0090.2483/90/1812-1423802.00/0 (Cares Cans Mepicase (Copricht 1990 6 The Wiliams & Wikins Co RRR EES sane: Vol. 18, No.2 Praniodin OSA Endotracheal tube cuff pressure assessment: Pitfalls of finger estimation and need for objective measurement RAFAEL FERNANDEZ, MD; ANTONIO ARTIGAS, MD Estimation of endotracheal (ET) cuff pressure by finger palpation is one of the methods currently used in the clinical setting. We compared the accuracy of this ‘method with instrumental intracuff pressure measure- ‘ment in tracheal model tests by 20 members of our ICU team. Four different ET tubes at three different pressure levels were examined. Accuracy for the estimated method by finger palpa- tion was 69% for high pressures, 58% for normal pres- sures, and 73% for low ‘ences in terms of sensitivity, specificity, and posi predictive power between different tubes reflecting ferences in tube characteristics and interobserver va ability. We conclude that precise intracuff pressure Tissue damage and other problems attributable to endotracheal (ET) intubation occur frequently in me- chanically ventilated patients, originating in most cases at the cuff site of the ET tubes. Although deleterious, consequences have decreased with the routine use of high-volume, low-pressure cuffs, tracheal stenosis or ‘racheoesophageal fistula can still occur (1-3). Ischemia of the tracheal mucosa originating at the interface be- tween tube cuff and tracheal epithelium is widely rec- ognized as the major determinant of tracheal injury in these patients, with the ischemia being proportional to cuff pressures >20 to 25 cm HO, which is the perfusion, pressure of the tracheal mucosa and submucosa (4, 5). At present, the ET tubes in regular use have an external reservoir that proportionally expands in re- sponse to the downward pressure in the cuff (6). For practical reasons, estimating cuff pressure by finger palpation of the reservoir is one of the most widely used. methods in the clinical setting. Nevertheless, this may lead to erroneous conclusions unless a direct measure- ment of cuff pressure is performed at the bedside, In this study, we tested the hypothesis that subjective finger estimation could misjudge the appropriate infla- tion pressure duc to the different characteristics of the ‘tube components (namely, clasticity and distensibility) Secvei de Medicina Intensiva, Hospital de Sabadell. (Drs. Fernandes, Blanch, Mancebo, and Bonsoms), and the Departament de Fisiologia (Dr. Artigas) de la Facultat de Medicina de la Universitat Autonoma de Barcelona, Sabadell, Spain, 1423 LLUIS BLANCH, MD; JORDI MANCEBO, MD; NATALIA BONSOMS, MD; used by the different manufacturers. Observer exper cence was also considered because it was thought this could add to the unreliability of the manual estimation, ‘method. This approach, if our hypothesis were to be con- firmed, would demonstrate the need for periodic instru- ment checking and/or continuous monitoring of cuff pressure to avoid deleterious consequences in intubated patients (7). MATERIALS AND METHODS We tested high-volume, low-pressure cuff ET tubes of 8 mm ID from four different manufacturers (Shiley, Irvine, CA; Sheridan, Argyle, NY; Rusch, Waiblingen, FRG; and Mallinckrodt, Athlone, Ireland). The ET tubes were inflated with 10, 20, and 35 cm HO corre- sponding to low-, normal-, and high-pressure reference values, respectively. The volume needed to achieve each pressure level was measured with a calibrated syringe. ‘The tubes were introduced in a trachea simulator (6), consisting ofa rigid, 2-cm ID plastic cylinder. The distal end of the tubes was introduced in an opaque recipient without contact between the walls of the cuff and the recipient. The observers were prevented by the experi- ment from knowing the true cuff inflation pressure and the cuff was then randomly inflated with 10, 20, and 35 om HO pressure, ‘The observers were randomly selected from among our ICU team. Four physicians and 16 nurses partici pated in this study. Mean experience with intubated patients was 2.7 yr (range 0.5 to 12). The observers estimated the cuff pressure by manual palpation of the reservoir and labeled the pressure as infra-, normo-, or hyperinflated to classify the cuff pressure of each tube at cach level. Cuff pressures were measured by means of an aneroid ‘manometer (109-01, Mallinckrodt). The range of mea- surement