Knowledge and practice of tracheal tube cuff pressure monitoring: a multicenter survey of anaesthesia and critical care providers in a developing country

Background Tracheal tubes are routinely used during anaesthesia and in the intensive care unit. Subjective monitoring of cuff pressures have been reported to produce consistently inappropriate cuffs pressures, with attendant morbidity. But this practice of unsafe care remains widespread. With the proliferation of intensive care units in Nigeria and increasing access to surgery, morbidity relating to improper tracheal cuff pressure may assume a greater toll. We aimed to evaluate current knowledge and practice of tracheal cuff pressure monitoring among anaesthesia and critical care providers in Nigeria. Methods This was a multicenter cross-sectional study conducted from March 18 to April 30, 2021. The first part (A) was conducted at 4 tertiary referral hospitals in Nigeria by means of a self-administered questionnaire on the various cadre of anaesthesia and critical care providers. The second part (B) was a nation-wide telephone survey of anaesthesia faculty fellows affiliated to 13 tertiary hospitals in Nigeria, selected by stratified random sampling. Results Only 3.1% (6/196) of the care providers admitted having ever used a tracheal cuff manometer, while 31.1% knew the recommended tracheal cuff pressure. The nationwide telephone survey of anaesthesia faculty fellows revealed that tracheal cuff manometer is neither available, nor has it ever been used in any of the 13 tertiary hospitals surveyed. The ‘Pilot balloon palpation method’ and ‘fixed volume of air from a syringe’ were the most commonly utilized method of cuff pressure estimation by the care providers, at 64.3% and 28.1% respectively in part A survey (84.6% and 15.4% respectively, in the part B survey). Conclusion The use of tracheal cuff manometer is very limited among the care providers surveyed in this study. Knowledge regarding tracheal cuff management among the providers is adjudged to be fair, despite the poor practice and unsafe care.

Transesophageal echocardiography-associated tracheal microaspiration and ventilator-associated pneumonia in intubated critically ill patients: a multicenter prospective observational study

Background Microaspiration of gastric and oropharyngeal secretions is the main causative mechanism of ventilator-associated pneumonia (VAP). Transesophageal echocardiography (TEE) is a routine investigation tool in intensive care unit and could enhance microaspiration. This study aimed at evaluating the impact of TEE on microaspiration and VAP in intubated critically ill adult patients. Methods It is a four-center prospective observational study. Microaspiration biomarkers (pepsin and salivary amylase) concentrations were quantitatively measured on tracheal aspirates drawn before and after TEE. The primary endpoint was the percentage of patients with TEE-associated microaspiration, defined as: (1) ≥ 50% increase in biomarker concentration between pre-TEE and post-TEE samples, and (2) a significant post-TEE biomarker concentration (> 200 μg/L for pepsin and/or > 1685 IU/L for salivary amylase). Secondary endpoints included the development of VAP within three days after TEE and the evolution of tracheal cuff pressure throughout TEE. Results We enrolled 100 patients (35 females), with a median age of 64 (53–72) years. Of the 74 patients analyzed for biomarkers, 17 (23%) got TEE-associated microaspiration. However, overall, pepsin and salivary amylase levels were not significantly different between before and after TEE, with wide interindividual variability. VAP occurred in 19 patients (19%) within 3 days following TEE. VAP patients had a larger tracheal tube size and endured more attempts of TEE probe introduction than their counterparts but showed similar aspiration biomarker concentrations. TEE induced an increase in tracheal cuff pressure, especially during insertion and removal of the probe. Conclusions We could not find any association between TEE-associated microaspiration and the development of VAP during the three days following TEE in intubated critically ill patients. However, our study cannot formally rule out a role for TEE because of the high rate of VAP observed after TEE and the limitations of our methods.

Comparison of three different techniques of endotracheal tube cuff inflation: just seal, stethoscope guided and pressure volume loop: a prospective randomized study

Background: Cuffed endotracheal tubes not only ensure a proper seal during positive pressure ventilation, but at the same time also prevent aspiration of gastric secretions. The aim of this prospective, randomized study was to compare three methods of ETT cuff inflation-- palpation of the leak in suprasternal notch (Just seal), a stethoscope guided method of tracheal tube cuff inflation and PVL guided cuff inflation.Methods: After approval by institutional ethical committee, 192 patients of either sex in age group of 18-50 years belonging to ASA physical status I or II were enrolled. Each patient was randomly allocated into one of three groups: one group received standard 'just seal' method of tracheal cuff inflation (JS), the second group, the stethoscope-guided method (SG) and in third group cuff was inflated using Pressure Volume Loop (PVL). Volume of air introduced into the cuff and pressure within the cuff was recorded.Results: A total of 192 patients were recruited to the study. The median (IQR [range]) tracheal cuff pressure was 12 (10-22 [6-28]) cm H2O, 16 (12-24[6-38]) and 14 (10-22[8-32]) cmH2O in JS, SG and PVL group respectively. Cuff pressures within the recommended range of 20-30 cm H2O fell in 25% of the patients in both JS and SG group and 31% patients in PVL group. The mean volumes of air introduced in the cuff and the resultant mean cuff pressure in all groups was found to be statistically insignificant (p= 0.4, 0.18 respectively). Tidal volume discrepancy was more and 75% of cuff pressures were less than the recommended range in JS than the other two groups.Conclusions: Real time PVL displayed on most modern anaesthesia machine is a good alternative to check for proper ETT cuff inflation, avoid high cuff pressure and monitor air leak.