Children are sometimes transported via fixed or rotary wing aircraft for medical care. If they are intubated with a cuffed endotracheal tube (ETT), changes in environmental pressure during transport can alter cuff pressure. Cuff management in this setting varies widely by region and by organization. In this historical review, we sought to delineate the evolution of ETT cuff management in children undergoing aeromedical retrieval in order to progress the field toward an optimum strategy in the future.

Problems with extremely high ETT cuff pressures in adults due to altitude gain were identified by the 1970s. During subsequent decades, this topic was the subject of fervent research and device development, with a relative waning in interest more recently. Children, being transported less frequently and almost always with non-cuffed ETTs, were not included in these research efforts. During a similar epoch, the field of hyperbaric medicine also recognized the issue of ETT cuff pressure changes and almost uniformly changed to cuff insufflation with an incompressible liquid. This was based on cuff pressure measurements and deductive reasoning, rather than on evidence from patient outcome trials. Aeromedical retrieval has not consistently adopted this technique. Further investigation and discussion on an optimum strategy of cuff management in aeromedical transport of children is needed to reach an agreement on best practice.

Elevated endotracheal tube (ETT) cuff pressures during surgery can lead to tracheal ischemia and airway complications, including postoperative sore throat, subglottic edema, and tracheal stenosis. The insertion of a transesophageal echocardiography (TEE) probe, commonly used in cardiac surgeries, may increase ETT cuff pressure due to its proximity to the trachea. This study assesses the impact of TEE probe insertion on ETT cuff pressures and related postoperative airway complications in patients undergoing coronary artery bypass graft (CABG) surgery.

In this prospective, randomized controlled trial, 40 patients undergoing CABG were assigned to either a control group (Group C, n = 20) or an intervention group (Group T, n = 20). Cuff pressures were monitored at baseline (T1), during TEE probe manipulation (T2), after initial examination (T3), and during recovery (T4). In Group T, cuff pressures were adjusted to 20-30 cmH2O if they exceeded 30 cmH2O during T2 and T3. Postoperative complications, including sore throat, hoarseness, and cough, were assessed using standardized scales.

TEE probe manipulation significantly increased ETT cuff pressures in both groups, with lower pressures consistently observed in Group T (P < 0.05). At T3, the mean cuff pressure in Group C was 41.00 cmH2O versus 33.30 cmH2O in Group T (P < 0.001). The control group experienced more severe postoperative airway complications, while Group T had a significantly reduced risk of severe complications (odds ratio < 0.2).

TEE probe manipulation significantly increases ETT cuff pressures, but cuff deflation during manipulation effectively reduces these pressures and lowers the risk of postoperative airway complications.

Excessive cuff pressure can lead to complications associated with endotracheal intubation. This study aims to compare the effects of cuff inflation guided by a pressure indicator versus the tactile estimation method on postoperative airway-related complications in neurosurgical patients.

This study employed a prospective, randomized, double-blind, controlled design. Blinding was implemented for the subjects and data collectors. Subjects were randomly divided into two groups. The intervention group used tracheal tubes with pressure indicators. The control group used standard reinforced tracheal tubes. The primary outcome measure was the score of tracheal mucosal injury in two groups of subjects under bronchoscopy assistance with extubation. Secondary outcome measures included: (1) the incidence of tracheal mucosal injury assessed by bronchoscopy at the time of extubation; (2) the incidence of blood-stained cuff during extubation; (3) the incidence and severity of sore throat, and the incidence of hoarseness, blood-stained sputum, and coughing at 1 h and 24 h post-extubation.

The intervention group demonstrated a significantly lower tracheal mucosal injury score before extubation compared to controls (1.4 ± 0.274 vs. 2.7 ± 0.335; P = 0.009). There were no significant differences in immediate post-extubation complications or short-term (1-hour) postoperative symptoms. Notably, while the majority of 24-hour post-extubation outcomes remained comparable between groups, the intervention group exhibited significantly reduced sore throat severity at this timepoint (P = 0.044).

The use of tracheal tubes with pressure indicators to control intraoperative cuff pressure could reduce postoperative airway mucosal damage in neurosurgical patients and alleviated post-extubation pharyngeal pain after 24 h.

ChiCTR2200065315, first registered on 02/11/2022. The study was retrospectively registered.

Orotracheal intubation is commonly performed for inhalation anaesthesia in horses to ensure safe and reliable administration of volatile anaesthetics and to secure the airways. In human and equine medicine, the occurrence of intubation-associated complications has been described, which can range from mild mucosal irritation to severe necrosis. However, there are only sparse descriptions of mucosal alterations and the course of healing after elective surgery in horses.

To investigate the prevalence and severity of tracheal lesions following endotracheal intubation associated with general anaesthesia in equine patients.

Prospective, clinical study.

Forty adult Warmblood horses, weighing 400-600 kg, presented for elective surgery under general anaesthesia were included. For orotracheal intubation, a silicone tube was used and inflated until a cuff pressure of 40 cmH2O was confirmed. In all horses, endoscopic examination of the trachea with video documentation was performed prior to intubation and immediately after extubation, as well as 1, 3, 5 and 7 days after general anaesthesia. The type (redness, secretion, bleeding, erosions) and degree (0 = non-existent to 4 = severe) of corresponding lesions were assessed and scored. The occurrences of clinical signs were recorded. Statistical evaluation was performed using Friedman's test and Pearson correlation.

The median score immediately after recovery from anaesthesia was 6 (2-12) and increased significantly to 11 (4-15) after 1 day (p = 0.021). At day 7, the median score was 0 (0-2) with only four horses showing signs of mild tracheitis, and clinical signs were not observed throughout this time period. The duration of intubation correlated with the degree of tracheal damage (r2 = 0.67, p < 0.001).

Clinical, non-randomised study without a control group.

Although orotracheal intubation was accompanied by focal inflammation of the trachea, in the present study no horses showed clinical signs and lesions healed within a week.

Post-intubation and post-tracheostomy tracheal stenoses are relatively uncommon common complications of prolonged intubation. Patients with tracheal stenosis usually present with stridor and dyspnea once a significant portion of their airway is compromised. Tracheal resection and reconstruction offer durable treatment options for these patients with minimal risk once initial endoscopic treatment has failed.

Postoperative sore throat (POST) is a common complication following endotracheal tube removal, and effective preventive strategies remain elusive. This trial aimed to determine whether actively regulating intraoperative cuff pressure below the tracheal capillary perfusion pressure threshold could effectively reduce POST incidence in patients undergoing gynecological laparoscopic procedures.

This single-center, randomized controlled superiority trial allocated 60 patients scheduled for elective gynecological laparoscopic procedures into two groups: one designated for cuff pressure measurement and adjustment (CPMA) group, and a control group where only cuff pressure measurement was conducted without any subsequent adjustments. The primary outcome was POST incidence at rest within 24 h post-extubation. Secondary outcomes included cough, hoarseness, postoperative nausea and vomiting (PONV) incidence, and post-extubation pain severity.

The incidence of sore throat at rest within 24 h after extubation in the CPMA group was lower than in the control group, meeting the criteria for statistically significant superiority based on a one-sided test (3.3% vs. 26.7%, P < 0.025). No statistically significant differences were observed in cough, hoarseness, or pain scores within 24 h post-extubation between the two groups. However, the CPMA group had a higher incidence of PONV compared to the control group. Additionally, the control group reported higher sore throat severity scores within 24 h post-extubation.

