1. Releasing the Pressure: Finding a solution to low tracheostomy cuff pressures in ward based patients
Hayley Allen, Critical Care Outreach Nurse, Royal Victoria Hospital, Belfast Health and Social Care Trust, Grosvenor Road, Belfast, BT12 6BA.
BACCN Conference, September 2018, Bournemouth.
Introduction
The checking of cuff pressure in the tracheostomies of our ward based patients showed a pattern of extremely low readings.Other signs of a cuff leak; no desaturation, no gurgling or airway noise, no audible voice or air leak were absent. The Critical Care Outreach Team (CCOT) had been recording manometer pressures of between 5-8 cmH2O on patients whose cuff had been inflated to 28 cmH2O the previous day.
of air is released each time the pilot balloon is accessed, this in addition to any natural leak over time (Sole et al. 2011). This suggested that we were causing our patients to aspirate upper airway secretions by lowering the pressure during the measuring process.
cuff pressure range via the SCM daily.
Results
Over 2 months,
ward staff
reported a
decrease in the
frequency of
suctioning and
anecdotally we
saw a decrease
in antibiotic use for LRTI.
In those who had subglottic
tubes there seemed to be an
increase in subglottic volumes.
No unplanned tube changes
due to possible cuff failure
occurred.
Daily checks demonstrated a
cuff pressure range of 23-26
cmH2O with the SCM in situ
and gave confidence in the
device.
Feedback from staff was very
positive and they required
minimal support due to the
simplicity of the device. 100%
were happy to use the device in
future.
Analysis
I am retrospectively gathering data and assessing subglottic volumes, antibiotic usage, occurrence of unplanned tube changes and cuff pressures before and after SCM.
Development
A larger sample size is required to assess if the device does indeed prevent unscheduled tube changes due to low cuff pressures and avoid aspiration incidences in future. The potential benefit to patients is huge.
Solution
The SMART cuff manager (SCM) by Tracoe remains connected to the pilot balloon and continuously maintains a cuff pressure of between 20-30cmH2O by way of a balloon and valve system. It requires only a visual check of a balloon to confirm that the cuff is inflated optimally and therefore it was felt that this would empower ward staff who would not readily have used a manometer when they had concern. It does not require intermittent connection, cuts down on the user causing inadvertent air loss.
Background
Over 5 months, 3 patients had 6 unscheduled tubes changes due to a suspected cuff leak. 5 of those tube changes were based on recorded low cuff pressures only. 2 of the removed tubes went for laboratory testing by the manufacturer. Some cuff leak was detected but this may have been caused during removal and could not be directly linked to our problem.
Research
Evidence suggests that the pressure checking process itself releases air from the cuff (Asai et al. 2014). This was confirmed by our tracheostomy tube manufacturer. Results of their laboratory tests showed mls
Trials
Initially in one clinical area so that the CCOT could focus on supporting staff with the introduction of the device; one patient who had been subject to several tube changes secondary to low cuff pressures had the SCM applied. This was later extended to a further 2 specialties, a total of 3 patients. Training and a laminated poster aide memoir were provided. CCOT checked and recorded the
References
Asai, S et. al, (2014). ‘Decrease in cuff pressure during the measurement procedure: an experimental study’. Journal of Intensive Care Vol 2:34, accessed 25/03/18 <
Sole, M et al, (2011). ‘Evaluation of an intervention to maintain endotracheal tube cuff pressure within therapeutic range’. American Journal of Critical Care Vol 20, No 2, pp accessed 25/03/18 <