Subjective method for tracheal tube cuff inflation: performance of anesthesiology residents and staff anesthesiologists. Prospective observational study / Insuflação de balonete de tubo traqueal por método subjetivo: desempenho de médicos residentes e especialistas em anestesiologia. Estudo prospectivo observacional

Abstract Background and objectives: Poor monitoring of tracheal tube cuff pressure may result in patient complications. The objective method of using a manometer is recommended to keep safe cuff pressure values (20‒30 cm H2O). However, as manometers are not readily available, anesthesiologists use subjective methods. We aimed to assess appropriateness of a subjective method for attaining cuff pressure and the expertise level of manometer handling among anesthesiology staff and residents in a university teaching hospital. Methods: Prospective observational study, recruiting participants that performed tracheal intubation and the subjective method for tube cuff inflation. Patients with difficult airway, larynx and trachea anatomic abnormality and emergency procedures were not included. Up to 60 minutes after tracheal intubation, an investigator registered the cuff pressure using an aneroid manometer (AMBU®) connected to the tube pilot balloon. Results: Forty-seven anesthesiologists were included in the study - 24 residents and 23 staff. Mean (SD) and medians (IQR) measured in cmH2O were, respectively, 52.5 (27.1) and 50 (30‒70). We registered 83% of measurements outside the recommended pressure range, with no difference between specialists and residents. The level of expertise with the objective method was also similar in both groups. Pressure adjustments were performed in 76.6% of cases. Conclusion: The subjective method for inflating the tracheal tube cuff resulted in a high rate of inadequate cuff pressures, with no difference in performance between anesthesiology specialists and residents.

Resumo Justificativa e objetivos: O controle inadequado da pressão dos balonetes dos tubos traqueais pode resultar em complicações. A técnica objetiva com uso de manômetro é a recomendada para manutenção de valores seguros de pressão (20-30 cm H2O). Mas como ese instrumento é pouco disponível, os anestesiologistas recorrem a técnicas subjetivas. O objetivo deste estudo foi avaliar a adequação da técnica subjetiva para obtenção das pressões dos balonetes e o nível de experiência com uso do manômetro entre médicos especialistas e residentes de anestesiologia de um Hospital Universitário. Método: Estudo observacional prospectivo, com participantes que realizaram intubação traqueal e técnica subjetiva para insuflação dos balonetes. Pacientes com via aérea difícil, anormalidades anatômicas de laringe e traqueia, risco de broncoaspiração e os casos de emergência não foram incluídos. Até 60 minutos após a intubação, um investigador registrava a pressão do balonete utilizando um manômetro aneroide (AMBU®) conectado ao balonete guia do tubo. Resultados: Quarenta e sete anestesiologistas foram incluídos no estudo - 24 residentes e 23 especialistas. As pressões (cm H2O) média (DP) e mediana (IQR) encontradas foram, respectivamente, 52,5 (27,1) e 50 (30-70). Da amostra, 83% estavam fora da faixa adequada de pressão, sem diferença entre especialistas e residentes. O nível de experiência com a técnica objetiva também foi semelhante entre os grupos. Correção da pressão foi realizada em 76,6% dos casos. Conclusões: A técnica subjetiva para insuflar os balonetes dos tubos traqueais resultou em alta prevalência de pressões inadequadas, sem diferença no desempenho entre especialistas e residentes.

Effects of intubation with a double-lumen endotracheal tube on intraocular pressure during rapid sequence induction using succinylcholine chloride in patients with or without underlying systemic hypertension

