Safeguarding Pediatric Airways: A Closer Look at Cuff Pressure Control Comparative Study of Insuflation Technique, Operator and Clinical Context
Main Article Content
http://orcid.org/0000-0002-7772-7561
Steven Osorio
Armando Pulido
Jaddy Bedoya
Abstract
Background: Proper insufflation of the tube cuff is critical in pediatric endotracheal intubation. However, the widespread use of subjective techniques for measuring cuff pressure by healthcare workers has raised concerns due to the potential for airway damage and subsequent impact on laryngotracheal tissue.
Objective: This study aims to evaluate tube cuff pressure variations based on operator expertise and clinical context among pediatric patients undergoing endotracheal intubation and compare the measurements obtained through subjective techniques with those obtained using an objective method involving a manometer.
Methods: This cross-sectional observational quantitative study obtained Institutional Ethics Committee approval and was conducted between October 2022 and January 2023. Descriptive statistics and frequency distributions were used for variable characterization. The Kolmogorov-Smirnov test assessed normality. A bivariate analysis employed chi-square tests and ANOVA, establishing a 95% confidence interval and significance level at p < 0.05.
Results: Seventy pediatric patients (mean age: 7.53 years) participated. Anesthesiology residents primarily performed intubation (28.6%), while tube cuff inflation was predominantly executed by nursing staff (38.6%), except within the intensive care unit where respiratory therapists assumed responsibility (20%). Manometric measurements indicated an average tube cuff pressure of 30.8 cm H2O (SD 17.4) across all scenarios. Notably, higher pressures were recorded in emergency contexts, with a statistically significant correlation between cuff pressure and insufflation personnel (P < 0.001), particularly evident when nursing staff was involved, with a mean difference of up to 18 cm H2O (P < 0.001). A statistically significant link existed between pressure levels and clinical context (P = 0.030).
Conclusion: This study underscores the discord between cuff pressures when measured by subjective techniques, highlighting the importance of objective manometric measurements. There is a necessity for comprehensive training of healthcare professionals working in surgical, emergency, and pediatric intensive care units, enabling them to proficiently utilize manometers for precise pressure evaluations that limit the risk of injury due to high pressures or aspiration and subsequent ventilator-associated pneumonia due to inadequate inflation.
Article Details
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
2. Ahmed RA, Boyer TJ. Endotracheal Tube. In: StatPearls. StatPearls Publishing; 2023. Accessed June 12, 2023. http://www.ncbi.nlm.nih.gov/books/NBK539747/
3. Am D, Jb S. Airway Management and Ventilator-Associated Events. Respir Care. 2019; 64 (8). doi:10.4187/respcare.07107
4. A OA, M Y van G, G D, Z H, E K, M U. Effect of patient position on endotracheal cuff pressure in mechanically ventilated critically ill patients. Aust Crit Care Off J Confed Aust Crit Care Nurses. 2017; 30(5). doi:10.1016/j.aucc.2016.11.006
5. Kumar CM, Seet E, Van Zundert TCRV. Measuring endotracheal tube intracuff pressure: no room for complacency. J Clin Monit Comput. 2021; 35 (1):3-10. doi:10.1007 /s10877-020-00501-2
6. Murugiah UR, Ramoo V, Jamaluddin MFH, et al. Knowledge acquisition and retention among nurses after an educational intervention on endotracheal cuff pressure. Nurs Crit Care. 2021; 26 (5):363-371. doi:10.1111/nicc.12600
7. Ramírez Y, Tripp FL, Sandoval L, Santana ÁD, Jiménez F. Assessment of cuff presure during general anesthesia in adult patients. Rev Médica Hosp Gen México. 2014; 77 (4):167-172. doi:10.1016/j.hgmx.2014.10.004
8. Vocal Cord Paralysis as a Complication of Endotracheal... : Journal of Craniofacial Surgery. LWW. doi:10.1097/SCS.0000000000005959
9. Tracheal stenosis due to endotracheal tube cuff hyperinflation: a preventable complication. Periodikos. Accessed November 5, 2022. http://www.autopsyandcasereports.org/article/doi/10.4322/acr.2018.072
10. Sevdi MS, Demirgan S, Erkalp K, et al. Continuous Endotracheal Tube Cuff Pressure Control Decreases Incidence of Ventilator-Associated Pneumonia in Patients with Traumatic Brain Injury. J Invest Surg. 2022; 35 (3):525-530. doi:10.1080/08941939.2021.1881190
11. López-Herranz GP. Intubación endotraqueal: importancia de la presión del manguito sobre el epitelio traqueal. Rev Médica Hosp Gen México. 2013; 76 (3):153-161.