was 0 to 120 cm HO. Linearity of response ‘was compared using the manometer and a differential pressure transducer (HP 270, Hewlett-Packard, Waltham, MA). Statistics were performed using a concordance analy- sis between the manometer and the differential pressure ‘transducer (8). To test the differences between esti- ‘mated and measured cuff pressures, we calculated sen- sitivity (true positive/true positive + false negative) x1424 CRITICAL CARE MEDICINE Decenper, 19) 100, specificity (true negative/false positive + true neg- ative) X 100, positive predictive power (true positive/ ‘true positive + false positive) x 100, and accuracy (true positive + true negative/total number) x 100 for each level of pressure and for each tube. RESULTS Analysis of linearity for the aneroid manometer showed a mean difference of 3.2 cm HO for the range between 0 and 70 cm HO, but the difference increased progressively above this level (Fig, 1). For the purpose of this study, the difference between measured pressures with the aneroid manometer and the differential pres- sure transducer ranged between 10%. The volume of air required to inflate the cuff was different for the various tubes at each level of pressure (Fig. 2), It was observed that the intracuff pressure increased very slowly to reach 10 cm HO, after which the addition of small amounts of volume induced sub- stantial increments in cuff pressure. The diameter reached for a pressure level of 20 cm HO was 24 mm for Shiley, 28 mm for Rusch, 32 mm for Sheridan, and 35 mm for Mallinckrodt. ‘Volume requirements were smaller when tubes were inflated into the artificial trachea than when there was no restriction (Fig. 3). Also, after the pressure reached allevel of 10-cm HO, the addition of small amounts of volume (0.5 to I ml) induced high-pressure increments (10 to 25 em H0).. In the study phase of the protocol, the results showed little coincidence between the estimated pressures and the measured pressures (Fig. 4). We were unable to demonstrate any relation between the reliability of the 140. 120: e 100: 80. 60: (cm H20) 40 MALLINCKRODT MANOMETER 20 0 0 20 40 60 80 100 120 140 DIFFERENTIAL PRESSURE TRANSDUCER (om H20) Fic. 1. Accuracy of the Mallinckrodt manometer compared with the ferential pressure transducer HP 270 PRESSURE (emHi20) Bs 8 8B 70 Ea VOLUME (mi) Fic, 2. Volume pressure cures fr inflaton for each tube wil restiation. 100. Bw z E 2 ow, g S «| 3 8 g ° VOLUME (mi) iG. 3. Volume pressure curves for inflation for cach (le ‘confined in a tracheal model Fig, 4, Number of cases estimated as high, and the true inflation pressures. Mall, Mal Shi, Shiley; R, Rusch estimation and the experience of the obsl\t differences were detected in the accuriey of | mation of the cuff pressure in relation (0 pf status (physicians or nurses). The resilis if sensitivity, specificity, positive predictive ji accuracy to detect either low, normal, of IVol. 18, No. 12 pressures are shown in Table 1. The indices for each lube are shown in Figures 5, 6, and 7. DISCUSSION The results of the present study support the hypoth- esis that the reliability of cuff pressure estimation is very low. Consequently, the use of objective systems for measurement is mandatory and is reemphasized in ‘our study to diminish the likelihood of tracheal injury. ‘The incidence of tracheal sequelae due to ET intu- bation with cuffed tubes has been widely described since mechanical ventilation was first introduced as a sup- portive method. The first ET tubes had a low compli- ance latex rubber cuff requiring a high level of pressure to seal the tracheal lumen, which has since been re- placed by cuff tubes made of high compliance plastic. ‘Thus, high volumes can be achieved with only a small increment of pressure, thereby reducing the incidence of tracheal injury (6). Despite the use of low-pressure, high-volume cuffed tubes, a recent study (1) reported some degree of laryn- eal or tracheal damage in all patients after elective ET intubation, despite hyperinflation hazards that can be avoided through close monitoring of cuff pressure. Nevertheless, different epidemiologic studies (3) re- ported an incidence of postintubation tracheal stenosis as high as 20%. Factors associ sted with tracheal injury in patients ‘TasLe I. Diagnostic power (in percent) to detect high, normal, and low cuff pressures by subjective