Cuff-leak test for predicting postextubation airway complications: a systematic review

Abstract Background Clinical practice guidelines recommend performing a cuff leak test in mechanically ventilated adults who meet extubation criteria to screen those at high risk for post-extubation stridor. Previous systematic reviews demonstrated excellent specificity of the cuff leak test but disagreed with respect to sensitivity. We conducted a systematic review and meta-analysis to assess the diagnostic accuracy of the cuff leak test for predicting post-extubation airway complications in intubated adult patients in critical care settings. Methods We searched Medline, EMBASE, Scopus, ISI Web of Science, the Cochrane Library for eligible studies from inception to March 16, 2020, without language restrictions. We included studies that examined the diagnostic accuracy of cuff leak test if post-extubation airway obstruction after extubation or reintubation was explicitly reported as the reference standard. Two authors in duplicate and independently assessed the risk of bias using the Quality Assessment for Diagnostic Accuracy Studies-2 tool. We pooled sensitivities and specificities using generalized linear mixed model approach to bivariate random-effects meta-analysis. Our primary outcomes were post-extubation airway obstruction and reintubation. Results We included 28 studies involving 4493 extubations. Three studies were at low risk for all QUADAS-2 risk of bias domains. The pooled sensitivity and specificity of cuff leak test for post-extubation airway obstruction were 0.62 (95% CI 0.49–0.73; I2 = 81.6%) and 0.87 (95% CI 0.82–0.90; I2 = 97.8%), respectively. The pooled sensitivity and specificity of the cuff leak test for reintubation were 0.66 (95% CI 0.46–0.81; I2 = 48.9%) and 0.88 (95% CI 0.83–0.92; I2 = 87.4%), respectively. Subgroup analyses suggested that the type of cuff leak test and length of intubation might be the cause of statistical heterogeneity of sensitivity and specificity, respectively, for post-extubation airway obstruction. Conclusions The cuff leak test has excellent specificity but moderate sensitivity for post-extubation airway obstruction. The high specificity suggests that clinicians should consider intervening in patients with a positive test, but the low sensitivity suggests that patients still need to be closely monitored post-extubation.

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PREDICTING LARYNGEAL EDEMA AND STRIDOR UTILIZING CUFF LEAK TEST VS LARYNGEAL AIR COLUMN WIDTH DIFFERENCE: SYSTEMATIC REVIEW AND META-ANALYSIS

CHEST Journal ◽

10.1016/j.chest.2018.08.336 ◽

2018 ◽

Vol 154 (4) ◽

pp. 368A

Author(s):

TAMER SAID AHMED ◽

ZUBAIR KHAN ◽

KHALED SROUR ◽

ALI ELTATAWY ◽

MUJAHED ALKHATHLAN ◽

...

Keyword(s):

Systematic Review ◽

Meta Analysis ◽

Laryngeal Edema ◽

Leak Test ◽

Width Difference ◽

Cuff Leak ◽

Air Column

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Cuff-leak test for the diagnosis of upper airway obstruction in adults: a systematic review and meta-analysis

Applied Physiology in Intensive Care Medicine 1 ◽

10.1007/978-3-642-28270-6_35 ◽

2012 ◽

pp. 171-179 ◽

Cited By ~ 1

Author(s):

Maria Elena Ochoa ◽

Maria del Carmen Marín ◽

Fernando Frutos-Vivar ◽

Federico Gordo ◽

Jaime Latour-Pérez ◽

...

Keyword(s):

Systematic Review ◽

Airway Obstruction ◽

Meta Analysis ◽

Upper Airway ◽

Upper Airway Obstruction ◽

Leak Test ◽

Cuff Leak

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Cuff-leak test for the diagnosis of upper airway obstruction in adults: a systematic review and meta-analysis

Intensive Care Medicine ◽

10.1007/s00134-009-1501-9 ◽

2009 ◽

Vol 35 (7) ◽

Cited By ~ 66

Author(s):

Maria Elena Ochoa ◽

Maria del Carmen Marín ◽

Fernando Frutos-Vivar ◽

Federico Gordo ◽

Jaime Latour-Pérez ◽

...