12. Gj S, Jw W, Jk A, Sd B. Intraoperative Endotracheal Cuff Pressure Study: How Education and Availability of Manometers Help Guide Safer Pressures. Mil Med. 2018; 183 (9-10). doi:10.1093/milmed/usx127
13. Bulamba F, Kintu A, Ayupo N, et al. Achieving the Recommended Endotracheal Tube Cuff Pressure: A Randomized Control Study Comparing Loss of Resistance Syringe to Pilot Balloon Palpation. Anesthesiol Res Pract. 2017; 2017:e2032748. doi:10.1155/2017/2032748
14. Delgado Gómez FM, Athié García JM, Díaz Castillo CY. Evaluación de la presión del globo traqueal insuflado por técnica de escape mínimo en el Hospital Ángeles Mocel. Acta Médica Grupo Ángeles. 2017; 15(1):8-12. doi: 10.35366/70722
15. Atd Ö, C D, A B, I K, Şm A. Comparison of endotracheal tube cuff pressure values before and after training seminar. J Clin Monit Comput. 2018; 32(3). doi:10.1007/s10877-017-0046-7
16. In vitro evaluation of the method effectiveness to limit inflation pressure cuffs of endotracheal tubes. Braz J Anesthesiol Engl Ed. 2016; 66(2):120-125. doi:10.1016/j.bjane.2014.06.012
17. S B, R C, A L, P B, K K. Monitoring endotracheal tube cuff pressure using a blood pressure manometer. J Anaesthesiol Clin Pharmacol. 2022; 38(2). doi:10.4103/joacp.JOACP_406_19
18. Bloria SD. Identifying endotracheal tube (ETT) cuff hyperinflation without a manometer: a simple method. J Clin Monit Comput. 2021; 35(1):207-208. doi:10.1007/s10877-020-00498-8
19. Using a central venous pressure sensor for continuous monitoring of endotracheal tube cuff pressure. J Clin Anesth. 2021; 73:110300.doi:10.1016/j.jclinane.2021.110300
20. Jh K, Jj A, Y J, et al. Rapid Establishment of Tracheal Stenosis in Pigs Using Endotracheal Tube Cuff Overpressure and Electrocautery. Curr Med Sci. 2021; 41(2). doi:10.1007/s11596-021-2351-0
21. Wang R, Qin X, Zhou W, et al. The Relationship between Cuff Pressure and Air Injection Volume of Endotracheal Tube: A Study with Sheep Trachea Ex Vivo. Algalil FA, ed. Appl Bionics Biomech. 2022; 2022:1-10. doi:10.1155/2022/1748233
22. Sg K, M H, R S, Hl D, D T, Jd T. Cuffed endotracheal tubes in children: the effect of the size of the cuffed endotracheal tube on intracuff pressure. Paediatr Anaesth. 2017; 27(5). doi:10.1111/pan.13099
23. A L, P K, Pc S, N S, P RW, Mh K. Frequent Versus Infrequent Monitoring of Endotracheal Tube Cuff Pressures. Respir Care. 2018; 63(5). doi:10.4187/respcare.05926
24. F S, Yr J, S M, et al. Utility of Endotracheal Tube Cuff Pressure Monitoring in Mechanically Ventilated (MV) Children in Preventing Post-extubation Stridor (PES). Indian J Crit Care Med Peer-Rev Off Publ Indian Soc Crit Care Med. 2021; 25(2). doi:10.5005/jp-journals-10071-23737
25. Nazari R, Boyle C, Panjoo M, Salehpour-Omran M, Nia H, Yaghoobzadeh A. The changes of endotracheal tube cuff pressure during manual and intermittent controlling in intensive care units. Iran J Nurs Midwifery Res. 2020;25(1):71. doi:10.4103/ijnmr.IJNMR_55_19
26. Leung S, Chung A, Chan W, Tsui S. Case Series of Inflation Pressures of the Endotracheal Tube Cuffs among Intubated Patients at an Accident and Emergency Department in Hong Kong. Hong Kong J Emerg Med. 2016; 23(1):42-50. doi:10.1177/102490791602300105
27. R B. Endotracheal Tube Cuff Pressure Monitor: A Fancy Gadget or Necessary Tool in Intensivist’s Armamentarium. Indian J Crit Care Med Peer-Rev Off Publ Indian Soc Crit Care Med. 2021; 25(2). doi: 10.5005/jp-journals-10071-23742
28. Antwi-Kusi A, Boakye G, Awortwi WS. Endotracheal Cuff Pressures Generated by Different Members of the Anaesthesia Services in a Ghanaian Teaching Hospital. Open J Anesthesiol. 2013; 3(10):427-432. doi:10.4236/ojanes.2013.310089
29. Rw W, Dd G, S W, Ke R, Rd R. Endotracheal cuff pressures in the PICU: Incidence of underinflation and overinflation. Can J Respir Ther CJRT Rev Can Ther Respir RCTR. 2020; 56. doi: 10.29390/cjrt-2019-018
30. Miranda JE, Herrera M, Villalobos M, Rodríguez L, Jiménez E. Lesiones traqueales por intubación prolongada y su relación con la presión del balón del tubo endotraqueal. Med Leg Costa Rica. 2001; 18(1):23-28.
31. Tracheal Injuries Complicating Prolonged Intubation and Tracheostomy - ClinicalKey. Accessed November 5, 2022. https://clinicalkey.cesproxy.elogim.com/#!/content/playContent/1-s2.0-S154741271830001X?returnurl=null&referrer=null
32. B V, Mj K, G K, L R. Under or overpressure: an audit of endotracheal cuff pressure monitoring at the tertiary care center. Acute Crit Care. 2021; 36(4). doi:10.4266/acc.2021.00024
33. Kebapci A, Ozkaynak M. Endotracheal Tube Cuff Pressure Management: An Observational Study Guided by the SEIPS Model. Dimens Crit Care Nurs. 2022; 41(2):64-75. doi:10.1097/DCC.0000000000000512