Continuous monitoring and maintenance of tracheal tube cuff pressure at 18 mmHg were superior to merely monitoring without adjustment, effectively reducing the incidence of POST during quiet within 24 h after tracheal tube removal in gynecological laparoscopic surgery patients.

The study was registered at www.chictr.org.cn (ChiCTR2200064792) on 18/10/2022.

The optimal endotracheal tube (ETT) cuff pressure remains contentious. In the traditional consideration that the level 30 cmH2O is considered safe, balancing the prevention of reflux aspiration against airway mucosal damage. Whether this pressure level can cause potential damage to the airway mucosa remains to be discussed.

Airway mucosa damage and structural changes at 30 cmH2O were examined in patients under general anesthesia and in rabbit mechanical ventilation models. Prior to this, we also interviewed some anesthesiologists about the level of concern about ETT cuff pressure.

A total of 634 valid questionnaires suggested that anesthesiologists generally do not pay enough attention to ETT cuff pressure and the average established cuff pressure significantly exceeded 30 cmH2O. Airway mucosa images of 100 general anesthesia patients with different ventilation duration indicated that maintaining the pressure at 30 cmH2O did not cause significant damage to airway mucosa in a short period of time, while it still caused damage to airway mucosa in patients with long-term ventilation, with damage severity increasing with longer ventilation periods. This correlated strongly with postoperative sore throat (R 2 = 0.3884, p < 0.001). In rabbits, 4 h of ventilation at this pressure resulted in significant loss of ciliated epithelium and inflammation. Calculations suggested an effective dose (ED50) to prevent mucosal injury at a cuff pressure of 25.64 cmH2O (95% CI: 19.268-29.367 cmH2O).

The currently established cuff pressure of 30 cmH2O is associated with airway mucosal damage in both clinical and animal models. Lowering the safety threshold of cuff pressure may be necessary to mitigate mucosal injury.

Laparoscopic surgery is a popular alternative for resection of colorectal neoplasms. Carbon dioxide pneumoperitoneum and Trendelenburg positioning in procedure can significantly increase airway pressure, when endotracheal tube cuff pressure is not monitored. This prospective observational study aimed to evaluate indicators, changes and its correlation factors of endotracheal tube cuff pressure during laparoscopic resection of colorectal neoplasms.

122 patients scheduled for laparoscopic resection of colorectal neoplasms under propofol/remifentanil total intravenous anesthesia with orotracheal intubation were included. Tracheal tube cuff pressure was monitored continuously by calibrated pressure transducers. The ability of several predictors to predict out-of-range tracheal tube cuff pressure at different time points and its correlation factors were assessed.

ROC analysis showed that waist-to-hip ratio has the highest AUC for predicting out-of-range tracheal cuff pressure (AUC: 0.86 [95% CI: 0.77-0.95]); Tracheal tube cuff pressure provided by palpation was 41.0 (29.0-53.3) cmH20. Cuff pressure was 33.7 ± 2.9 cmH20 at 15 min and comparable at 30 and 45 min after insufflation, all values were significantly higher than 25 cmH20 (p < 0.001). Multiple linear regression showed tracheal tube cuff pressure was associated with peak airway pressure (p < 0.001).

Patients with normal BMI undergoing laparoscopic resection of colorectal neoplasms require continuous monitoring and timely adjustments of tracheal tube cuff pressure. Compared with BMI, waist-to-hip ratio is a better predictor of out-of-range tracheal tube cuff pressure.

Chinese Clinical Trial Registry, identifier: ChiCTR2100054089, Date: 08/12/2021.

Postoperative sore throat (POST) is a common complaint after general anesthesia. POST is defined by the presence of a self-reported foreign body sensation or a painful sensation in the throat after general anesthesia. This condition may affect recovery and patient satisfaction and is associated with many factors, including intubation tools. Previous studies have reported conflicting results on POST. This retrospective cohort study, with sample size of 9,881 patients, was conducted to confirm the hypothesis that the use of video laryngoscopy (VL) is associated with a lower incidence of POST compared with direct laryngoscopy (DL).

Data were extracted from a prospectively maintained quality improvement database. A total of 9,881 patients were included in the study. Statistical analysis was conducted for comparisons of demographic characteristics and to determine the effect of intubation tools on the incidence of POST.

The patients had similar baseline demographic characteristics. Compared with DL, VL was associated with a lower incidence of POST (12.98% vs. 17.49%, P < 0.001). In addition, the use of Pentax Airway Scope (AWS) was associated with a lower incidence of POST compared with the use of GlideScope (GVL, 8.14% vs. 16.25%, P < 0.001). To better adjust for possible confounding factors, mixed-effects generalized linear model analysis revealed that older age (odds ratio [OR]: 0.995, 95% confidence interval [CI]: 0.992-0.999, P = 0.006), AWS compared to DL (OR: 0.416, 95% CI: 0.350-0.494, P < 0.001), and male sex (OR: 0.836, 95% CI: 0.747-0.935, P = 0.002) are associated with reduced incidence of POST.

Compared with DL, VL is associated with a lower incidence of POST. In addition, the use of AWS is associated with a lower incidence of POST compared with the use of GVL.

Retrospectively registered, NCT06515808, date of registration: 23/07/2024.

The cuff of endotracheal tube (ETT) is an indispensable device for establishing an artificial airway, yet cuff-induced compression often causes damage to the airway mucosa. The mechanism of this damage involves mucosal compression ischemia and the oxidative stress injury following reperfusion. Currently, there is a lack of effective strategies to protect the mucosa. Hydrogen, as a natural antioxidant, has demonstrated significant potential in the prevention and treatment of oxidative stress injuries. This study aimed to determine the protective effects of hydrogen on compressed airway mucosa. We found that the damage to the airway mucosa caused by ETT cuff compression was associated with oxidative stress-induced pyroptosis of airway epithelial cells. Inhalation of hydrogen effectively reduced the levels of reactive oxygen species, significantly ameliorating changes in epithelial cell pyroptosis, and this protective effect is linked to the inhibition of the NLRP3-GSDMD pathway. Further cellular studies, involving knockdown and overexpression of NLRP3, clarified that hydrogen exerts its protective effects on the airway mucosa by inhibiting epithelial cell pyroptosis. Additionally, we observed that using hydrogen-rich saline to inflate the ETT cuff in patients under general anesthesia significantly reduced postoperative sore throat. This study confirms that hydrogen effectively enhances tolerance of airway mucosa to oxidative stress injuries, offering a potential preventive and therapeutic strategy for protecting the airway mucosa in patients undergoing endotracheal intubation.

Assessment of the effect of continuous cuff pressure control on airway injury in middle-aged and elderly patients undergoing endoscopic submucosal dissection (ESD).

