Only YOU Can Prevent Overinflation of an ETT Cuff!

QI Presentation: Does it matter how much air we put in the cuff QI Presentation: Does it matter how much air we put in the cuff? Reducing endotracheal tube cuff over-inflation with utilization of manometers Greg Schmitz, Shannon Simon, Aaron Persinger, Jeffrey Gonzales, Patrick Fernandez

Background: The 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. http://www.hospitech.co.il/solutions/

Complications of Over-inflation Sore throat Stridor Dysphagia Vocal Cord or Nerve Damage/Paralysis Tracheal ulcerations or granulations Bleeding, hemoptysis Tracheal stenosis Tracheal Rupture T-E Fistula One death reported in literature from perforation

Background - Literature 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. The finger palpation method has been shown to be unreliable. The sensitivity and specificity of this method is no better than 50%. Fernandez et al. 1990. Endotracheal tube cuff pressure assessment: Pitfalls of finger estimation and need for objective measurement. Critical Care Medicine 18 1426-1432.

Background – Literature (continued) It has been demonstrated that 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.)

Solution: Workflow Adjustment 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

Future Directions/Next Steps Getting a manometer in each OR Trialing different manometers currently Increase provider awareness and use Consider checking cuff pressure a standard of care for airway management (as in the ICU) Future study looking for objective improvements in reduction in post-op sore throat Could apply this to LMA’s as well

Proposed Methods Time Frame: 3-6 months Team members involved: all anesthesia personnel at UCH Randomize patients to 2 groups: cuff-pressure checked vs. not checked Assess for decrease in sore throat, hoarseness, etc Relationship to patient satisfaction?

Potential Findings Lower incidence of sore throat Could document as VAS score Nurse could assess in PACU prior to discharge Lower incidence of lingual nerve palsy with LMA’s? Possible increased patient satisfaction Decrease our contribution to overall incidence of tracheal stenosis

Conclusions/Recommendations Over-inflation is common, and easily reduced Checking cuff pressure in the OR should become standard of care, as it is in the ICU Recommend having manometer in each OR, so providers have a way to check Once providers incorporate this into their routine, this practice is easily sustainable

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