Endotracheal cuff pressures in the PICU: Incidence of underinflation and overinflation

Abstract

Background: While uncuffed endotracheal tubes have been traditionally used in the pediatric intensive care unit (PICU) population, evidence suggests cuffed endotracheal tubes (ETTs) are also safe to use within this population. Nevertheless, risks related to the use of cuffed ETTs increase when guidelines for safe and appropriate use are not followed. The primary goal of this study was to measure the cuff pressure (CP) using a cuff pressure manometer in a group of intubated pediatric subjects and determine the rate of cuff underinflation (<20 cm H 2 0) or overinflation (>30 cm H 2 0). The secondary aim was to determine whether CP was associated to gender, age, ETT size, and PICU length of stay prior to CP measurement. Methods: This was a prospective observational study conducted in an urban PICU. Pediatric subjects intubated with cuffed ETTs from 1 April 2017 to 1 May 2017 were included in the study. ETT CPs were measured daily to determine degree of inflation and compared according to gender, age, ETT size, and number of days intubated prior to CP measurement. Descriptive data are expressed as means and standard deviations. A two-sample t test was used to compare groups according to age, gender, and number of days present. And significance was considered with a P < 0.05. Pearson chi test was used to evaluate correlation between CPs and size of the ETT, number of days intubated prior to CP measurement, gender, and age. Results: Twenty pediatric subjects admitted during the study period were included for analysis. Eleven cuff measurements were found to be within normal limits, while 9 cuff measurements were found to be underinflated. No cases of overinflation were found. There were no significant associations between CP and size of the ETT (r = -0.08), number of days intubated prior to CP measurement (r = 0.19), gender (r = 0.09), and age (r = 0.12). Conclusions:Our study suggests that endotracheal cuff underinflation occurs often in the PICU population. Strategies to ensure appropriate ETT CPs are maintained are essential in the intubated pediatric population. Additional studies are necessary to develop interventions and training focused on the use of a cuff pressure manometer to measure CPs in the PICU by respiratory therapists and ensure consistent measurement using inter rater evaluation processes are needed.

AARC Clinical Practice Guideline: Management of Pediatric Patients With Tracheostomy in the Acute Care Setting

“…26 Although there remains a paucity of clinical data, an intracuff pressure of 20-30 cm H 2 O sufficiently creates a seal, which reduces risk for microaspiration. 27,28 Complications associated with excessive cuff pressure mirror those reported in the literature for cuffed endotracheal tubes, such as tracheal necrosis, tracheal rupture, and tracheomegaly. 29,30 Pressure exerted by the cuff on the tracheal wall depends on the child's anatomical features and is also affected by positional changes.…”

Intermittent versus continuous control of tracheal cuff pressure in patients undergoing mechanical ventilation: A systematic review and meta‐analysis

“…This is because the intervention of the trachea damages the function of the airway to exclude foreign bodies, causing respiratory secretions to gather above the cuff. When the cuff is underflated, the accumulated secretions above the cuff flows down the gap into the airway, causing aspiration (Parsian et al, 2019; Wettstein et al, 2019). A previously published meta‐analysis (Ying et al, 2016) has found that continuous monitoring of cuff pressure is beneficial to reduce the incidence of aspiration and VAP, which is similar to the results of this study.…”

Endotracheal Tube Cuff Pressure Monitor: A Fancy Gadget or Necessary Tool in Intensivist&#39;s Armamentarium

“… 4 , 5 In a prospective observational study, Wettstein et al found that cuff underinflation is an essential phenomenon in PICU patients. 6 The above fact highlights the importance of standard guidelines for monitoring cuff pressure in critically ill intubated pediatric patients. The various traditional monitoring methods are minimal leak technique, manual palpation of the pilot balloon, bedside manometry, and direct intracuff monitoring.…”