estimation Sensitivity Specificity PPP Accuracy High pressure 70 oO Normal pressure 2 Ce Low pressure 37 uo 7 8 PPP, postive pred ive power. LOW INFLATING PRESSUnc Wioccinoy ~— Shite BS fuseh EBB Sheridan 109: ME iallinckrout ‘Senativly Spectcly Predictive Azouracy Fic. 5. Diagnostic accuracy forthe estimated low inflation pressure ofeach tue, Fernandez et al—CUFF PRESSURE ESTIMATION NORMAL INFLATING PRESSURE ee one Shitey Rusch qn E53 Sheridon MB Mallinckrodt Poste Prete Acorosy Senay Specialy Frc. 6, Diagnostic accuracy forthe estimated normal inflation pres: sure of each tube, HIGH INFLATING PRESSURE (35 em H20) Shiley Rusch Sheridan Mallinckrodt 100: §820 Posie Preicive fecurcy Sencivy Spee Fic. 7. Diagnostic accuracy forthe estimate high inflation pressure of each tube include the reduction in mucosal blood flow (hypoten- sive states, shock, and anemia) and a low oxygen deliv- ery to tracheal tissue (hypoxemia and metabolic aci- dosis) (4). Additionally, mechanical factors, such as an NG tube positioned in the lumen of the esophagus, seem to increase the risk of developing tracheoesopha- geal fistulas (2), Pressure exerted by the cuff on the tracheal mucosae seems to be the major cause of postintubation sequelae (1-4, 6). Ischemic damage of the trachea depends on the balance between mucosal perfusion pressure and the pressure exerted by the cuff. If the cuff pressure exceeds mucosal perfusion pressure, the induction of ischemia and/or necrosis is only a question of time (5) ‘The initial injury consists of tracheitis without ulcera- tion, after which mucosal denudation with cartilage exposure will appear within a variable period of time 0). On the other hand, problems attributable to an in-1426 CRITICAL CARE MEDICINE sufficient cuff inflation have been reported (9). These include leaks of the tidal volume supplied by the ven- tilator and microaspirations of oropharyngeal secre- tions that could produce nosocomial pulmonary infec- tions (10). One study (11) showed that by inflating the cuff only to avoid airleaks but without achieving a sufficient cuff pressure, bronchial aspirations may occur due to the negative swings of intrathoracic pressure and. the increase in tracheal diameter during the patient's active inspiration, We observed that low-pressure, high-volume culls behaved as low compliance reservoirs in the artificial human trachea model (Fig. 3), corresponding with pre- vious studies (12) that found steep pressure-volume curves when tubes were confined within a trachea. ‘Although the balloon cuff may be easily distensible in open air, when confined within the trachea, small in- ‘crements in the inflation volume may produce high pressure The demonstration of such a low accuracy for finger pressure estimation of the downward cuff pressure is the most important finding of this study. Because of volume and shape differences in external reservoirs, finger pressure on the reservoir will produce varying sensations. On the other hand, the change in pressure perception when the tube is placed in the trachea needs to be considered. The variability in elasticity and com- pliance among the trachea of different patients can induce added errors (6). In the present study, we avoided this interference by using tubes without any physical restriction, testing the characteristics solely attributable to the tubes. The lack of correlation between the ability to detect cuff pressure and the professional status of the observers or their experience caring for intubated patients suggests that this hazard cannot be avoided by careful training of the healthcare team, but by using an objective system to measure cuff pressure. Additionally, our results sug- gest that patients are more frequently exposed to risks derived from underinflation than hyperinflation. Decesmii, | We demonstrated that the manometers recvhily | troduced to measure cuff pressure (7, 8) can be use a basic tool in the care of intubated patients. {lie of systems to continuously monitor cuff presse (1 should be further investigated. In conclusion, if sults suggest that manual estimation is an uni ‘method to monitor cuff pressure, mostly becis physical properties of the tubes and the variabilly the observers. Reliable systems of measurenvetit i be used to avoid deleterious effects due 10 alii cuff pressures. 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