BACKGROUND: Tracheal intubation is closely associated with increases in intraocular pressure (IOP); however, the effects of double-lumen tube (DLT) intubation on IOP have not been validated. Systemic hypertension (HTN) is another factor that may increase IOP. In this study, we observed differences in IOP increases between DLT and single-lumen tube (SLT) intubation, and evaluated the influence of underlying HTN during rapid sequence induction.METHODS: Sixty-eight patients were allocated into one of the following group: SLT/without HTN (n = 17), SLT/HTN (n = 17), DLT/without HTN (n = 17), and DLT/HTN (n = 17). An SLT was inserted for orthopedic or gynecological surgery, and a DLT was inserted for lung surgery after rapid sequence induction using succinylcholine. IOP was measured before anesthetic induction and until 10 min after intubation using a handheld tonometer (Tono-Pen AVIA®).RESULTS: In the DLT/without HTN and DLT/HTN groups, the maximum increases in IOPs after tracheal intubation were 7.9 and 12.2 mmHg, respectively, compared to baseline. In the SLT/without HTN and SLT/HTN groups, the maximum increases were 5.0 and 4.9 mmHg, respectively, compared to baseline. In comparisons between patients with and without underlying HTN, the values of IOPs were comparable.CONCLUSIONS: Tracheal intubation with a DLT is associated with more increases in IOPs than with an SLT in rapid sequence induction. Well-controlled underlying hypertension did not increase IOP during tracheal intubation.

Comparison of hemodynamic responses to laryngoscopy and intubation with Truview PCDTM, McGrath® and Macintosh laryngoscope in patients undergoing coronary artery bypass grafting: A randomized prospective study.

Context: We hypothesized that reduced oropharyngolaryngeal stimulation with video laryngoscopes would attenuate hemodynamic response to laryngoscopy and intubation. Aim: Comparison of hemodynamic response to laryngoscopy and intubation with video laryngoscopes and Macintosh (MC) laryngoscope. Setting and Design: Superspecialty tertiary care public hospital; prospective, randomized control study. Methods: Sixty adult patients undergoing elective coronary artery bypass grafting (CABG) were randomly allocated to three groups of 20 each: MC, McGrath (MG), and Truview (TV). Hemodynamic parameters were serially recorded before and after intubation. Laryngoscopic grade, laryngoscopy, and tracheal intubation time, ST segment changes, and intra‑/post‑operative complications were also recorded and compared between groups. Statistical Analysis: SPSS version 17 was used, and appropriate tests applied. P < 0.05 was considered significant. Results: Heart rate and diastolic arterial pressure increased at 0 and 1 min of intubation in all the three groups (P < 0.05) while mean arterial pressure increased at 0 min in the MG and TV groups and at 1 min in all three groups (P < 0.05). A significant increase in systolic arterial pressure was only observed in TV group at 1 min (P < 0.05). These hemodynamic parameters returned to baseline by 3 min of intubation in all the groups. The intergroup comparisons of all hemodynamic parameters were not significant at any time of observation. Highest intubation difficulty score was observed with MC (2.16 ± 1.86) as compared with MG (0.55 ± 0.88) and TV (0.42 ± 0.83) groups (P = 0.003 and P = 0.001, respectively). However, duration of laryngoscopy and intubation was significantly less in MC (36.68 ± 16.15 s) as compared with MG (75.25 ± 30.94 s) and TV (60.47 ± 27.45 s) groups (P = 0.000 and 0.003, respectively). Conclusions: Video laryngoscopes did not demonstrate any advantage in terms of hemodynamic response in patients with normal airway undergoing CABG.

Knowledge and Management of Tracheal Tube Cuffs Among ICU Nurses in Korea / 성인간호학회지

PURPOSE: The aim of this research was to determine knowledge and management of tracheal tube cuffs among nurses of ICU. METHODS: This descriptive survey recruited 150 nurses working at 8 different adult ICUs within 2 tertiary hospitals in Seoul. A survey questionnaire was developed to measure cuff management. The internal reliability of the tool was examined by Cronbach's alpha Descriptive statistics and multiple regressions were used to analyze data. RESULTS: Among the 150 nurses, 94.0% replied that they would measure the pressure themselves. With regard to nurses' knowledge about tracheal tube cuffs, only 6% answered that they knew 'the appropriate cuff pressure'. The existence of a measuring device (p < .001), a guideline (p < .001), the level of knowledge on its related complications(p = .003), and clinical experience (p < .001) together accounted for 35.0% of the total variation in cuff management. They pointed out that the lack of time and the lack of education were major barriers to appropriate management; whereas education update was the most imperative factor for good management. CONCLUSION: ICU nurses have inappropriate knowledge and practice in cuff management. Therefore continuing education is necessary for better practice of tracheal tube cuff management.

