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      Endotracheal cuff pressure changes with change in position in neurosurgical patients

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          Abstract

          Background:

          Placement of a cuffed endotracheal tube for the administration of general anesthesia is routine. The cuff of the endotracheal tube is inflated with air to achieve an adequate seal to prevent micro-aspiration. Over inflation of the cuff can decrease the mucosal perfusion, leading to pressure necrosis and nerve palsies. Inadequate seal can lead to micro aspiration. So the cuff pressure has to be monitored and kept within the prescribed limits of 20-30 cms of water.

          Aim of the Study:

          To observe the effect of different positions on the endotracheal cuff pressure in patients undergoing neurosurgical procedures.

          Materials and Methods:

          This is an observational study conducted on 70 patients undergoing neurosurgical procedures in various positions. After intubation, the cuff pressure was checked with a cuff pressure manometer, Endotest (Teleflex Medical, Rush) and adjusted to be within the allowable pressure limits as is the routine practice. The cuff pressure was checked again at three time points after achieving the final position with the head on pins, at the end of the procedure and before extubation. Various factors such as the age, position, duration of surgery were studied. There were no major complications like aspiration, stridor or hoarseness of voice post extubation in any of the patients.

          Results:

          A significant decline in the cuff pressures were noted from the initial supine position to extubation ( P < .001) in the supine group. Also a significant decline in the cuff pressures were found in the prone group from their initial intubated supine position to all the other three corresponding time points namely after final positioning ( P < .001), at the end of the procedure ( P < .001) and before extubation ( P < .001).

          Conclusion:

          Cuff pressure has to be checked after achieving the final positioning of the patient and adjusted to the prescribed limits to prevent micro aspiration.

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          Most cited references27

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          Correlations between controlled endotracheal tube cuff pressure and postprocedural complications: a multicenter study.

          Postoperative respiratory complications related to endotracheal intubation usually present as cough, sore throat, hoarseness, and blood-streaked expectorant. In this study, we investigated the short-term (hours) impact of measuring and controlling endotracheal tube cuff (ETTc) pressure on postprocedural complications. Five hundred nine patients from 4 tertiary care university hospitals in Shanghai, China scheduled for elective surgery under general anesthesia were assigned to a control group without measuring ETTc pressure, and a study group with ETTc pressure measured and adjusted. The duration of the procedure and duration of endotracheal intubation were recorded. Twenty patients whose duration of endotracheal intubation was between 120 and 180 minutes were selected from each group and examined by fiberoptic bronchoscopy immediately after removing the endotracheal tube. Endotracheal intubation-related complications including cough, sore throat, hoarseness, and blood-streaked expectorant were recorded at 24 hours postextubation. There was no significant difference in sex, age, height, weight, procedure duration, and duration of endotracheal intubation between the 2 groups. The mean ETTc pressure measured after estimation by palpation of the pilot balloon of the study group was 43 ± 23.3 mm Hg before adjustment (the highest was 210 mm Hg), and 20 ± 3.1 mm Hg after adjustment (P < 0.001). The incidence of postprocedural sore throat, hoarseness, and blood-streaked expectoration in the control group was significantly higher than in the study group. As the duration of endotracheal intubation increased, the incidence of sore throat and blood-streaked expectoration in the control group increased. The incidence of sore throat in the study group also increased with increasing duration of endotracheal intubation. Fiberoptic bronchoscopy in the 20 patients showed that the tracheal mucosa was injured in varying degrees in both groups, but the injury was more severe in the control group than in the study group. ETTc pressure estimated by palpation with personal experience is often much higher than measured or what may be optimal. Proper control of ETTc pressure by a manometer helped reduce ETT-related postprocedural respiratory complications such as cough, sore throat, hoarseness, and blood-streaked expectoration even in procedures of short duration (1-3 hours).
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            Endotracheal tube cuff pressure in three hospitals, and the volume required to produce an appropriate cuff pressure

            Background Cuff pressure in endotracheal (ET) tubes should be in the range of 20–30 cm H2O. We tested the hypothesis that the tube cuff is inadequately inflated when manometers are not used. Methods With IRB approval, we studied 93 patients under general anesthesia with an ET tube in place in one teaching and two private hospitals. Anesthetists were blinded to study purpose. Cuff pressure in tube sizes 7.0 to 8.5 mm was evaluated 60 min after induction of general anesthesia using a manometer connected to the cuff pilot balloon. Nitrous oxide was disallowed. After deflating the cuff, we reinflated it in 0.5-ml increments until pressure was 20 cmH2O. Results Neither patient morphometrics, institution, experience of anesthesia provider, nor tube size influenced measured cuff pressure (35.3 ± 21.6 cmH2O). Only 27% of pressures were within 20–30 cmH2O; 27% exceeded 40 cmH2O. Although it varied considerably, the amount of air required to achieve a cuff pressure of 20 cmH2O was similar with each tube size. Conclusion We recommend that ET cuff pressure be set and monitored with a manometer.
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              Cuff pressure of endotracheal tubes after changes in body position in critically ill patients treated with mechanical ventilation.

              In order to avoid microaspiration and tracheal injury, the target for endotracheal tube cuff pressure is 20 to 30 cm H2O. To assess the effect of changes in body position on cuff pressure in adult patients. 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 H2O. Then, 16 changes in position were performed: anteflexion head, hyperextension 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 H2O) were considered clinically relevant. A total of 192 measurements were performed (12 subjects × 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 H2O). Pressures were greater than the upper limit (30 cm H2O) 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). Simple changes in patients' positioning can result in potentially harmful cuff pressures.
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                Author and article information

                Journal
                Int J Crit Illn Inj Sci
                Int J Crit Illn Inj Sci
                IJCIIS
                International Journal of Critical Illness and Injury Science
                Medknow Publications & Media Pvt Ltd (India )
                2229-5151
                2231-5004
                Oct-Dec 2015
                : 5
                : 4
                : 237-241
                Affiliations
                [1]Department of Anesthesiology, Washington University in St. Louis, Missouri, USA
                [1 ]Department of Anesthesiology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
                [2 ]Department of Anesthesiology and Critical Care, Christian Medical College, Vellore, Tamil Nadu, India
                Author notes
                Address for correspondence: Dr. UmeshKumar Athiraman, Washington University in St. Louis, Missouri, 63110, USA. E-mail: athiramanu@ 123456anest.wustl.edu
                Article
                IJCIIS-5-237
                10.4103/2229-5151.170841
                4705569
                26807392
                b177d2fe-cbe0-45e1-922c-ed0a8b2ce3d5
                Copyright: © International Journal of Critical Illness and Injury Science

                This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

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                Original Article

                Emergency medicine & Trauma
                different positions,ett cuff pressure,neurosurgical patients
                Emergency medicine & Trauma
                different positions, ett cuff pressure, neurosurgical patients

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