Emergency medical service/airway/brief research report
Intracuff Pressures of Endotracheal Tubes in the Management of Airway Emergencies: The Need for Pressure Monitoring

https://doi.org/10.1016/j.annemergmed.2005.08.012Get rights and content

Study objective

Excessive pressure exerted on the tracheal mucosa is an avoidable factor implicated as a cause of damage after intubation of the trachea with cuffed tubes. Many patients are intubated in the out-of-hospital setting by emergency medical teams. The time spent in the out-of-hospital setting could very well be long enough for tracheal mucosal damage to occur if cuff pressure is not controlled. The objective of this study is to assess the incidence of intracuff excessive pressure in the out-of-hospital setting.

Methods

We performed an observational prospective study. Every patient who required tracheal intubation was included in the study, regardless of indication. When the patient was stabilized, the cuff was connected to a manometer, and pressure was systematically recorded. Corrections to inflation were performed if necessary to achieve a cuff pressure of 14 to 27 cm H2O.

Results

One hundred seven patients were included. Eighty-five were out-of-hospital patients and 22 were transfers between 2 hospitals who had been previously intubated when the mobile intensive care unit team arrived. The first recorded cuff pressures were greater than 27 cm H2O among 79% of patients (85/107), with a mean pressure of 56 cm H2O (SD±34 cm H2O) in out-of-hospital patients and 69 cm H2O (SD±37 cm H2O) for transferred patients. Pressure correction was made in 72% of patients (77/107). There were corrections in 69% (59/85) of out-of-hospital patients and 82% (18/22) of transferred patients.

Conclusion

This study revealed that the majority of cuff pressures exceeded safe pressure and required correction. Frequent measurement and adjustment of cuff pressure has been recommended, but this method requires a specific manometer.

Introduction

The endotracheal tube’s inflatable cuff should seal the airway, thus preventing aspiration of pharyngeal contents into the trachea, and it should ensure that there are no leaks past the cuff during positive pressure ventilation. At the same time, the pressure exerted by the inflated cuff on the trachea should not be so high that capillary circulation is compromised. Excessive pressure exerted on the tracheal mucosa is an avoidable factor that has been implicated as a cause of damage after intubation of trachea with cuffed tubes.1 Although the exact pathophysiology of postintubation airway symptoms is not fully elucidated, mucosal damage occurring at the cuff level is thought to be an important causative factor for tracheal morbidity.2 A cuff pressure greater than 30 cm H2O for 15 minutes was sufficient to induce histological evidence of tracheal mucosal lesions,3, 4, 5 which is probably the first step in development of mucosal damage or immediate complications such as tracheal rupture.6 Many patients are intubated in the out-of-hospital setting by emergency medical teams for respiratory distress. The time spent in the out-of-hospital setting may very well be long enough for tracheal mucosal damage to occur if cuff pressure is not controlled.

The objective of this study is to assess the incidence of cuff excessive pressure in the out-of-hospital setting.

Section snippets

Materials and methods

We performed an observational prospective study. This study was performed according to French ethics law (Loi Huriet), and because the procedure did not vary in any case from our standard clinical practice, neither specific informed consent nor ethics committee approval was required. One out-of-hospital emergency service using mobile intensive care units and located in an urban area participated in this study. In France, management of out-of-hospital medical emergencies is the responsibility of

Results

One hundred seven patients were included between January 1, 2003, and June 30, 2003. Eighty-five were out-of-hospital patients, and 22 patients were transferred between 2 hospitals and had been previously intubated when the mobile intensive care unit team arrived. Indications for intubation were alteration of consciousness (41%), cardiac arrest (29%), respiratory distress (16%), hemodynamic instability (10%), and other (4%). The first recorded cuff pressures were greater than 27 cm H2O among

Limitations

This study was not blinded. The operator knew that pressure was measured and knew the result of each pressure; therefore, he could change his procedure about cuff injected volume throughout the survey. This was a bias of this study.

There was no specific manufacturer instruction for calibration of the device. A progressive loss of accuracy of the device was therefore possible.

Discussion

This study showed that the majority of cuff pressures exceeded safe pressure and needed correction. Furthermore, this measurement was simple to do in the out-of-hospital setting. Although cuff pressure measurement is recommended in French guidelines about airway management, its use was unusual in our out-of-hospital emergency medical practice before this survey.7 It has been shown in humans that tracheal mucosal blood flow is impaired when cuff pressure increases above 30 cm H2O.3 Seegobin and

References (10)

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    Furthermore, a twofold to a threefold higher incidence of cuff underinflation was recorded in air-leakage techniques compared with the air-return method. In line with former findings, the limited published data are confirmatory of the high incidence of underinflation and risk of abundant microaspiration in the air-leak practices, being more pronounced in the MinVol technique.10,14,16 A survey conducted in an intensive care unit, which applied MinVol as the sole method for ETTc inflation, reported a marked risk of aspiration because of progressive cuff deflation involving most cases (93%), whereas loss of positive end-expiratory pressure or interference with mechanical ventilation and tube migration or extubation was recorded in 21% and 12% of the cases, respectively.16

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    The injection of air into the cuff with a syringe is still the most widely used method because it is simple, fast and cheap,15 but the relationship between the volume injected and the pressure detected in the tracheal wall (C-T pressure) is not linear and can cause the phenomena of overinsufflation, due to the distension of the cuff in 30–98% of the cases. This phenomenon depends on the type of tube used, the population studied and the clinical context.13–17 In normotensive patients, the tracheal wall capillary blood flow is compromised with a pressure of 30 cmH2O and blocked with a pressure of over 50 cmH2O.

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    These injuries range from mucosal tears, exposed cartilage to complete tracheal rupture. In addition, circumferential necrosis due to poor mucosal perfusion can occur as a result of an endotracheal tube that is too large or from overinflation of the tracheal cuff [9,10]. The type of treatment for these patients, conservative vs surgical, ultimately depends on the size and location of the tracheal tear as well as the condition of the patient.

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Supervising editors: Richard M. Levitan, MD; Robert K. Knopp, MD

Author contributions: MG and BG conceived the study and designed the survey. FA and FL provided advice on study design. MG analyzed the data. MG and SWB drafted the manuscript. VT and the other authors contributed to its revisions. MG takes responsibility for the paper as a whole.

Funding and support: The authors report this study did not receive any outside funding or support.

Reprints not available from the authors.

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