Medidas dos níveis de pressão do balonete em unidade de terapia intensiva: considerações sobre os benefícios do treinamento / Measurement of tube cuff pressure levels in intensive care unit: considerations on the benefits of training

JUSTIFICATIVA E OBJETIVOS: A pressão do balonete transmitida diretamente na parede da traquéia de forma irregular pode ocasionar lesões e levar a broncoaspiração. O objetivo deste estudo foi demonstrar que ao implantar uma rotina de mensuração da pressão do balonete, obtém-se controle fidedigno para manter as medidas dentro dos parâmetros considerados seguros, evitando assim, as complicações descritas. MÉTODO: Foram avaliadas 3195 medidas de pressão de balonete em 1194 pacientes dos sexos masculino e feminino, internados nas unidades de terapia intensiva (UTI) e coronariana (UC), que estavam sob ventilação mecânica com uso de prótese endotraqueal e cânula de traqueostomia, nos períodos matutino e vespertino. RESULTADOS: Durante o período de março a agosto de 2005 foi realizado acompanhamento das medidas colhidas pelos profissionais de fisioterapia e observou-se que as medidas foram irregulares, em média, em 80 por cento dos casos. Diante desse fato foi elaborado um programa de treinamento, com foco nas Equipes de Enfermagem das UTI e UC, que consistiu na orientação dos procedimentos adequados realizados à beira do leito (treinamento em loco). Os treinamentos foram realizados em dois períodos (matutino e vespertino) para abranger toda a equipe. CONCLUSÕES: Sugere-se a necessidade da vigilância das pressões do balonete através da implantação de uma rotina de mensurações matutina, vespertina e noturna, como meio profilático, para prevenir as possíveis complicações da pressão de balão da prótese traqueal.

BACKGROUND AND OBJECTIVES: The tube cuff pressure directly transmitted on the tracheal wall in an irregular form can cause injuries and lead to bronchoaspiration. The aim of this study was to demonstrate that the implementation of routine tube cuff pressure measurements result in a reliable control to maintain the measurements within the parameters considered safe, thus preventing the described complications. METHODS: A total of 3,195 tube cuff measurements were obtained from 1,194 male and female patients admitted at the Intensive Care Unit (ICU) and Coronary Unit (CU), who were undergoing mechanical ventilation with endotracheal prosthesis and tracheotomy cannula, during the morning and afternoon periods. RESULTS: From March to August 2005 the follow-up of the measurements obtained by the physical therapy professionals was carried out and it was observed that the measurements were irregular, on average, in 80 percent of the cases. Thus, a training program was established, which was focused on the Nursing Teams of the ICU and CU, consisting in providing directions for the adequate procedures performed at the bedside (in loco training). The training procedures were carried out at two different periods (morning and afternoon) in order to include the whole team. CONCLUSIONS: It is suggested that it is necessary to monitor tube cuff pressure through the implementation of routine measurements in the morning, afternoon and evening periods as a prophylactic measure, in order to prevent the possible complications of tracheal prosthesis balloon pressure.

Effects of the Size of the Uncuffed Tracheal Tube on Verifying Tube Position by Auscultation in Children / 대한마취과학회지

BACKGROUND: In pediatric anesthesia, a method using deliberate endobronchial intubation and auscultation has been used for proper endotracheal tube depth. Tube size, however, may influence on auscultation for air leak between the tube and main bronchus. We attempted to ascertain whether the uncuffed tracheal tube (TT) size affects verifying tube placement by auscultation in children. METHODS: In 23 children, we measured the distance from the carina to the tip of a tube when the first auscultatory sound could be detected on the left chest and when the breathing sound of both chests equalized during withdrawal from right main bronchus. Then, we compared them with those of either a one-size larger or a one-size smaller tube. RESULTS: The distance from the carina to the tip at the first sound was significantly longer in the smaller tracheal tube (1.8 cm vs 1.5 cm, P = 0.01). The tube tip at the equalized breath sounds was 0.6 cm below the carina in both tubes. CONCLUSIONS: These results suggest that detecting endobronchial intubation may be more difficult when using uncuffed tracheal tubes with one-size smaller tube and that auscultation with deliberate bronchial intubation can place the uncuffed TT deeper than an intended depth.