Keyword(s):

Systematic Review ◽

Airway Obstruction ◽

Meta Analysis ◽

Upper Airway ◽

Upper Airway Obstruction ◽

Leak Test ◽

Cuff Leak

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Cuff-leak test combined with interventional bronchoscopy benefits early extubation for patients who received tarp surgery

European Spine Journal ◽

10.1007/s00586-016-4487-3 ◽

2016 ◽

Vol 26 (3) ◽

pp. 840-846

Author(s):

Jian-qiang Dai ◽

Wei-Feng Tu ◽

Qing-shui Yin ◽

Hong Xia ◽

Guo-dong Zheng ◽

...

Keyword(s):

Early Extubation ◽

Leak Test ◽

Interventional Bronchoscopy ◽

Cuff Leak

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Detection of a Tracheal Obstruction Caused by a Retrosternal Goiter by the Use of a Cuff Leak Test

Anesthesia & Analgesia ◽

10.1213/00000539-200004000-00049 ◽

2000 ◽

Vol 90 (4) ◽

pp. 1002 ◽

Cited By ~ 1

Author(s):

Torsten Meier ◽

Thorsten Leibecke ◽

Jan Schumacher ◽

Klaus Berger ◽

Karl F. Klotz

Keyword(s):

Leak Test ◽

Tracheal Obstruction ◽

Retrosternal Goiter ◽

Cuff Leak

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Comparison between Cuff Leak Test and Ultra Sound Assessment of Laryngeal Edema in Predicting Successful Extubation in Mechanically Ventilated Patients

Journal of Advances in Medicine and Medical Research ◽

10.9734/jammr/2020/v32i2230704 ◽

2020 ◽

pp. 43-51

Author(s):

Manar Mohammed Ismail ◽

Sohair Mostafa Soliman ◽

Hoda Alsaid Ahmed Ezz ◽

Amr Arafa Elbadry

Keyword(s):

Endotracheal Intubation ◽

Ultra Sound ◽

Laryngeal Edema ◽

Leak Test ◽

Vocal Cords ◽

Mechanically Ventilated ◽

Mechanically Ventilated Patients ◽

Cuff Leak ◽

Ventilated Patients ◽

Successful Extubation

Objects: Endotracheal intubation commonly leads to local complications, including mechanical lesions, such as friction and compressions between the tube and the anatomic structures of the larynx leading to laryngeal edemamanifested as ‘‘stridor’’ after extubation. There is no standard method to predict patients at risk of post-extubation stridor. This study was conducted to compare between cuff leak test and ultra sound in predicting successful extubation in mechanically ventilated patients. Patients and Methods: We included a total of 83 mechanically ventilated patients with endotracheal intubation > 24 hours. They were divided according to the outcome after extubation into 72 patients who didn’t develop laryngeal edema and 11 patients who developed laryngeal edema. The patients were extubated when they fulfilled the criteria of extubation and become negative to cuff leak test. All patients underwent both cuff leak test (CLT) and ultra-sound to assess air column width difference (ACWD) after intubation and before extubation. Results: All patients were matched as regard demographic data. There was a significant increase in the duration of mechanical ventilation in the LE group. No significant difference was detected between the two groups regarding CLT and ACWD after intubation. However, cases with laryngeal edema had significantly lower CLT and ACWD before extubation. Using a cut off value of 1.52 mm, ACWD had sensitivity and specificity of 90.9 and 91.7% respectively to predict laryngeal edema after extubation. Conclusions: Laryngeal Ultrasonography could be a useful, reliable, non-invasive method in the evaluation of vocal cords, laryngeal morphology and airflow passing through the vocal cords or subglottic area in intubated patients in comparison with cuff leak test.

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Predictors of post-extubation stridor in patients on mechanical ventilation: a prospective observational study

Scientific Reports ◽

10.1038/s41598-021-99501-8 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Aiko Tanaka ◽

Akinori Uchiyama ◽

Yu Horiguchi ◽

Ryota Higeno ◽

Ryota Sakaguchi ◽

...

