Intubation-related tracheal ischemic lesions: incidence, risk factors, and outcome

Touat, Lylia; Fournier, C.; Ramon, P; Salleron, Julia; Durocher, A.; Nseir, Saad

doi:10.1007/s00134-012-2750-6

Cited by 59 publications

(48 citation statements)

References 26 publications

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“…In addition, intubation-related tracheal injury contributes to health care costs via increased costs of care and length of hospitalization during the index admission and future costs for treatment and repair. 25 In a recent study, 26 83% of patients included in an randomized trial had at least 1 tracheal ischemic lesion. Yet, findings on fiber-optic tracheoscopy 2 weeks after intubation were normal in all except 1 patient, who experienced tracheal rupture.…”

Section: Discussionmentioning

confidence: 99%

Cuff Pressure of Endotracheal Tubes After Changes in Body Position in Critically Ill Patients Treated With Mechanical Ventilation

Lizy¹,

Swinnen²,

Labeau³

et al. 2014

American Journal of Critical Care

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Background In order to avoid microaspiration and tracheal injury, the target for endotracheal tube cuff pressure is 20 to 30 cm H 2 O. Objective To assess the effect of changes in body position on cuff pressure in adult patients. Methods Twelve orally intubated and sedated patients received neuromuscular blockers and were positioned in a neutral starting position (backrest, head-of-bed elevation 30º, head in neutral position) with cuff pressure at 25 cm H 2 O. Then, 16 changes in position were performed: anteflexion head, hyper extension head, left and right lateral flexion of head, left and right rotation of the head, semirecumbent position (head-of-bed elevation 45°), recumbent position (head-of-bed elevation 10°), horizontal backrest, Trendelenburg position (10°), and left and right lateral positioning over 30°, 45°, and 90°. Once a patient was correctly positioned, cuff pressure was recorded during an end-expiratory ventilatory hold. The pressure observed was compared with the cuff pressure at the starting position. Values outside the target range (20-30 cm H 2 O) were considered clinically relevant. Results A total of 192 measurements were performed (12 subjects x 16 positions). A significant deviation in cuff pressure occurred with all 16 changes (P < .05). No pressures were less than the lower limit (20 cm H 2 O). Pressures were greater than the upper limit (30 cm H 2 O) in 40.6% of the measurements. In each position, the upper target limit was exceeded at least once. Within-patient variability was substantial (P = .02). Conclusion Simple changes in patients' positioning can result in potentially harmful cuff pressures.

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Section: Discussionmentioning

confidence: 99%

Cuff Pressure of Endotracheal Tubes After Changes in Body Position in Critically Ill Patients Treated With Mechanical Ventilation

Lizy¹,

Swinnen²,

Labeau³

et al. 2014

American Journal of Critical Care

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“…A 2013 paper by Touat et al used tracheoscopy on newly extubated patients to evaluate the degree of injury with a tracheal ischemia score. They found that ETTCP > 30 cm H 2 O was associated with an elevated tracheal ischemia score 8. This demonstrates that the issue persists despite the introduction of modern high-volume, low-pressure cuffs.…”

Section: Discussionmentioning

confidence: 98%

“…Less severe complications related to over-inflation of ETT cuffs include hoarseness, sore throat and hemoptysis 8. More severe complications include post-intubation stridor,9 tracheal stenosis10 and even reports of tracheal rupture 11,12.…”

Section: Discussionmentioning

confidence: 99%

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Endotracheal Tube Cuff Pressures in Patients Intubated Prior to Helicopter EMS Transport