Comparison of Ventilations with LMA and Endotracheal Tube during Closed Circuit Anesthesia / 대한구급학회지

BACKGROUND: LMA has larger dead-space than tracheal tube, ventilation may be influenced by difference of dead space. Closed circuit mechanical ventilation has high risk of hypercarbia because of inadequate CO2 elimination or gas supply. Thus, end-tidal carbon dioxide tension (EtCO2) and arterial carbon dioxide tension (PaCO2) were compared during closed circuit mechanical ventilation with LMA or tracheal tube. METHODS: Thirty adult patients scheduled for general anesthesia were divided into 2 groups. After induction of general anesthesia, laryngeal mask airway (Group 1, n=15) or tracheal tube (Group 2, n=15) were randomly inserted and closed circuit mechanical ventilation was initiated. When steady state had been reached, PaCO2 and EtCO2 were recorded. RESULTS: The PaCO2 was 32.2+/-2.8 (Group 1), 31.5+/-2.2 (Group 2) and the EtCO2 was 33.0+/-2.9, 31.6+/-2.4 respectively and there was no statistical significance between groups. The difference of arterial and end-tidal carbon dioxide tension in each group was -0.8+/-2.6, -0.03+/-2.2 respectively and there was no statistical significance between groups. CONCLUSIONS: The results indicate that in patients who are mechanically ventilated via the closed circuit system, EtCO2, PaCO2, and the difference between arterial and end-tidal carbon dioxide tension were not significantly different between groups.

Modified Peritoneal Dialysis Treats Acute Renal Failure in Children / 实用儿科临床杂志

Objective To explore a kind of modified peritoneal dialysis (PD) adapt for acute renal failure (ARF) in children. Methods After punctured many pinholes in tail end and sterilized by ethylene oxide the ID 2. 5 tracheal tube and urinary catheter were used as PD - catheter for children. The tracheal tube or urinary catheter was placed in abdomen with Seldinger's techniques Then the PD was carried out in the way that dialysis solution passing in and out of abdomen in two different pipelines Results The edema, circulation and respiration of the 21 children with ARF were improved after PD in this way and the urine quantity increased too, although 5 of them died of D1C and MOSF. No peritonitis or leakage of PD solution was taken place. The Scr.BUN,UA,K + ,CO2- CP of the chidren were decreased from(424? 133)?mol/L,(41.5? 12 6) mmol/L, (764 ? 187) ?mol/L,(6 7 ?2. 1) mmol/L, (14 5 ? 3.7) mmol/L before PD to( 166?37) ?mot/L,(8.9?3 1) mmol/L,(350?74) ?mol/L,3.7?0 4 mmol/L,(23.0? 1. 8) ?mol/L.Conclusion Tracheal tube or urinary catheter may be used as PD- catheter for ARF in children.

The Effectiveness of the Use of ETCO2 Cuffed Tracheal Tube for the Measurement of End Tidal CO2 Tension / 대한마취과학회지

To evaluate the relationship between arterial and ent tidal carbon dioxide teneion, we use ETCO2cuffed tracheal tude. Twenty five patients were selected for the study. The anesthesia was induced by pentothal sodium 4-5mg/kg, succinylcholine 1-1.5mg/kg After intubation, anesthesia was maintained by halothane, nitrous oxide and oxygen. The patients were ventilated mechanically with tidal bolume 10 ml/kg and respiration rate 12/min When anesthesia was stabilized, end tidal cardon dioxide tension were measured at proximal and distal site of ETO2cuffed tracheal tube. The arterial blood sample were taken for arterial carbon dioxide tension from radial artery simultaneously. The results were as follows: 1) Both the end tidal carbon dioxide tension at proximal and distal sites of the tube showed close correlationship with arterial carbon dioxide tension 2) There was no statistical significant difference in carbon dioxide tension between proximal and distal site of ETCO2cuffed tracheal tube.