal transplant addresses this concern.

CLINICAL FINDINGS

The patient was a 56-year-old woman with a history of obesity, type 2 diabetes, hypertension, hyperlipidemia, liver sarcoidosis, 105-pack-year smoking history, and asthma. A severe asthma exacerbation in 2014 required prolonged intubation, and she subsequently developed long-segment cricotracheal stenosis. In 2015 she underwent an unsuccessful tracheal resection followed by failed attempts at tracheal stenting and dilation procedures. These attempts at stenting resulted in a permanent extended-length tracheostomy and ultimately ventilator dependency.

INTERVENTIONS

The patient underwent a single-stage long-segment deceased donor tracheal transplant. Important nursing considerations included hemodynamic monitoring, airway management and securement, graft assessment, stoma and wound care, nutrition, medication administration, and patient education.

CONCLUSION

High-quality nursing care postoperatively in the intensive care unit is critical to safe and effective treatment of the tracheal transplant recipient and success of the graft. To effectively treat these patients, nurses need relevant education and training. This article is the first documentation of postoperative nursing care following single-stage long-segment tracheal transplant.

Endotracheal Tube Cuff Pressure Management: An Observational Study Guided by the SEIPS Model

INTRODUCTION

The aim of the rigorous endotracheal tube cuff pressure (ETTCP) management is to maintain cuff pressures within the recommended values during the mechanical ventilation period. However, hyperinflation or hypoinflation of cuff has been reported because of inconsistent clinical practices in intensive care unit (ICU) settings. Furthermore, there is no available best evidence for clinical decision-making regarding the ETTCP management provided by international institutes.

PURPOSE

The aim of this study was to examine the ETTCP management work system in ICU settings in urban hospitals of Turkey and the United States using the Systems Engineering Initiative for Patient Safety model.

METHODS

This was a direct observational, prospective field study, in which the COREQ (Consolidated Criteria for Reporting Qualitative Research) tool was used. The direct observations and follow-up interviews were conducted, and the results were reported using the Systems Engineering Initiative for Patient Safety model.

RESULTS

We identified important characteristics of the ETTCP management work system in each of the 4 ICU and differences across the settings.

CONCLUSION

Common use of the evidence-based and internationally used protocols may standardize the management of ETTCP, improve communication among ICU staff, and promote desired patient outcomes.

RELEVANCE TO CLINICAL PRACTICE

There is a need for developing strategies to provide standardized ETTCP management and to improve patient's quality of care. To improve the patient outcomes and quality of care, ICU managers should consider clear expectations for ETTCP management in each job description, structured and evidence-based protocols, and effective communication among disciplines and provide teaching opportunities to encourage physicians, nurses, and respiratory therapists to meet their educational needs.

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.

Endotracheal Tube Intracuff Pressure Changes in Patients Transported by a Helicopter Emergency Medical Service: A Prospective Observational Study

OBJECTIVE

The pressure within an endotracheal tube cuff is of particular importance in helicopter emergency medical services (HEMS) transport because the unpressurized cabin is subjected to decreases in atmospheric pressure. This can cause the cuff to overinflate and may be associated with clinical complications. We sought to evaluate endotracheal tube cuff pressure changes among intubated patients during HEMS transport.

METHODS

A prospective observational study was performed including adult patients who were intubated and transported by helicopter between April 2017 and October 2018. Cuff pressures were measured before, during, and after HEMS transport with a commercial manometer.

RESULTS

A total of 208 patients were included. The median maximum flight altitude was 3,000 (interquartile range [IQR], 2,000-5,000) ft. The median initial cuff pressure before takeoff was 35 (IQR, 24-50) cm H₂O, which increased to 50 (IQR, 35-70) cm H₂O at maximum altitude. A total of 169 (81.3%) patients had a cuff pressure > 30 cm H₂O at maximum altitude. There was a moderate correlation between altitude and cuff pressure (r = 0.532, P < .001).

CONCLUSIONS

Cuff pressure increased during HEMS transport, demonstrating the need for routine cuff pressure monitoring during flight. Further research is required to determine if exposure to transient increases in cuff pressure for short durations is clinically significant.

Does the endotracheal tube cuff pressure increases with transesophageal probe insertion?

Context:

The cuff pressure (CP) of the endotracheal tube (ETT) exceeding 30 cm of H₂O results in reduced perfusion of lateral mucosa of trachea leading to complications. As the posterior tracheal wall is in contact with the esophagus, there is a possibility that the insertion of transesophageal echo (TEE) probe may compress the tracheal wall and increase CP.