A total of 104 eligible middle-aged and elderly patients requiring esophageal ESD from July 2022-September 2023 at the First Affiliated Hospital of Nanchang University were selected and randomly divided into two groups: the group undergoing general anesthesia tracheal intubation with continuous control of cuff pressure after intubation (Group A, n = 51) and the group undergoing general anesthesia tracheal intubation with continuous monitoring without control of cuff pressure (Group B, n = 53). After endotracheal intubation in Group A, under the guidance of an automatic cuff pressure controller, the air was used to inflate the tracheal cuff until the cuff pressure was 25-30cmH2O. The cuff pressure after intubation was recorded, and then the cuff pressure parameters were directly adjusted in the range of 25-30cmH2O until tracheal extubation after the operation. After endotracheal intubation, patients in Group B inflated the tracheal cuff with clinical experience, then monitored and recorded the cuff pressure with a handheld cuff manometer and instructed the cuff not to be loosened after being connected to the handheld cuff manometer-continuous monitoring until the tracheal extubation, but without any cuff pressure regulation. The patients of the two groups performed esophageal ESD. The left recumbent position was taken before the operation, and the cuff's pressure was recorded. Then, insert the gastrointestinal endoscope to find the lesion site and perform appropriate CO2 inflation to display the diseased esophageal wall for surgical operation fully. After determining the location, the cuff pressure of the two groups was recorded when the cuff pressure was stable. After the operation, the upper gastrointestinal endoscope was removed and the cuff pressure of the two groups was recorded. Postoperative airway injury assessment was performed in both groups, and the incidence of sore throat, hoarseness, cough, and blood in sputum was recorded. The incidence of postoperative airway mucosal injury was also observed and recorded in both groups: typical, episodic congestion spots and patchy local congestion.

The incidence of normal airway mucosa in Group A was higher than that in Group B (P < 0.05). In comparison, the incidence of occasional hyperemia and local plaque congestion in Group A was lower than in Group B (P < 0.05).

Continuous cuff pressure control during operation can reduce airway injury in patients with esophageal ESD and accelerate their early recovery after the operation.

Endotracheal intubation is a frequently performed procedure in anesthesia practice, and ensuring the correct inflation of the cuff is essential for maintaining the airway seal. Overinflation of endotracheal tube (ETT) cuffs can lead to complications, such as postoperative sore throat. This study aimed to compare the incidence of elevated ETT cuff pressure between saline and air inflation in elective laparoscopic abdominal surgery.

The study involved 60 participants ranging in age from 18 to 65, with American Society of Anesthesiologists physical status levels 1-2, who underwent laparoscopic abdominal surgery. We randomly assigned patients to two groups: Group A (air-filled ETT cuffs, N.=30) and Group S (saline-filled ETT cuffs, N.=30). Intra-cuff pressure was recorded before and after CO2 insufflation, as well as during changes in patient position. The number of interventions to restore intra-cuff pressure to 18 mmHg was documented. Peak airway pressure, plateau pressure, and positive end-expiratory pressure (PEEP) were measured at 15-minute intervals.

The number of interventions needed to maintain intra-cuff pressure was significantly lower in the saline group compared to the air group. All patients started with initial cuff pressures above 20 mmHg. After insufflation, the first-minute cuff pressures were higher in the air group (P=0.001). Both groups experienced a significant increase in intra-cuff pressure with the Trendelenburg position, and after moving to the reverse Trendelenburg position (saline and air groups, P=0.001 and 0.012, respectively), the air group had higher intra-cuff pressure than the saline group (P=0.002). There were no significant differences between groups in peak airway pressure, plateau pressure, and PEEP.

Inflating ETT cuffs with saline instead of air during laparoscopic abdominal surgeries led to a reduced requirement for interventions in maintaining pressure. This indicates that the use of saline inflation may significantly lower the risk of high cuff pressure and related complications.

The endotracheal tube (ETT) contains a cuff that is placed in the trachea to prevent gas leakage and aspiration of secretions and gastric contents. However, patient positioning after intubation may cause ETT displacement and changes in cuff pressure.

Evaluate the effect of different patient positions on ETT cuff pressure in patients undergoing urological procedures in supine, prone, lateral flank, and lithotomy positions.

Prospective and observational study.

A university hospital in Turkey.

Patients who underwent surgeries under general anesthesia in different patient positions were involved. After intubation (T0), the cuff pressure was checked with a manometer and adjusted to 25 cmH2O and continuously monitored. The cuff pressure was checked before (T1) and after achieving the final position (T2) and then at 5, (T3), 10, (T4), 15 minutes (T5) of the position, at the end of the procedure (T6) and before extubation (T7). At postoperative 2nd and 12th hours, the patients were interviewed for sore throat, hoarseness, and cough.

The effect of different patient positions on the ETT cuff pressure.

200 patients.

The cuff pressure increased significantly at T2 in the lithotomy, lateral flank, and prone groups (P<.001 each). The highest increase in cuff pressure occurred in the prone group (34.3 [7.5] cmH2O). Over time, the cuff pressure decreased in all groups during surgery. Postoperative complications at the 2nd postoperative hour were similar in all groups; however, the mean cuff pressure was significantly higher in the patients with postoperative sore throat or cough (sore throat: P=.003; cough: P=.047).

ETT cuff pressures are affected by different patient positioning; therefore, regular recording and adjustment of cuff pressure are necessary for patient safety.

We used ETT of a single manufacturer. Therefore, our findings may not be applicable to other types of ETT.

Postoperative sore throat is one of the main postoperative complaints in patients undergoing tonsillectomy. As the primary outcome, we aimed to determine whether endotracheal tube cuffs filled with alkalinized lidocaine are associated with a lower incidence of postoperative sore throat and anesthesia emergence phenomena in children undergoing tonsillectomy or adenotonsillectomy. We also assessed the potential additional benefits of IV dexamethasone in reducing postoperative laryngotracheal morbidity.

This is a clinical prospective, randomized, controlled trial. Patients were randomly allocated to one of four groups, as follows: air - endotracheal tube cuff filled with air; air/dex - endotracheal tube cuff filled with air and intravenous dexamethasone; lido - endotracheal tube cuff filled with alkalinized lidocaine; and lido/dex - endotracheal tube cuff filled with alkalinized lidocaine and intravenous dexamethasone. Perioperative hemodynamic parameters and the incidence of postoperative nausea and vomiting, coughing and hoarseness were recorded. Postoperative sore throat was assessed in the postanesthetic care unit and 24 hours post tracheal extubation.

In total, 154 children aged 4-12 years, ASA physical status I or II, undergoing general anesthesia for elective tonsillectomy and adenotonsillectomy, were assessed for postoperative sore throat in this study. The incidence of postoperative sore throat 24 hours after tracheal extubation was significantly lower in the lido/dex group compared to groups air and air/dex (p = 0.01). However, no additional reduction in these symptoms was observed from the intravenous administration of dexamethasone when comparing the lido and lido/dex groups. Similarly, there were no differences among groups regarding perioperative hemodynamic variables or postoperative nausea and vomiting, coughing, and hoarseness during the study period.

Intracuff alkalinized lidocaine, associated with intravenous dexamethasone, might be effective in reducing sore throat 24 hours post-tonsillectomy or adenotonsillectomy in children when compared to the use of air as the cuff insufflation media.

Accurate management of endotracheal tube cuff pressure is essential to prevent patient morbidity and mortality. Due to increased length of stay of critically ill patients in emergency departments, it has become an increasingly important skill among Emergency Department nurses.

This prospective longitudinal interventional study was performed among registered nurses at the emergency departments in a Johannesburg Academic Hospital. The study aimed to determine their current knowledge and practical skills on endotracheal tube cuff manometry and assess the effectiveness of a training program. The training program was provided once, in the form of a narrated PowerPoint presentation developed by the researchers and involved theoretical and practical components. The participants' theoretical knowledge and practical skills were measured by using questionnaires and skill assessments. The theoretical and practical scores were compared pre- and post-training.

