Manometer Usage to Decrease Sore Throat Incidence Shannon Simon, Greg Schmitz, Shelby Badani Faculty Mentors: Aaron Persinger, Christine Zanghi University of Colorado QI Improvement May 8, 2017

Problem Endotracheal tube cuffs are routinely over-inflated after intubations at UCH (~78% of the time in 2014), which can lead to airway complications and morbidity (Sore throat, stridor, dysphagia, VC damage, tracheal Ulcerations or granulations, tracheal stenosis, tracheal rupture, T-E fistula, death)

Fishbone Diagram

Background Providers of all backgrounds are unable to reliably tell if the pressure in the cuff inflation is appropriate Grant, Thomas. 2013. Do current methods for endotracheal tube cuff inflation create pressures above the recommended range? A review of the evidence. Journal of Perioperative Practice (12):292-5 Hoffman et al. 2006. Experienced emergency medicine physicians cannot safely inflate or estimate endotracheal tube cuff pressure using standard techniques. American Journal of Emergency Medicine. 24 (2) 139-143. Sultan et all. 2011. Endotracheal tube cuff pressure monitoring: a review of the evidence. Journal of Perioperative Practice 21 379-386. Finger palpation method has been shown to be unreliable Fernandez et al. 1990. Endotracheal tube cuff pressure assessment: Pitfalls of finger estimation and need for objective measurement. Critical Care Medicine 18 1426-1432. Sore throats are reduced by checking cuff pressures Suzuki et al. 1999. Postoperative hoarseness and sore throat after tracheal intubation: Effect of low intracuff pressure of endotracheal tube and usefulness of cuff pressure indicator. Masui 48 (10) 1091-1095. Sore throat, hoarseness, hemoptysis, and tracheal ischemic damage on bronchoscopy was reduced by checking ETT cuff pressures Liu et al. 2010. Correlations between controlled endotracheal tube cuff pressure and postprocedural complications: a multcenter study. Anesthesia & Analgesia 111 (5) 1133-1137.

Process Map OLD PROCESS Intubation  OR nurse pushes in 10 cc of air in cuff  tube secured, often without anyone checking pressure, or listening for a leak  no documentation of addressing this part of airway management  patient now at increased risk for cough, sore throat, hoarseness, stridor, hemoptysis, tracheal ulceration, and tracheal stenosis, or under-inflation and at risk for ventilator-associated or aspiration pneumonia NEW PROCESS Intubation  anesthesia team inflates cuff  team quickly checks pressure in cuff (after confirmed endotracheal, ventilator and gas are on, and ETT secured)  team documents proper pressure when charting intubation note  patient now at reduced risk of sore throat and intubation-related complications

SMART Aim Statement Using ETT cuff manometers in the UCH AIP will reduce the incidence of sore throats on discharge from PACU by 10%

PDSA

Plan Sore throat is a common problem with general anesthesia and endotracheal intubation Plan to see if using an ETT cuff manometer decreases the incidence of sore throat Survey was administered by PACU nurses to assess whether sore throat was present upon patient discharge from PACU Data collected over 4 weeks

Do Exclusions criteria included: LMA’s, DLT’s, repeated intubation attempt, intubations marked as moderate-difficult, endoscopies 300 surveys printed, with 180 surveys returned Did not control for type or length of surgery or for positioning for surgery Prolonged neck extension, etc. Did not account for OGT/NGT or aggressive/repeated suctioning

The Survey

Study Found that there was a greater than 10% decrease in the incidence of sore throat!

Data * Distributed 300 surveys. 180 returned. * 32 excluded: - DLT: 6 - Difficult/ multiple attempts: 15 - Endoscopy: 2 - LMA: 7 MAC: 2 * Of 148 remaining, 87 used ETT manometer, 61 did not use manometer (59% usage rate) * Percentage sore throat overall: 31% * Percentage sore throat when manometer used: 21/87 = 24.1% incidence. Average severity = 29.5, Median severity = 28, Max = 70, Min = 1. * Percentage sore throat when manometer not used: 24/58 (3 did not document sore throat incidence) = 41.3% incidence. Average severity = 26.6, Median severity = 27.5, Max = 90, Min = 2.

Act Having ETT cuff manometers become standard of care at our institution Having ETT cuff manometers throughout hospital—OB, AOP, ICU’s, airway boxes Broaden the standard of care to use manometers for LMA placement throughout hospital

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