Aims:

This study was aimed to assess the impact of TEE probe insertion on CP in adults undergoing cardiac surgery.

Settings and Design:

Prospective observational study of 65 patients at tertiary care level hospital.

Subjects and Methods:

After balanced general anesthesia, patients were intubated with high volume low-pressure ET.TEE probe was then inserted with gentle jaw thrust. CP was measured by standard invasive pressure monitoring device at four points: T1 at baseline before TEE probe insertion; T2 maximum CP noted at TEE probe insertion; T3 at 5 min post TEE probe insertion; and T4 at post-TEE exam.

Statistical Analysis Used:

CP was compared between pairs of time points (T1 vs. T2; T1 vs. T3; and T1 vs. T4) using Mann-Whitney U test. Factors predicting CP >30 cm of H₂O at T4 were assessed by backward stepwise regression.

Results:

CP (mean ± S.D.) at T1, T2, T3, and T4 was 22 ± 3, 38 ± 10, 30 ± 6, and 30 ± 7, respectively. CP increased significantly from T1 to T2 (P < 0.001), T1 to T3 (P < 0.001), and T1 to T4 (P < 0.001). There were 26 patients (40%) with CP >30 cm of H₂O at end of TEE exam (T4). On multivariate analysis baseline, CP (T1) >20 cm of H₂O was significantly associated with CP >30 cm of H₂O at end of TEE exam with Odd's Ratio (OR) of 8.5 (1.76–41.06, P = 0.008).

Conclusions:

To conclude, the CP increases significantly with TEE probe insertion in 40% of patients exceeding a safe limit of 30 cm of H₂O. The monitoring and optimization of CP is advisable.

Comparison of effects of volume-controlled and pressure-controlled mode of ventilation on endotracheal cuff pressure and respiratory mechanics in laparoscopic cholecystectomies: A randomised controlled trial

Background and Aims:

One of the pathophysiological consequences of pneumoperitoneum is variations in endotracheal cuff pressure (ETTc). Volume-controlled mode and pressure-controlled mode of ventilation being two modes of ventilatory strategies; we intended to find out variations in ETTc governed by respiratory mechanics between these two modes during laparoscopic cholecystectomies.

Methods:

After obtaining ethics committee approval, this randomised (1:1), active-controlled, parallel-assigned study was done on 60 patients undergoing laparoscopic cholecystectomies. These patients were allocated into two groups by computer-generated randomisation: Volume-controlled mode (V) and pressure-controlled mode (P). We observed for variations in ETTc which was the primary aim and haemodynamic parameters; respiratory mechanics at baseline (T1), at pneumoperitoneum (T2), after 10 min (T3), 20 min (T4) of pneumoperitoneum and at desufflation (T5). Post-operative laryngotracheal co-morbidities were also observed. Analysis was done using Statistical Package for the Social Sciences version 16.0 (IBM SPSS Statistics, Somers NY, USA).

Results:

No statistically significant difference was found in both groups either concerning ETTc, haemodynamic parameters or complications. In both groups, ETTc variation was statistically significant when compared from baseline to desufflation (T1 versus T5) and in group V additionally from baseline to time of pneumoperitoneum (T1 versus T2). Group P showed lower peak airway pressure at desufflation and higher mean airway pressure throughout at all the time intervals.

Conclusions:

There is no variation in ETTc between the two modes. Group P appears to be better in terms of lower Ppeak and better Pmean.

Multidisciplinary Safety Recommendations After Tracheostomy During COVID-19 Pandemic: State of the Art Review

OBJECTIVE

In the chronic phase of the COVID-19 pandemic, questions have arisen regarding the care of patients with a tracheostomy and downstream management. This review addresses gaps in the literature regarding posttracheostomy care, emphasizing safety of multidisciplinary teams, coordinating complex care needs, and identifying and managing late complications of prolonged intubation and tracheostomy.

DATA SOURCES

PubMed, Cochrane Library, Scopus, Google Scholar, institutional guidance documents.

REVIEW METHODS

Literature through June 2020 on the care of patients with a tracheostomy was reviewed, including consensus statements, clinical practice guidelines, institutional guidance, and scientific literature on COVID-19 and SARS-CoV-2 virology and immunology. Where data were lacking, expert opinions were aggregated and adjudicated to arrive at consensus recommendations.