Of the 63 registered nurses employed in the emergency departments, 95 % (60) participated in this study. 86 % reported having never received any formal training on endotracheal tube cuff manometry. Only 38.9 % used cuff manometry as standard practice and only 12.8 % checked it at appropriate 12-hourly intervals. The pre-training median score on theory was 4.5 (IQR=3.0) and improved to 7.0 (IQR=3.0) post-training. The maximum achievable score was 11 with a pre-training average of 41.8 % and post-training of 64.5 % (p = 0.001).The practical pre-training median score was 1.0 (IQR=8.0) and improved to 12.0 (IQR=2.0) post-training. The maximum achievable score was 12 with a pre-training average of 29.1 % and a post-training average of 93.3 % (p = 0.001).

This study showed inadequate knowledge and skills on endotracheal cuff pressure manometry among registered nurses in the emergency department. It also correlates with other evidence that supports the need for ongoing training programs. Our training program led to significant improvement among participants in both knowledge and practical skills. This training program was well received by participants and deemed to be practice changing. The recommendation after this study will be for South African emergency units to consider using this study and training material as a guide for annual in-service training.

Background Endotracheal tube (ETT) cuff pressure changes during general anesthesia. Endotracheal cuff pressure ideally should be maintained between 20 and 30 cm of H2O. Cuff pressure of less than 25 cm of H2O increases the chances of aspiration while pressure of more than 40 cm of H2O causes tracheal mucosa damage. The study aimed to monitor and compare variations of endotracheal cuff pressure during general anesthesia with oxygen-air or oxygen-nitrous oxide. Methods This prospective, randomized, double-blinded, observational study was conducted on 40 patients. After approval from the institutional ethics subcommittee, 40 patients of either gender, aged 18-60 years, belonging to ASA grades I and II, who were undergoing elective surgery under general anesthesia, were enrolled in this study. The patients were randomly divided into two groups, with 20 in each group. In Group A, oxygen-air and Group N, oxygen-nitrous oxide was used as a gaseous mixture in general anesthesia with ETT. The ETT cuff pressure was recorded with the help of a cuff manometer at intervals of five, 10, 20, 30, 40, 50, 60, 70, 80, and 90 minutes after intubation. If pressure was more than 40 cm of H2O, it was reduced to 25-30 cm of H2O. Data were collected and analyzed using methods described in Primer of Biostatistics by Stanton A. Glantz. Quantitative data were analyzed using the Student's t-test. Qualitative data were analyzed using the chi-square test. Results An increase in cuff pressure was noted more in Group N as compared to Group A. The pressure in the endotracheal cuff started to gradually increase after 30-40 minutes in Group N after intubation, while in Group A, there was no significant increase. The average number of times the cuff deflated was 0.2 ± 0.41 in Group A and 1.55 ± 0.51 in Group N, which was highly significant. Conclusion Changes in endotracheal cuff pressure were observed when using different gas mixtures for inflation. Specifically, cuff pressure increased with oxygen and nitrous oxide compared to oxygen with air. This suggests that anesthetic gas composition can impact cuff pressure, potentially affecting tracheal mucosal perfusion and patient safety. Therefore, regular monitoring and adjustment of cuff pressure is crucial, especially when using nitrous oxide, to prevent complications and ensure optimal patient care.

The use of cuffed endotracheal tubes (ETTs) has become the standard of care in pediatric practice. The rationale for the use of a cuffed ETT is to minimize pressure around the cricoid while providing an effective airway seal. However, safe care requires that the cuff lie distal to the cricoid ring following endotracheal intubation. The current study demonstrates the capability of computed tomography (CT) imaging in identifying the position of the cuff of the ETT in intubated patients.

The study included patients ranging in age from 1 month to 10 years who underwent neck and chest CT imaging that required general anesthesia and endotracheal intubation. The location of the ETT and of the cuff within the airway was determined from axial CT images at three levels (proximal, middle, and distal). Anatomical orientations were tabulated, and percent chances of each orientation were determined for the ETT and the cuff.

The study cohort included 42 patients ranging in age from 1 to 114 months. An ETT with a polyvinylchloride cuff was used in 24 patients, and an ETT with a polyurethane cuff was used in 18 patients. The ETT was located near the posterior wall of the trachea in approximately 24-38% of patients, being most likely to be centrally located at the proximal end and at its mid-portion. The middle part of the cuff was most likely to be positioned in the mid-portion of the trachea but tended to skew anteriorly at both the proximal and distal ends.

This is the first study using CT imaging to identify the uniformity of cuff inflation within the trachea in children. With commonly used cuffed ETTs, cuff inflation and the final position of ETT cuff within the tracheal lumen were not uniform. Future investigations are needed to determine the reasons for this asymmetry and its clinical implications.

Appropriate selection of double-lumen tube sizes for one-lung ventilation is crucial to prevent airway damage. Current selection methods rely on demographic factors or 2D radiography. Prediction of left bronchial diameter is indispensable for choosing the adequate tube size. This prospective observational study investigates if current selection methods sufficiently predict individuals' left bronchial diameters for DLT selection compared to the 3D reconstruction.

100 patients necessitating thoracic surgery with one-lung ventilation and left-sided double-lumen tubes, ≥ 18 years of age, and a set of chest X-rays and 2D thorax CT scans for 3D reconstruction of the left main bronchus were included between 07/2021 and 06/2023. The cross-validated prediction error and the width of the 95%-prediction intervals of the 3D left main bronchial diameter utilizing linear prediction models were based on current selection methods.

The mean bronchial diameter in 3D reconstruction was 13.6 ± 2.1 mm. The ranges of the 95%-prediction intervals for the bronchial diameter were 6.4 mm for demographic variables, 8.3 mm for the tracheal diameter from the X-ray, and 5.9 mm for bronchial diameter from the 2D-CT scans. Current methods violated the suggested '≥1 mm' safety criterion in up to 7% (men) and 42% (women). Particularly, 2D radiography overestimated women's left bronchial diameter. Current methods even allowed the selection of double-lumen tubes with bronchial tube sections greater than the bronchial diameter in women.

Neither demographic nor 2D-radiographic methods sufficiently account for the variability of the bronchial diameter. Wide 95%-prediction intervals for the bronchial diameter hamper accurate individual double-lumen tube selection. This increases women's risk of bronchial damage, particularly if they have other predisposing factors. These patients may benefit from 3D reconstruction of the left main bronchus.

Not applicable.

There was no evidence regarding the relationship between septic shock and tracheal injury scores. Investigate whether septic shock was independently associated with tracheal injury scores in intensive care unit (ICU) patients with invasive ventilation.

Prospective observational cohort study.

Our study was conducted in a Class III hospital in Hebei province, China.

Patients over 18 years of age admitted to the ICU between 31 May 2020 and 3 May 2022 with a tracheal tube and expected to be on the tube for more than 24 hours.

Tracheal injuries were evaluated by examining hyperaemia, ischaemia, ulcers and tracheal perforation by fiberoptic bronchoscope. Depending on the number of lesions, the lesions were further classified as moderate, severe or confluent.

Among the 97 selected participants, the average age was 56.6±16.5 years, with approximately 64.9% being men. The results of adjusted linear regression showed that septic shock was associated with tracheal injury scores (β: 2.99; 95% CI 0.70 to 5.29). Subgroup analysis revealed a stronger association with a duration of intubation ≥8 days (p=0.013).

Patients with septic shock exhibit significantly higher tracheal injury scores compared with those without septic shock, suggesting that septic shock may serve as an independent risk factor for tracheal injury.

ChiCTR2000037842, registered 03 September 2020. Retrospectively registered, https://www.chictr.org.cn/edit.aspx?pid=57011&htm=4.