Tennyson

Ford-Webb

Weisberg

et al. 2016

WestJEM

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IntroductionEndotracheal intubation is a common intervention in critical care patients undergoing helicopter emergency medical services (HEMS) transportation. Measurement of endotracheal tube (ETT) cuff pressures is not common practice in patients referred to our service. Animal studies have demonstrated an association between the pressure of the ETT cuff on the tracheal mucosa and decreased blood flow leading to mucosal ischemia and scarring. Cuff pressures greater than 30 cmH2O impede mucosal capillary blood flow. Multiple prior studies have recommended 30 cmH2O as the maximum safe cuff inflation pressure. This study sought to evaluate the inflation pressures in ETT cuffs of patients presenting to HEMS.MethodsWe enrolled a convenience sample of patients presenting to UMass Memorial LifeFlight who were intubated by the sending facility or emergency medical services (EMS) agency. Flight crews measured the ETT cuff pressures using a commercially available device. Those patients intubated by the flight crew were excluded from this analysis as the cuff was inflated with the manometer to a standardized pressure. Crews logged the results on a research form, and we analyzed the data using Microsoft Excel and an online statistical analysis tool.ResultsWe analyzed data for 55 patients. There was a mean age of 57 years (range 18–90). The mean ETT cuff pressure was 70 (95% CI= [61–80]) cmH2O. The mean lies 40 cmH2O above the maximum accepted value of 30 cmH2O (p<0.0001). Eighty-four percent (84%) of patients encountered had pressures above the recommended maximum. The most frequently recorded pressure was >120 cmH2O, the maximum pressure on the analog gauge.ConclusionPatients presenting to HEMS after intubation by the referral agency (EMS or hospital) have ETT cuffs inflated to pressures that are, on average, more than double the recommended maximum. These patients are at risk for tracheal mucosal injury and scarring from decreased mucosal capillary blood flow. Hospital and EMS providers should use ETT cuff manometry to ensure that they inflate ETT cuffs to safe pressures.

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“…Previous study reported that HVLP cuffs are unable to be maintained at a stable low pressure during the entire period of intubation, such that in 73% of patients the cuff pressure becomes higher than the original pressure5. The incidence of ischemic tracheal lesions caused by HVLP cuffs varies from 31–95% of critical care patients, and 1–4% patients develop various degrees of tracheal stenosis after extubation678.…”

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confidence: 99%

A canine model of tracheal stenosis induced by cuffed endotracheal intubation

Zhou

et al. 2017

Sci Rep

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Postintubation tracheal stenosis is a complication of endotracheal intubation. The pathological mechanism and risk factors for endotracheal intubation-induced tracheal stenosis remain not fully understood. We aimed to establish an animal model and to investigate risk factors for postintubation tracheal stenosis. Beagles were intubated with 4 sized tubes (internal diameter 6.5 to 8.0 mm) and cuff pressures of 100 to 200 mmHg for 24 hr. The status of tracheal wall was evaluated by bronchoscopic and histological examinations. The model was successfully established by cuffed endotracheal intubation using an 8.0 mm tube and an intra-cuff pressure of 200 mmHg for 24 hr. When the intra-cuff pressures were kept constant, a larger sized tube would induce a larger tracheal wall pressure and more severe injury to the tracheal wall. The degree of tracheal stenosis ranged from 78% to 91% at 2 weeks postextubation. Histological examination demonstrated submucosal infiltration of inflammatory cells, hyperplasia of granulation tissue and collapse of tracheal cartilage. In summary, a novel animal model of tracheal stenosis was established by cuffed endotracheal intubation, whose histopathological feathers are similar to those of clinical cases of postintubation tracheal stenosis. Excessive cuff pressure and over-sized tube are the risk factors for postintubation tracheal stenosis.

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Intubation-related tracheal ischemic lesions: incidence, risk factors, and outcome

Abstract: Tracheal ischemic lesions are common in intubated, critically ill patients. Duration of assist-control mechanical ventilation through a tracheal tube is the only independent risk factor. These lesions healed in the majority of patients 2 weeks after extubation.

Cited by 59 publications

References 26 publications

Cuff Pressure of Endotracheal Tubes After Changes in Body Position in Critically Ill Patients Treated With Mechanical Ventilation

Cuff Pressure of Endotracheal Tubes After Changes in Body Position in Critically Ill Patients Treated With Mechanical Ventilation

Endotracheal Tube Cuff Pressures in Patients Intubated Prior to Helicopter EMS Transport

A canine model of tracheal stenosis induced by cuffed endotracheal intubation

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