CONCLUSIONS

Best practices in caring for patients after a tracheostomy during the COVID-19 pandemic are multifaceted, encompassing precautions during aerosol-generating procedures; minimizing exposure risks to health care workers, caregivers, and patients; ensuring safe, timely tracheostomy care; and identifying and managing laryngotracheal injury, such as vocal fold injury, posterior glottic stenosis, and subglottic stenosis that may affect speech, swallowing, and airway protection. We present recommended approaches to tracheostomy care, outlining modifications to conventional algorithms, raising vigilance for heightened risks of bleeding or other complications, and offering recommendations for personal protective equipment, equipment, care protocols, and personnel.

IMPLICATIONS FOR PRACTICE

Treatment of patients with a tracheostomy in the COVID-19 pandemic requires foresight and may rival procedural considerations in tracheostomy in their complexity. By considering patient-specific factors, mitigating transmission risks, optimizing the clinical environment, and detecting late manifestations of severe COVID-19, clinicians can ensure due vigilance and quality care.

[Clinical outcomes of vocal fold immobility after tracheal intubation]

OBJECTIVE

To assess the incidence of postoperative vocal cord immobility in patients following endotracheal intubation underwent general anesthesia.

METHODS

We retrospectively enrolled patients who underwent surgical procedures with endotracheal intubation under general anesthesia from January 2014 to December 2018 in Peking University First Hospital. Demographic and treatment data were obtained for patients with hoarseness and vocal cord fixation. The incidence of postoperative hoarseness and vocal cord fixation were presented and clinical outcomes were further analyzed.

RESULTS

A total of 85 998 patients following tracheal intubation and general anesthesia were enrolled in this study. Hoarseness was observed in 222 (0.26%) patients postoperatively. Sixteen patients (73%) were accomplished with symptoms of choking on water, dysphonia and sore throat. Twenty-nine patients with persistent hoarseness on the third postoperative day needed further treatment by otolaryngologists. Among them, seven patients had pharyngolaryngitis and twenty-two patients (0.026%) were demonstrated postoperative vocal cord immobility. There were seventeen patients (77%) with left-side vocal cord fixation and five patients (23%) with right-side vocal cord fixation. Nine patients were identified with arytenoid dislocation. Seven patients had left vocal cord fixation and two patients had right-side vocal cord fixation. Seven patients were intubated under the guidance of visual laryngoscope. One patient was confirmed difficult airway and intubated with light wand. One patient was inserted with laryngeal mask airway. One patient was suspected to have hoarseness caused by gastric tube before anesthesia. One patient showed simultaneously left recurrent laryngeal nerve abnormality on laryngeal electromyography result. The symptom of hoarseness ranged between 6 and 31 days. Three patients underwent closed reduction under local anesthesia and one patient demonstrated spontaneous recovery. Among the remaining thirteen patients with vocal cord immobility, two patients were demonstrated vocal cord paralysis. Eleven patients underwent neck surgery, thyroid surgery and cardiothoracic surgery and further examinations including laryn-geal electromyography and computed tomography help to determine the diagnosis were not performed. All patients were treated with inhaled corticosteroid conservatively. Five patients had significant improvement of symptom and almost regained normal voice. One patient had slight improvement and sixteen patients were not relieved before discharge.

CONCLUSION

Patients with hoarseness and vocal fold immobility after endotracheal intubation should be treated properly and immediately.

Speech-Language Pathology Guidance for Tracheostomy During the COVID-19 Pandemic: An International Multidisciplinary Perspective

Purpose As the COVID-19 pandemic has unfolded, there has been growing recognition of risks to frontline health care workers. When caring for patients with tracheostomy, speech-language pathologists have significant exposure to mucosal surfaces, secretions, and aerosols that may harbor the SARS-CoV-2 virus. This tutorial provides guidance on practices for safely performing patient evaluation and procedures, thereby reducing risk of infection. Method Data were collated through review of literature, guidelines, and consensus statements relating to COVID-19 and similar high-consequent infections, with a focus on mitigating risk of transmission to health care workers. Particular emphasis was placed on speech-language pathologists, nurses, and other allied health professionals. A multinational interdisciplinary team then analyzed findings, arriving at recommendations through consensus via electronic communications and video conference. Results Reports of transmission of infection to health care workers in the current COVID-19 pandemic and previous outbreaks substantiate the need for safe practices. Many procedures routinely performed by speech-language pathologists have a significant risk of infection due to aerosol generation. COVID-19 testing can inform level of protective equipment, and meticulous hygiene can stem spread of nosocomial infection. Modifications to standard clinical practice in tracheostomy are often required. Personal protective equipment, including either powered air-purifying respirator or N95 mask, gloves, goggles, and gown, are needed when performing aerosol-generating procedures in patients with known or suspected COVID-19 infection. Conclusions Speech-language pathologists are often called on to assist in the care of patients with tracheostomy and known or suspected COVID-19 infection. Appropriate care of these patients is predicated on maintaining the health and safety of the health care team. Careful adherence to best practices can significantly reduce risk of infectious transmission.

