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Endotracheal intracuff pressures in the ED and prehospital setting: is there a problem?

https://doi.org/10.1016/j.ajem.2006.09.001Get rights and content

Abstract

Introduction

Cuffed endotracheal tubes are used to prevent gas leak and also pulmonary aspiration in ventilated patients. The pressure exerted on the tracheal wall is similar to intracuff pressure. The perfusion pressure for the tracheal mucosa is 40 cm H2O. Cuff pressures greater than 40 cm H2O may cause various ischemic changes and complications. High cuff pressures have also been implicated in postoperative sore throat and nonischemic complications. Postintubation endotracheal tube cuff pressures are not routinely measured in the ED or prehospital setting. The time spent in these settings may be long enough for pressure-induced tracheal mucosal injury to occur. The purpose of this study is to assess cuff pressures in intubated patients before aeromedical transport.

Methods

All intubated patients transported by an aeromedical transport program during a 3-month period were included in this study. Patients were intubated either by helicopter physicians or before helicopter arrival at the referring hospital or by ambulance personnel. Cuff pressure was measured using a manometer (Cuffpressure, Posey Co, USA). This measurement was recorded, and correction was performed, if necessary, to achieve a cuff pressure of 14 to 27 cm H2O while preventing an air leak. Data were analyzed for the distribution of intracuff pressures and incidence of elevated pressure on first measurement and the need for correction.

Results

There were 62 patients in this study. The mean first recorded pressure was 63 ± 34 cm H2O. Initial cuff pressures were greater than 40 cm H2O in 36 (58%) patients and required correction.

Conclusions

In this study, most cuff pressures exceeded safe pressure and required correction. Measurement of intracuff pressure is a simple and inexpensive procedure and should be done whenever a patient is intubated, in either the prehospital or hospital setting, because this may reduce long-term morbidity.

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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Cited by (44)

  • Endotracheal tube cuff pressures and tube position in critically injured patients on arrival at a referral centre: Avoidable harm?

    2016, African Journal of Emergency Medicine
    Citation 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.

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Presented at the 11th International Conference on Emergency Medicine, June 2006, Halifax, Nova Scotia.

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