Postoperative sore throat (POST) is an unpleasant outcome that can occur as a result of tracheal intubation in adults. Increased pressure from the endotracheal tube (ETT) cuff often leads to local mucosal injury, resulting in sore throat. The purpose of this study was to compare the effect of two different ETT cuff pressure monitoring systems vs. no cuff pressure monitoring on the incidence and severity of POST in adults.

One hundred and fourteen ASA I-III patients of either gender, aged 18-65 years, and undergoing surgery requiring endotracheal intubation were included in this study. Patients were randomized into three groups: control (C), cuff pressure gauge (G), and automated cuff controller (A). The ETT cuff pressure was not monitored intraoperatively in group C but was monitored using a cuff pressure gauge and an automated cuff controller in groups G and A, respectively. Postoperatively, patients were assessed at 2, 24, and 48 h for the presence and severity of POST, hoarseness and cough.

One hundred and eleven patients completed the study. POST occurred in 40.5% of the patients in group G (n = 37) (p = 0.013) and 23.7% of the patients in group A (n = 38) (p < 0.001) within 48 h after surgery, compared to 69.4% in group C (n = 36). There were no significant differences in hoarseness, coughing, and dysphagia across the groups at any time. When comparing groups A and C, individuals in group A exhibited a lower occurrence of significant (grade ≥ 2) POST and hoarseness (10.5% vs. 41.7%, p = 0.002; 26.3% vs. 58.3%, p = 0.005). The incidence of significant cough and dysphagia did not differ substantially across the patient groups within 48 h after surgery. POST scores in group A at 2, 24 h postoperatively were both 0 (0-0), which was significantly lower than those in group C (1 (0-2) at 2 h, p < 0.001 ; 1 (0-1) at 24 h, p = 0.001). POST in group G at 2 h postoperatively was graded as 0 (0-1.5) which was milder than group C (P = 0.024). The severity of hoarseness in group A with scores of 0 (0-2) was superior to that in group C (2 (0-2), p = 0.006) at 2 h postoperatively.

In conclusion, the findings of this study indicated that the occurrence of POST can be reduced by using either the cuff pressure gauge approach or the automated cuff controller method. The automated cuff controller monitoring can potentially decrease the severity of POST and hoarseness.

Chinese Clinical Trial Registry, identifier: ChiCTR2100054089, Date: 08/12/2021.

Obstructive fibrinous tracheal pseudomembrane (OFTP) is a relatively rare complication of endotracheal intubation. Despite being well documented, the exact pathogenesis of OFTP remains unclear. Some studies suggest that it may arise from the early stage of ischemic tracheal wall injury caused by the cuff pressure during intubation. Diagnosis and treatment of OFTP can be facilitated through therapeutic bronchoscopy. In this case report, we describe a patient who presented with dyspnea following repeated intratracheal interventions and was diagnosed with OFTP. The patient was successfully treated with bronchoscopic cryotherapy and was subsequently discharged from the hospital.

Postoperative sore throat (POST) is the most common discomfort after endotracheal intubation. Damage to the tracheal mucosa caused by inappropriate endotracheal tube (ETT) cuff pressure has been shown as the major factor. Monitoring the ETT cuff pressure at a certain value reduces this damage. Benzydamine hydrochloride (BH) has proven to be effective on sore throat and studies have shown that it is also effective on POST. In this study, the efficacy of BH and ETT cuff pressure monitoring on POST was evaluated.

After ethics committee approval 210 patients in the ASA (American Society of Anesthesiologists) I-III risk group undergoing elective surgery were included in the study. Routine anesthesia monitoring, induction, and maintenance were provided. Patients were randomly divided into three groups. Thirty minutes before surgery, the posterior pharyngeal wall was sprayed with BH in group 1 and distilled water in groups 2 and 3. Intraoperatively, the first and second groups were monitored to keep the ETT cuff pressure between 22 and 26 cmH2O, while no intervention was performed in the third group. The incidence and severity of postoperative dysphagia, hoarseness, and POST were questioned.

There was no difference between demographic data, and gender was not associated with POST. There was a statistically significant difference between the first and second groups and the third group in terms of all three symptoms questioned (p<0.01). No difference was observed between the first and second groups. Side effect rates were similar. Smoking was not found to be associated with symptoms.

The incidence and severity of POST, dysphagia, and hoarseness are reduced when the ETT cuff is inflated with a pressure of 22-26 cmH2O after intubation with a manometer and maintained at this pressure range throughout the operation. There was no beneficial effect of BH.

Gas leakage around the cuff of a tracheal tube may frequently occur after tracheal intubation and inflation of the cuff. We assessed if the SmartCuff (Smiths Medical Japan, Tokyo, Japan), an automatic cuff pressure controller, would effectively prevent gas leakage.

Seventy adult patients were allocated randomly to one of two groups. After induction of general anesthesia and tracheal intubation, in one group (Syringe group), a syringe was used to inflate the cuff, until there was no audible gas leakage, at the airway pressure at 20 cmH2O. In the other group (SmartCuff group), the SmartCuff was used to maintain the cuff pressure to be 20 cmH2O. The mechanical ventilation (tidal volume of 8 ml.kg-1 and 12 breaths per min) was started. The incidence and percentage of gas leakage, and the proportion of adequate seal (defined as gas leakage of < 10%) between the groups were compared.

The incidence of audible gas leakage was significantly higher in the Syringe group (10 of 35 patients (28%)) than in the SmartCuff group (none of 35 patients (0%)) (P = 0.00046, 95%CI for difference: 15-43%), and the proportion of adequate seal was significantly lower in the Syringe group (19 of 35 patients (54%)) than in the Smart cuff group (33 of 35 patients (94%)) (P = 0.0001, 95% CI for difference: 20-58%).

Gas leakage may frequently occur after tracheal intubation, and the use of the SmartCuff can effectively maintain the sealing effect of the cuff.

How to cite this article: Kumar AKA. Endotracheal Cuff-pressure Monitoring in ICU: A Standard of Care Yet to be Standardized, and Often Neglected. Indian J Crit Care Med 2024;28(1):8-10.

The aeromedical transportation (AMT) of critically ill cardiac patients can enable access to advanced specialized medical attention, or provide improved care for operational, psychosocial, political, or economic reasons. However, AMT is a complex undertaking necessitating extensive clinical, operational, administrative, and logistical planning to ensure that the patient receives an equivalent level of critical care monitoring and management in the air as on the ground. This paper is the second of a 2-part series. Part 1 focused on the preflight planning and preparation for critically ill cardiac patients during AMT aboard commercial platforms, while this current part aims to provide an overview of in-flight considerations for the same population.

During inhalation anesthesia with nitrous oxide in oxygen the pressure in the cuff of the endotracheal tube may increase due to diffusion of nitrous oxide into the cuff. The aim of the study was to investigate the development of cuff pressure during nitrous oxide anesthesia under clinical conditions in feline patients and to identify possible influencing factors such as tube size and gas flow rate.

The prospective study included cats scheduled for inhalation anesthesia with nitrous oxide for a minimum duration of 60 minutes at the Department for Small Animals of the University of Leipzig. Cuff pressure was adjusted with a cuff manometer and its development was recorded.

In total, the cuff pressure values of 24 cats were recorded. Animals were allocated into groups by tube size (ID 4.0 mm and ID 4.5 mm) and by fresh gas flow rate: low flow rate (0.6 l/min) and high flow rate (3 l/min). During anesthesia, cuff pressure increased over time, with statistical significance occurring from 45 minutes onwards in comparison to the initial cuff pressure (p=0.005). After 60 minutes, there was a mean cuff pressure increase of 3 cmH2O. Despite this moderate mean increase, highly variable pressure values up to 48 cmH2O in individual animals were recorded. No cat reached the termination criterion of 60 cmH2O cuff pressure. Effects of tube size (p=0.63) and flow rate (p=0.334) on the cuff pressure were not evident.