Keyword(s):

Mechanical Ventilation ◽

Observational Study ◽

Critically Ill ◽

Critically Ill Patients ◽

Prospective Observational Study ◽

Spontaneous Breathing Trial ◽

Leak Test ◽

Endotracheal Suctioning ◽

Cuff Leak ◽

The Impact

AbstractThe cuff leak test (CLT) has been widely accepted as a simple and noninvasive method for predicting post-extubation stridor (PES). However, its accuracy and clinical impact remain uncertain. We aimed to evaluate the reliability of CLT and to assess the impact of pre-extubation variables on the incidence of PES. A prospective observational study was performed on adult critically ill patients who required mechanical ventilation for more than 24 h. Patients were extubated after the successful spontaneous breathing trial, and CLT was conducted before extubation. Of the 191 patients studied, 26 (13.6%) were deemed positive through CLT. PES developed in 19 patients (9.9%) and resulted in a higher reintubation rate (8.1% vs. 52.6%, p < 0.001) and longer intensive care unit stay (8 [4.5–14] vs. 12 [8–30.5] days, p = 0.01) than patients without PES. The incidence of PES and post-extubation outcomes were similar in patients with both positive and negative CLT results. Compared with patients without PES, patients with PES had longer durations of endotracheal intubation and required endotracheal suctioning more frequently during the 24-h period prior to extubation. After adjusting for confounding factors, frequent endotracheal suctioning more than 15 times per day was associated with an adjusted odds ratio of 2.97 (95% confidence interval, 1.01–8.77) for PES. In conclusion, frequent endotracheal suctioning before extubation was a significant PES predictor in critically ill patients. Further investigations of its impact on the incidence of PES and patient outcomes are warranted.

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The cuff leak test prior to extubation: A practice based on limited evidence

Saudi Critical Care Journal ◽

10.4103/sccj.sccj_27_17 ◽

2017 ◽

Vol 1 (6) ◽

pp. 22

Author(s):

Waleed Alhazzani ◽

Kim Lewis

Keyword(s):

Limited Evidence ◽

Leak Test ◽

Cuff Leak

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Cuff Leak Test and Airway Obstruction in Mechanically Ventilated ICU Patients (COMIC): a pilot randomised controlled trial protocol

BMJ Open ◽

10.1136/bmjopen-2019-029394 ◽

2019 ◽

Vol 9 (7) ◽

pp. e029394 ◽

Cited By ~ 1

Author(s):

Kimberley Lewis ◽

Sarah Culgin ◽

Roman Jaeschke ◽

Dan Perri ◽

Corry Marchildon ◽

...

Keyword(s):

Mechanical Ventilation ◽

Controlled Trial ◽

Invasive Mechanical Ventilation ◽

Laryngeal Oedema ◽

Leak Test ◽

Icu Patients ◽

Pilot Randomised Controlled Trial ◽

Mechanically Ventilated ◽

Cuff Leak ◽

Randomised Controlled

IntroductionEndotracheal intubation and invasive mechanical ventilation are lifesaving interventions that are commonly performed in the intensive care unit (ICU). Laryngeal oedema is a known complication of intubation that may cause airway obstruction in a patient on extubation. To date, the only test available to predict this complication is the cuff leak test (CLT); however, its diagnostic accuracy and utility remains uncertain. Herein, we report the protocol for the CuffLeak and AirwayObstruction in MechanicallyVentilated ICU Patients (COMIC) pilottrial.Methods and analysisThis will be a multicentred, pragmatic, pilot randomised controlled trial (RCT). We will enrol 100 mechanically ventilated patients in the ICU who are deemed ready for extubation. We will exclude patients at a high risk of laryngeal oedema. All enrolled patients will have a CLT done before extubation. In the intervention arm, the results of the CLT will be communicated to the bedside physician, and decision to extubate will be left to the treating team. In the control arm, respiratory therapist will not communicate the results of the CLT to the treating physician, and the patient will be extubated regardless of the CLT result. Randomisation will be done in a 1:1 allocation ratio, stratified by size of the endotracheal tube and duration of invasive mechanical ventilation.Although we will examine all clinical outcomes relevant for the future COMIC RCT, the primary outcomes of the COMIC pilottrial will be feasibility outcomes including: consent rate, recruitment rate and protocol adherence. Clinical outcomes include postextubation stridor, reintubation, emergency surgical airway, ICU mortality, in hospital mortality, duration of mechanical ventilation and ICU length of stay in days.Ethics and disseminationThe Hamilton Integrated Research Ethics Board, Imam Abdulrahman Bin Faisal University Institutional Review Board and Bioethical Commission of the Jagiellonian University approved this study. The trial results will be disseminated via publication in peer-reviewed journals.Trial registration numberNCT03372707.

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