NEW INSTRUMENT

Self-Inflating Parachute Cuff

A New Tracheostomy and Endotracheal Cuff

J. Abouav,

MD, San Francisco,

California California

T. N. Finley, MD, San Francisco,

There exists a direct relation between the pressure exerted on the tracheal mucosa by the cuffs of ventilating tubes and the damage that ensues [1,2]. Furthermore, the extent and degree of damage are related to the period of cuff inflation required for ventilation: the longer the patient is kept on the respirator, the more severe the damage [3,4]. In recent years many attempts to minimize the ofttimes life-threatening complications have been reported. Several have been directed at improving the methods and use of the ventilating tubes. These methods have included meticulous attention to the minimal occluding pressure [5], periodic deflation of cuffs [2], and the allowance of small leaks around the cuff [5,6]. Devices have been directed at achieving intermittent inflation of cuffs using additional equipment attached to the respirators [7-91 or improving the characteristics of the cuffs themselves, such as pre-stretching [IO] of the cuff and recently the use of the soft cuff as described by Grill0 et al [II]. Some investigators had previously designed other types of soft cuffs [12,13] and a few have attempted to design a self-inflating cuff of one characteristic or another [14--161. Most of the aforementioned methods have met with little acceptance: the method is ineffective, the apparatus is cumbersome, or the performance of the cuff is unreliable.

For the past two years we have been attempting to design a cuff with the following desirable characteristics: (1) The lateral wall pressure exerted by the cuff on the tracheal mucosa should not exceed the airway pressure. (2) The lateral pressure should be intermittent, exerted only during the inflation period. (3) The cuff should be reliable at all ventilatory pressures and flows and maintain this reliability for extended periods of time. (4) The cuff should not interfere with the normal movement of secretions in the tracheobronchial tree. (5) The cuff should be simple and require minimal attention by the nursing staff. We believe the present device, the self-inflating parachute cuff, satisfies these goals. The lateral

From the Department of Surgery and the Pulmonary Laboratory, Mount Zion Hospital and Medical Center, San Francisco, California. Reprint requests should be addressed to Dr Abouav, Department of Surgery, Mount Zion Hospital and Medical Center, 1600 Divisadero Street, San Francisco, California 94115.

Figure 1. Parachute cuff with open end facing distal end of endotracheal tube. Figure 2. The radially placed shrouds which prevent eversion of the open ended cuff.

Volume 125, May 1973

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Abouav and Finley

as long as six weeks without producing any damage to the mucosa. This design of cuff is proposed as an effective solution to some of the plaguing problems encountered in the care of critically ill patients requiring continuous ventilatory care.

Summary

A new self-inflating cuff for endotracheal or tracheostomy tubes is described. It is self-inflating, never exerts a lateral wall pressure greater than tracheal pressure, is reliable at all ventilating pressures and flows, and maintains its reliability for extended periods of time when tested in vivo.
References
1. Cooper DJ, Grill0 HC: The evolution of tracheal injury due to ventilating assistance through cuffed tubes. Ann Surg 169: 334, 1969. 2. Andrews MJ, Pearson FG: Incidence and pathogenesis of tracheal injury following cuffed tube tracheostomy with assisted ventilation. Ann Surg 173: 249, 1971. 3. Lester RE, Trimble K: Reappraisal of tracheal injury from cuffed tracheostomy tubes. Experiment in dogs. JAMA 2-15: 625, 1971. 4. Ching NP, Ayers SM, Paegle RP, Nealon TF Jr: The contribution of cuff volume and pressure in tracheostomy tube damage. J Thorac Cardiovasc Surg 62: 402, 1971. 5. Hardy KL, Fettel BE, Shiley DP: New tracheostomy tube. Ann Thorac Surg 10: 58, 1970. 6. Gibson P: Aetiology and repair of tracheal stenosis following tracheostomy and intermittent positive pressure respiration. Thorax 22: 1, 1967. 7. Crosby WM: Automatic intermittent inflation of tracheostomy tube cuff. Lancet 2: 509, 1964. 8. Rainer WG, Sanchez M: Tracheal cuff inflation: synchronous timed with inspiration. Ann Thorac Surg 9: 384, 1970. 9. Arens JF, Ochsner JL, Gee 0: Volume limited intermittent cuff inflation for long term respiratory assistance. J Thorat Cardiovasc Surg 58: 837, 1969. 10. Geffin B, Pontoppidan H: Reduction of tracheal damage by prestretching of inflatable cuffs. Anes 31: 462, 1969. 11. Grill0 HC, Cooper JD, Geffin B, Pontoppidan H: A low pressure cuff for tracheostomy tubes to minimize tracheal injury. J Thorac Cardiovasc Surg 62: 898, 1971. 12. Auchincloss JH Jr, Gilbert R, Mullison E: A new self inflating tracheostomy cuff of silicon rubber for use in patients requiring mechanical aid to ventilation. Amer Rev Resp Dis 97: 706, 1968. 13. Lomholt N: A new tracheostomy tube. Acta Anaesth Stand 11: 311, 1967. 14. Benveniste D: Endotracheal and tracheostomy tubes with self-inflating cuff. Acta Anaesth Stand 11: 85, 1967. 15. Jackson RR, Rokowski WJ: A disposable endotracheal tube with self inflating cuff. Arch Surg 94: 160, 1967. 16. Martinez HE: An improved cuffed tracheostomy tube for use with intermittent positive pressure breathing. J Thorac Cardiovasc Surg 47: 404, 1964.

Figure 3. A schematic diagram illustrating the inflation and deflation of the parachute during positive pressure ventilation.

wall pressure exerted by the cuff does not exceed airway pressure. The cuff is intermittently inflated. It is reliable at all pressures and flows for at least many weeks, does not cause pooling of secretions, requires practically no attention by the nursing staff, and functions effectively for extended periods of time. The self-inflating parachute cuff is made of latex rubber. It is fashioned like a parachute with open end toward the lung. (Figure 1.) Its free edge is fixed to the distal end of the ventilating tube by a series of radially placed shrouds which prevent it from becoming everted during its insertion and when subjected to the back-pressure in the trachea during the inflation period of ventilation. (Figure 2.) The cuff effectively traps the back-flow during the inflation period and produces an effective seal against the tracheal mucosa. (Figure 3A.) The cuff does not effect a complete seal during expiration and therefore does not interfere with the movement of secretions. (Figure 3B.) This design of cuff has now been used by us in the experimental laboratory of Mount Zion Hospital and Medical Center for over two years. It has worked effectively with both pressure and volume cycled respirators, at ventilating pressure ranging from 10 to 60 cm of water. It has been kept in the trachea of dogs

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The American Journal of Surgery