After a period of 45 minutes of nitrous oxide administration, a significant increase in cuff pressure occurs in the cat. However, tube size and total gas flow rate do not seem to influence the cuff pressure development.

When using nitrous oxide during inhalation anesthesia, regular cuff pressure evaluation and correction are necessary and hence recommended in feline patients. As individual pressure changes may be highly variable, no fixed recommendations for optimal management are possible.

The COVID-19 pandemic has exponentially expanded the number of patients requiring treatment for chronic respiratory failure. One consequence is an increase in the number of patients requiring intubation and mechanical ventilation. Benign inoperable tracheal stenosis presents a challenge, especially in COVID-19 patients.

We describe a case series of 15 patients with Benign inoperable tracheal stenosis treated with interventional bronchoscopy over a 15-month period. These patients were divided into two groups, COVID and non-COVID. We used an electrocautery snare as an electrocautery knife to cut the stenotic segment followed by four injections of 1 mg submucosal Decadron via a Wang needle. Patients were subsequently followed by the pulmonary clinic. Institutional review board approval was not required as per our institutional policy for a retrospective case series.

There was a high degree of success with this intervention, with a low rate of recurrence. We also noticed the following differences between the two subgroups. COVID tracheal stenosis was longer in length, had a higher percentage of cartilage involvement, and was located more distal to cords than the non-COVID group. The median age was younger in the COVID group.

COVID pandemic an enormous number of intubations and tracheotomies have been performed. As a result, there will be an increased prevalence of tracheal stenosis. Most of these cases can be effectively treated with surgery. Dealing with complex inoperable cases remains a dilemma. Our case series/research article is an attempt to provide an easy technique with a high cure rate.

The goal of this manuscript is to provide a comprehensive and multi-disciplinary review of the best nursing practices of caring for mechanically ventilated patients. By reviewing human medicine literature, the authors will extrapolate procedures that have been found to be most effective in reducing the risk of mechanical ventilation (MV) complications. Paired with review of the current standards in veterinary medicine, the authors will compile the best practice information on mechanically ventilated patient care, which will serve as a detailed resource for the veterinary nursing staff. Written from a nursing standpoint, this manuscript aims to consolidate the nursing assessment of a mechanically ventilated patient, addressing both systemic and physical changes that may be encountered during hospitalization. The goal of this review article is to present information that encourages a proactive approach to nursing care by focusing on understanding the effects of polypharmacy, hemodynamic changes associated with MV, complications of recumbent patient care, and sources of hospital acquired infections. When applied in conjunction with the more technical aspects of MV, this manuscript will allow veterinary technicians involved in these cases to understand the dynamic challenges that mechanically ventilated patients present, provide guidance to mitigate risk, address issues quickly and effectively, and create an up-to date standard of practice that can be implemented.

Postoperative sore throat (POST) is a common postoperative complication after endotracheal tube removal. There are still no effective preventive methods for POST. The aim of this trial is to confirm whether maintaining intraoperative cuff pressure below the tracheal capillary perfusion pressure could effectively reduce the incidence of POST among patients undergoing gynecological laparoscopic surgery.

This study is a single-center, randomized, parallel-controlled, superiority trial with a 1:1 allocation ratio. Sixty patients whose age is between 18 and 65 years and scheduled for gynecological laparoscopic surgery will be randomized to the cuff pressure measurement and adjustment (CPMA) group and the only cuff pressure measurement without adjustment group (control group). The primary endpoint is the incidence of sore throat at rest within 24 h after extubation. The secondary endpoints include the incidence of cough, the incidence of hoarseness, the incidence of postoperative nausea and vomiting (PONV), POST, and pain intensity within 24 h after extubation. Blocked randomization will be conducted with a computer-generated central randomization online service. The blind method will be applied to subjects, data collectors, outcome evaluators, and statisticians. Outcome assessments will be performed at 0 h and 24 h post-extubation.

This randomized controlled study hypothesizes that cuff pressure is the primary influencing factor of POST. By continuous monitoring of endotracheal tube cuff pressure and maintaining it within the range of 18-22 mmHg compared with only continuous measurement without adjustment, it aims to prove that continuous measurement and adjustment of endotracheal tube cuff pressure could be effective in reducing the incidence of POST in gynecological laparoscopic surgery patients. The result of this study could be used as a reference for future multicenter studies to confirm the effect of cuff pressure on POST and provides a scientific theoretical basis for preventing POST to further support comfort medicine.

Chinese Clinical Trial Registry ChiCTR2200064792. Registered on 18 October 2022. This protocol (version 1.0, 16 March 2022) was approved by the Ethics Committee of Beijing Chaoyang Hospital.

Benign subglottic/tracheal stenosis (SG/TS) is a life-threatening condition commonly caused by prolonged endotracheal intubation or tracheostomy. Invasive mechanical ventilation was frequently used to manage severe COVID-19, resulting in an increased number of patients with various degrees of residual stenosis following respiratory weaning. The aim of this study was to compare demographics, radiological characteristics, and surgical outcomes between COVID-19 and non-COVID patients treated for tracheal stenosis and investigate the potential differences between the groups.

We retrospectively retrieved electronical medical records of patients managed at two referral centers for airways diseases (IRCCS Humanitas Research Hospital and Avicenne Hospital) with tracheal stenosis between March 2020 and May 2022 and grouped according to SAR-CoV-2 infection status. All patients underwent a radiological and endoscopic evaluation followed by multidisciplinary team consultation. Follow-up was performed through quarterly outpatient consultation. Clinical findings and outcomes were analyzed by using SPPS software. A significance level of 5% (p < 0.05) was adopted for comparisons.

A total of 59 patients with a mean age of 56.4 (±13.4) years were surgically managed. Tracheal stenosis was COVID related in 36 (61%) patients. Obesity was frequent in the COVID-19 group (29.7 ± 5.4 vs. 26.9 ± 3, p = 0.043) while no difference was found regarding age, sex, number, and types of comorbidities between the two groups. In the COVID-19 group, orotracheal intubation lasted longer (17.7 ± 14.5 vs. 9.7 ± 5.8 days, p = 0.001), tracheotomy (80%, p = 0.003) as well as re-tracheotomy (6% of cases, p = 0.025) were more frequent and tracheotomy maintenance was longer (21.5 ± 11.9 days, p = 0.006) when compared to the non-COVID group. COVID-19 stenosis was located more distal from vocal folds (3.0 ± 1.86 vs. 1.8 ± 2.03 cm) yet without evidence of a difference (p = 0.07). The number of tracheal rings involved was lower in the non-COVID group (1.7 ± 1 vs. 2.6 ± 0.8 p = 0.001) and stenosis were more frequently managed by rigid bronchoscopy (74% vs. 47%, p = 0.04) when compared to the COVID-19 group. Finally, no difference in recurrence rate was detected between the groups (35% vs. 15%, p = 0.18).

Obesity, a longer time of intubation, tracheostomy, re-tracheostomy, and longer decannulation time occurred more frequently in COVID-related tracheal stenosis. These events may explain the higher number of tracheal rings involved, although we cannot exclude the direct role of SARS-CoV-2 infection in the genesis of tracheal stenosis. Further studies with in vitro/in vivo models will be helpful to better understand the role of inflammatory status caused by SARS-CoV-2 in upper airways.