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.

The Change of Endotracheal Tube Cuff Pressure During Laparoscopic Surgery

Background

We evaluated the endotracheal tube cuff pressure (P_cuff) changes during pneumoperitoneum for laparoscopic cholecystectomy and the correlations between body mass index (BMI), pneumoperitoneum time, and P_cuff changes.

Methods

Total 60 patients undergoing laparoscopic cholecystectomy were allocated to either a study group (BMI ≥ 25 kg/m²) or a control group (BMI < 25 kg/m²). The endotracheal intubation was performed with a high-volume low-pressure cuffed oral endotracheal tube. A manometer was connected to the pilot balloon using a 3-way stopcock and the cuff was inflated. The change in P_cuff was defined as the difference between the pressure just before intra-abdominal CO₂ insufflation and the pressure before CO₂ desufflation.

Results

P_cuff increased to 5.3 ± 3.6 cmH₂O in the study group and 5.7 ± 5.4 cmH₂O in the control group. There was no significant difference between two groups. While BMI was not correlated with change in P_cuff (r = 0.022, p = 0.867), there was a significant correlation between change in P_cuff and the duration of pneumoperitoneum (r = 0.309, p = 0.016).

Conclusion

The change in P_cuff was not affected by BMI and was significantly correlated with pneumoperitoneum time. We recommend regular measurement and adjustment of P_cuff during laparoscopic surgery.

Assessing the correct inflation of the endotracheal tube cuff: a larger pilot balloon increases the sensitivity of the 'finger-pressure' technique, but it remains poorly reliable in clinical practice

The pilot balloon palpation (or 'finger-pressure') method is still widely used to assess the endotracheal tube cuff inflation, despite consistent evidence of its poor sensitivity in recognizing cuff overinflation. It was recently speculated that this may be related to the lower wall tension (due to the smaller radius) of the pilot balloon as compared with the cuff, according to Laplace's law. To verify this hypothesis and, secondarily, to assess whether the use of a 'large' pilot balloon (identical to the cuff) increases the reliability of this technique, 62 anesthetists (41 experienced anesthesiologists and 21 residents) were asked to estimate the pressure of a cuff inflated to 88 mmHg into a simulated trachea by feeling both a usual and a modified 'large' pilot balloon. A similar test was repeated at 40 mmHg. After palpation of the usual pilot balloon, only 35% of participants (49% of experienced anesthesiologists and 10% of residents) recognized considerable overinflation (88 mmHg), as compared with 87% of participants (95% of experienced anesthesiologists and 71% of residents) after palpation of the 'large' pilot balloon. Moreover, 89% of participants (85% of experienced anesthesiologists and 95% of residents) believed that pressure was higher in the 'large' balloon than in the normal one. However, only 32% of participants (51% of experienced anesthesiologists and none of residents) recognized slight overinflation (40 mmHg) after feeling the 'large' balloon. The pilot balloon size affects the sensitivity of the 'finger-pressure' technique, but it remains poorly reliable with a larger pilot balloon.

Successful Management of Acquired Tracheomalacia of Patients With Amyotrophic Lateral Sclerosis: A Report of Three Cases

Tracheomalacia is characterized by weakness of the tracheal walls and supporting cartilage. It results in dynamic compression of the airway, where the cross-sectional area of the trachea is reduced by expiratory compression. Acquired tracheomalacia results from complications associated with the use of endotracheal or tracheostomy tubes. In this report, we present three cases of patients with amyotrophic lateral sclerosis (ALS) successfully treated for tracheomalacia, including one case where the patient underwent surgery for combined tracheoesophageal fistula. We discuss the appropriate management strategies for tracheomalacia in patients with ALS. Through these case reports, we note the results of ALS patients who will have tracheostomy, and who are therefore at risk of sustaining a long term high cuff pressure, this study provides an evaluation for tracheomalacia and therapeutic management which should be considered for improving patient care outcomes.