Brief ReportsEndotracheal intracuff pressures in the ED and prehospital setting: is there a problem?
Introduction
High compliance endotracheal tube cuffs are used to prevent gas leak and also pulmonary aspiration in intubated patients. The pressure exerted on the tracheal wall by the balloon cuff is similar to the intracuff pressure [1], [2]. Ischemic changes in the tracheal mucosa may occur if the pressure exerted by the cuff of the tube exceeds the capillary perfusion pressure, typically about 30 cm H2O [3], [4]. High cuff pressure has been implicated in postoperative sore throat and nonischemic complications [5]. The incidence of possible tracheal ischemia can be minimized by keeping the intracuff pressure lower than the perfusion pressure [6]. To allow effective ventilation, the cuff should be inflated until it just prevents an air leak [7].
Endotracheal tube cuff pressures are not routinely measured in the prehospital setting or the ED [8]. It has been demonstrated that palpation of the pilot balloon is insufficient to detect high cuff pressures [9]. Many patients intubated in the ED or prehospital setting do not have intracuff pressure measured and adjusted. Mucosal damage has been shown to occur after 15 minutes in an animal model, longer than the time spent in these settings [6].
The purpose of this study is to assess endotracheal tube cuff pressures in patients intubated before transport by a critical care aeromedical service.
Section snippets
Methods
This was a retrospective study. As part of a quality improvement program, intracuff pressures were measured and adjusted on intubated patients transported by a critical care aeromedical program. This program is a regional air ambulance service. All patients are transported by helicopter. The helicopter provides critical care transport for interfacility transfers (within approximately 250 miles) and scene flights (within approximately 75 miles). The program transports approximately 1300 patients
Results
During the study period, there were 345 patients transported. Of these patients, 69 (20%) were younger than 18 years and so were not included. Of the remaining 276 patients, 54 (19%) were transported from a scene, whereas 222 (81%) were transported from another hospital. There were 62 (22%) patients who were intubated. All patients intubated during the study period were included. Of the scene patients, 6 (11%) were intubated, 4 by ambulance personnel and 2 by flight physicians. Of the 222
Limitations
This study relied upon measurement of tube pressure by numerous physicians that staff the program. All flight physicians were familiar with the intracuff manometer and its use. However, there was no attempt to validate independent measurements. The individual and interobserver reliability were not measured.
For those intubated before helicopter arrival, there was no attempt to identify the skill level of the provider who intubated the patient. A number of patients transported from other EDs were
Discussion
In this study, most of the patients intubated in the prehospital or ED setting experience elevated endotracheal intracuff pressures that require correction.
The first-generation endotracheal tubes required high pressures to seal the lumen. Since the end of the 1970s, high-volume, low-pressure tubes have replaced these tubes. These tubes have a wider support surface on the tracheal mucosa, and therefore the pressure exerted is lower. Despite this, these low-pressure cuffs can exert pressures
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2018, Journal of Perianesthesia NursingEndotracheal tube cuff pressures and tube position in critically injured patients on arrival at a referral centre: Avoidable harm?
2016, African Journal of Emergency MedicineCitation Excerpt :While this is a well-known fact, few prehospital, emergency centre or anaesthesia services use cuff-manometry as the standard of care. Studies in paramedic systems have consistently demonstrated cuff over-inflation in services not using routine cuff-pressure monitoring and part of the challenge lies in the varied recommended range of pressures that are considered acceptable (between 20 and 45 cm H2O).15,21,23,27,28 On balance, current evidence suggests that the MOV to obviate air-flow past the cuff, up to a maximum pressure of less than 25 cm H2O, is probably the safest practice to minimise high ETT cuff pressures when a manometer is unavailable.
Pneumothorax volume expansion in helicopter emergency medical services transport
2013, Air Medical JournalSubjective method for tracheal tube cuff inflation: performance of anesthesiology residents and staff anesthesiologists. Prospective observational study
2020, Brazilian Journal of AnesthesiologyAirway obstruction due to endotracheal tube's lumen collapse secondary to cuff
2011, Anesthesia and Analgesia
Presented at the 11th International Conference on Emergency Medicine, June 2006, Halifax, Nova Scotia.