Pilot balloon palpation is still a commonly used method to evaluate cuff pressure of the endotracheal tube after intubation. This study determined whether the size of the tracheal tube influenced the accuracy of pilot balloon palpation. A prospective observational analysis of 208 patients intubated with an endotracheal tube of internal diameter (ID) 6.0 or 8.0 was conducted. An anesthesiologist judged the cuff pressure by manual pilot balloon palpation, and then measured the cuff pressure with a pressure gauge. Cuff pressure exceeding 20-30 cmH₂O was defined as false recognition. The intracuff pressure was significantly higher in ID 6.0 tube than in the ID 8.0 tube (41.9 ± 18.8 cmH₂O vs. 30.3 ± 11.9 cmH₂O, p < 0.001). The number of patients that were mistakenly perceived to have appropriate cuff pressure by pilot balloon palpation was significantly higher in the ID 6.0 group compared to the ID 8.0 group (85 (81.7%) vs. 64 (61.5%), p = 0.001). Therefore, a smaller tube size may further increase risk of inaccurate measurement by pilot balloon palpation and although pressure gauge is recommended for all sizes to maximize accuracy, groups with increased risk factors should be targeted for standardized use of the pressure gauge.

Prolonged intubation is associated with several complications leading to upper airway obstruction, including tracheal stenosis and tracheomalacia. Tracheostomy may potentially decrease the risk of tracheal injury in patients with upper airway obstruction. The ideal timing to perform tracheostomy remains controversial. Prolonged intubations were particularly common during the initial phase of the coronavirus disease 2019 (COVID-19) pandemic. This study aimed to present a series of five cases of upper airway complications in patients who underwent mechanical ventilation in the setting of COVID-19 and discuss their clinical aspects, risk factors, and therapeutic strategies.

Tracheal complications should be suspected in mechanically ventilated COVID-19 survivors with respiratory symptoms. Treatment requires a multimodal approach of interventional bronchoscopy and surgery with tight follow-up due to a high rate of restenosis. https://bit.ly/3iw05xQ.

Tracheostomy for prolonged ventilation of patients with COVID-19 was often delayed due to high viral loads and persistent high ventilatory requirements. With prolonged intubation and significant dose corticosteroid use, patients with COVID-19 are at risk for tracheomalacia, and urgent tube exchange may be required to address persistent cuff leak and to maintain adequate mechanical ventilation. We sought to describe our single center experience with COVID-19 patients requiring tracheostomy and the tracheal complications that followed. We performed a review of patients with COVID-19 who underwent tracheostomy from June 2020 to October 2021. 45 patients were identified; 82.2% survived their index hospitalization. Tracheostomy was performed after 16.4 days of mechanical ventilation. 22.2% required urgent exchange to an extended length tracheostomy tube after 7.2 days from initial tracheostomy. Placement of an extended length tracheostomy tube can reduce cuff leak in ventilated COVID-19 patients and may be considered during initial tracheostomy placement.

Tracheoarterial fistula is the most devastating complication after tracheostomy, and its mortality, without definitive treatment, approaches 100%. In general, the combination of bedside emergency management, that is, overinflation of the tracheostomy tube cuff, and definitive treatment such as surgical or endovascular intervention is necessary to prevent the poor outcome. Patients with neuromuscular diseases such as amyotrophic lateral sclerosis are susceptible to tracheoarterial fistula because of long-term mechanical ventilation and muscle weakness.

We describe a case of tracheoarterial fistula in a Japanese 39-year-old patient with amyotrophic lateral sclerosis with long-term ventilator management. The patient was clinically diagnosed with a tracheoarterial fistula because of massive bleeding following sentinel hemorrhage. The massive hemorrhage was controlled by overinflation of the tracheostomy tube cuff alone, without definitive treatment.

This case suggests overinflation of the tracheostomy tube cuff alone plays an important role, semi-permanently, in the management of tracheoarterial fistula, especially in cases where surgical or endovascular intervention is not indicated. Clinicians taking care of patients with tracheostomy undergoing long-term mechanical ventilation should be aware that tracheoarterial fistula might occur following tracheostomy.

Complications of the endotracheal tube (ETT) displacement during head and neck positional changes are related to not only the tip position but also the cuff pressure against the larynx. Here, we evaluated movement of the ETT cuff relative to laryngeal structures as well as tip displacement from the carina.Sixty-two patients scheduled for thyroidectomy were recruited. The distance from the cricoid cartilage to the upper margin of the cuff (CC) and that from the ETT tip to the carina (TC) were measured using ultrasonography and fiberoptic bronchoscopy, respectively, during flexion and extension. The total tracheal length (TTL) was defined as the combination of CC, TC, and the distance from the upper margin of the cuff to the tip.During flexion, the CC and TC were 1.5 ± 0.6 and 2.9 ± 1.0 cm respectively. Seven patients (11.7%) exhibited excessively deep intubation. After adjusting the cuff position under ultrasonography (CC = 0), the tip position was corrected in 96.7%. While the TC increased by 2.1 ± 1.0 cm after the positional change in extension, the CC decreased by 0.6 ± 0.7 cm because the TTL lengthened (1.4 ± 1.1 cm). Four patients (6.7%) exhibited excessive cuff displacement beyond the cricoid cartilage, which could have been corrected under ultrasonography.In conclusion, the ETT cuff displaced toward the larynx in a less degree than the tip did from the carina due to the tracheal lengthening during head and neck extension. Nevertheless, we suggest that ultrasonographic assessment of cuff position may avoid ETT misplacement. Trial registration https://cris.nih.go.kr/ (approval no. KCT0005319); registered on May 14, 2019.

This study aimed to assess the performance, accuracy, precision and repeatability of two single-use airway pressure manometers as a cost-effective alternative for inflation of endotracheal tubes with high-volume, low-pressure cuffs. The manometers were tested in a bench top model against a U-tube manometer. Eighteen units of each device were tested. Three consecutive measurements were performed at pressures of 20, 25 and 30 cmH₂O each. The mean ± SD of the recorded pressures and maximum deviation from the target pressures were calculated for each device and each target pressure. For device A, the mean ± SD pressures were 19.6 ± 0.7, 23.6 ± 0.8 and 28.3 ± 0.8 cmH₂O; for device B, the mean ± SD pressures were 19.3 ± 0.6, 24.3 ± 0.9 and 29.2 ± 0.67 cmH₂O for target pressures of 20, 25 and 30 cmH₂O, respectively. The bias for device A was -0.4, -1.4, and -1.7 cmH₂O and for device B, -0.7, -0.7, and -0.8 cmH₂O for target pressures of 20, 25, and 30 cmH₂O, respectively. Both devices showed results comparable to those reported for commercial cuff manometers. They represent inexpensive tools that provide clinically sufficient accuracy, precision and repeatability for ETT cuff inflation between pressures of 20 and 30 cmH₂O.

The cuff pressure of a tracheal tube may increase during robot-assisted laparoscopic surgery for prostatectomy (RALP), which requires pneumoperitoneum in a steep head-down position, but there have been no studies which confirmed this.

In study 1, we studied how frequently the cuff pressure significantly increased during anesthesia for the RALP. In study 2, we studied if the SmartCuff (Smiths Medical Japan, Tokyo) automatic cuff pressure controller would minimize the changes in the intracuff pressure. With approval of the study by the research ethics committee (approved number: 20115), we measured the cuff pressures in anesthetized patients undergoing RALP and in those undergoing gynecological laparotomy (as a reference cohort), with and without the use of the SmartCuff.

In 21 patients undergoing RALP, a clinically meaningful increase (5 cmH₂O or greater) was observed in all the 21 patients (P = 0.00; 95% CI for difference: 86-100%), whereas in 23 patients undergoing gynecological laparotomy, a clinically meaningful decrease (5 cmH₂O or greater) was observed in 21 of 23 patients (91%, P < 0.0001; 95% CI for difference: 72-99%). With the use of the SmartCuff, there was no significant increase in the incidence of a clinically meaningful change in the intracuff pressure in either cohort.

The cuff pressure of a tracheal tube would frequently increase markedly in patients undergoing RALP, whereas it would frequently decrease markedly in patients undergoing gynecological laparotomy. The SmartCuff may inhibit the changes in the cuff pressure during anesthesia.

Endotracheal tube (ETT) cuff pressures are frequently out of the recommended range of 20-30 cm H₂O. This can lead to multiple iatrogenic complications ranging from cough, sore throat, and tracheal edema to more serious medical issues such as tracheal stenosis, aspiration, nerve injuries, and tracheal rupture. Additionally, current methods to inflate ETT cuffs vary between anesthesia providers and are not consistent in the recommended range. The objective of this quality improvement project was to increase the percentage of cuff pressures between 20 and 30 cm H₂O.

Four plan-do-study-act (PDSA) cycles were completed in the operating rooms at Nationwide Children's Hospital over 9 months to assess ways to improve the accuracy of obtaining recommended ETT cuff pressures. Control charts were used to evaluate the primary outcome measure.

Preimplementation, ETT cuff pressures were out of the recommended range 76% of the time. Cuff pressures were out of the recommended range 64% of the time with the addition of the air method, 84% of the time in the tidal volume ratio cycle, and 50% of the time using the removal of air technique. The removal of air method was the most effective in achieving cuff pressures within the recommended pressure range (P < 0.001).

Using quality improvement methodology, the percentage of ETT cuff pressures falling within the recommended pressure range increased using the removal of air technique. This approach is a simple and practical method that can be easily implemented in the clinical setting and would provide additional safety in the anesthetic management of pediatric patients.

Laryngeal and tracheal injuries are known complications of endotracheal intubation. Endotracheal tubes (ETTs) with subglottic suction devices (SSDs) are commonly used in the critical care setting. There is concern that herniation of tissue into the suction port of these devices may lead to tracheal injury resulting in serious clinical consequences such as tracheal stenosis. We aimed to describe the type and location of tracheal injuries seen in intubated critically ill patients and assess injuries at the suction port as well as in-hospital complications associated with those injuries.

We conducted a prospective observational study of 57 critically ill patients admitted to a level 3 intensive care unit who were endotracheally intubated and underwent percutaneous tracheostomy. Investigators performed bronchoscopy and photographic evaluation of the airway during the percutaneous tracheostomy procedure to evaluate tracheal and laryngeal injury.

Forty-one (72%) patients intubated with ETT with SSD and sixteen (28%) patients with standard ETT were included in the study. Forty-seven (83%) patients had a documented airway injury ranging from hyperemia to deep ulceration of the mucosa. A common tracheal injury was at the site of the tracheal cuff. Injury at the site of the subglottic suction device was seen in 5/41 (12%) patients. There were no in-hospital complications.

Airway injury was common in critically ill patients following endotracheal intubation, and tracheal injury commonly occurred at the site of the endotracheal cuff. Injury occurred at the site of the subglottic suction port in some patients although the clinical consequences of these injuries remain unclear.

Endotracheal intubation is a routine procedure in veterinary anaesthesia, yet no consensus guidelines exist for endotracheal tube (ETT) cuff inflation and pressure measurement. The aim of this study was to assess current practice of ETT cuff inflation and seal verification in veterinary medicine. An online questionnaire was distributed among veterinary professionals who administer anaesthesia, comprising six demographic and twelve ETT cuff-related questions per species. N = 348 questionnaires were completed. Cuff pressure was measured by 30% of respondents in cats, 32% in dogs and 9% in both farm animals and horses. Anaesthesia diplomates were not more likely to measure cuff pressure than others, except in cats (OR: 1.8; 95% CI: 1.1−2.9). The most frequently selected recommended range of cuff pressure was 20−30 cm H2O, regardless of species, although >30 cm H2O was selected significantly more often in horses compared to dogs, cats and farm animals. The preferred technique to verify cuff seal was minimal occlusive volume in dogs, cats and farm animals, whereas in horses, the preferred method was verification of normal capnogram waveform. ETT cuff pressure measurement remains uncommon in veterinary anaesthesia. The development of consensus recommendations for cuff inflation, including evidence-based target cuff pressure ranges for various species and different ETT models or materials, can help to improve practice.

The impact of intraoperative esophageal device insertion (EDI) on endotracheal tube (ET) cuff inflation pressure remains unclear. Electronic databases including Medline, Embase, Google scholar, Web of Science™ and Cochrane Central Register of Controlled Trials were searched for studies involving EDI after placement of ETs from inception to July 7, 2022. The primary outcome was risk of high cuff pressure, while the secondary outcomes were increases in cuff pressure following EDI. Difference between adults and children was investigated with subgroup analysis. There were ten eligible studies (observation study, n = 9, randomized controlled study, n = 1) involving a total of 468 participants. EDI notably increased the risk of high cuff pressure (n = 7, risk ratio: 12.82, 95% confidence interval: 4.9 to 33.52, subgroup analysis: p = 0.008). There were significant elevations in cuff pressure in adults and children both during (13.42 and 7.88 cmH₂O, respectively, subgroup analysis: p = 0.15) and after (10.09 and 3.99 cmH₂O, respectively, subgroup analysis: p = 0.0003) EDI. Our results revealed an over 12-fold increase in the risk of high endotracheal tube cuff pressure in patients, especially adults, receiving EDI under endotracheal anesthesia. There were significant increases in both adults and children despite a higher increase in the former after device insertion.

Ultrasound is an everyday diagnostic tool. In anesthesia and intensive care, it has a role as an adjuvant for many procedures, including the evaluation of the airway. Ultrasound airway evaluation can help predict a difficult airway, visualize the proper positioning of an intubation cannula, or evaluate the airway post-intubation. Protocols need to be established for the better integration of ultrasound in the airway evaluation, however until a consensus is reached in this respect, the ultrasound is a reliable aid in anesthesia and intensive care.

Selection and insertion of an endotracheal tube (ETT) of appropriate size for airway management during general anesthesia in pediatric patients is very important. A very small ETT increases the risk of inadequate ventilation, air leakage, and aspiration, whereas a very large ETT may cause serious complications including airway damage, post-intubation croup, and, in severe cases, subglottic stenosis. Although the pediatric larynx is conical, the narrowest part, the rima glottidis, is cylindrical in the anteroposterior dimension, regardless of development, and the cricoid ring is slightly elliptical. A cuffed ETT reduces the number of endotracheal intubation attempts, and if cuff pressure can be maintained within a safe range, the risk of airway damage may not be greater than that of an ETT without cuff. The age-based formula suggested by Cole (age/4 + 4) has long been used to select the appropriate ETT size in children. Because age-based formulas in children are not always accurate, various alternative methods for estimating the ETT size have been examined and suggested. Chest radiography, ultrasound, and a three-dimensional airway model can be used to determine the appropriate ETT size; however, there are several limitations.