Comparative Efficacy of Intracuff 1% and 2% Alkalinized Lignocaine with Saline on Endotracheal Tube-Induced Hemodynamic Changes and Emergence Phenomena in Neurosurgical Patients.

Introduction Extubation is associated with hemodynamic changes and emergence phenomena leading to cough, sore throat, dysphonia, and dysphagia in the postoperative period. The aim of our study was to compare intracuff 2% alkalinized lignocaine with 1% alkalinized lignocaine and saline in reducing endotracheal tube induced emergence phenomena and haemodynamic changes at extubation in neurosurgical patients. Materials and Methods In this randomized controlled study, 90 adult patients of either sex, scheduled to undergo neurosurgical procedures were randomly divided into three groups of 30 each to receive either 1% alkalinized lignocaine (AL1), 2% alkalinized lignocaine (AL2), or saline as cuff inflation media. Intracuff pressures and haemodynamic variables were noted intraoperatively and during emergence. The presence of postextubation cough, sore throat, dysphonia, and dysphagia were monitored until 24 hours postoperatively. Data were analyzed using Chi-square test and ANOVA. A p -value of less than 0.05 was considered significant. Results The intracuff pressures were significantly less with alkalinized lignocaine as compared to saline, after 3 hours of induction. Post extubation, hemodynamic parameters and incidence of coughing and bucking at extubation were significantly less in Groups AL1 ( p = 0.024) and AL2 ( p = 0.02) as compared to saline. On assessment of laryngotracheal morbidity, the incidence of coughing was found to be significantly less with 2% alkalinized lignocaine as compared to saline ( p = 0.021) at 1 hour after extubation. Sore throat was significantly less in Groups AL1 and AL2 as compared with saline at 1 hour ( p = 0.008, 0.002 respectively) and 8 hours ( p = 0.01 in both groups), and in Group AL2 versus saline at 24 hours ( p = 0.044) after extubation. The incidence of dysphonia was significantly less in Groups AL1 and AL2 as compared with saline at 1 hour ( p = 0.016, p = 0.002) and 24 hours ( p = 0.012 in both groups) and in Group AL2 versus saline at 8 hours (p = 0.03) postoperatively. No significant differences were noted between 1% alkalinized lignocaine and 2% alkalinized lignocaine. Conclusion Intracuff alkalinized lignocaine 1% and 2% were significantly better than saline in reducing coughing and bucking at extubation, post extubation haemodynamic changes and incidence of postoperative cough, sore throat, and dysphonia.

Unifying Endotracheal Intracuff-Pressure Monitoring in the Intensive Care Unit: Bridging the Gap Between Standardization and Neglect.

Endotracheal cuff-pressure monitoring is a critical component of patient care in the intensive care unit, ensuring the safety and efficacy of mechanical ventilation. Despite its importance, there remains a lack of standardized protocols regarding optimal pressure targets and documentation practices. This editorial examines the significance of endotracheal intracuff-pressure monitoring in enhancing patient outcomes, highlighting the challenges and potential solutions in clinical practice.

Usefulness of an automatic cuff pressure controller (SmartCuff) in inhibiting gasleakage around the cuff after tracheal intubation: a randomized controlled study.

PURPOSE: Gas leakage around the cuff of a tracheal tube may frequently occur after tracheal intubation and inflation of the cuff. We assessed if the SmartCuff (Smiths Medical Japan, Tokyo, Japan), an automatic cuff pressure controller, would effectively prevent gas leakage. METHODS: Seventy adult patients were allocated randomly to one of two groups. After induction of general anesthesia and tracheal intubation, in one group (Syringe group), a syringe was used to inflate the cuff, until there was no audible gas leakage, at the airway pressure at 20 cmH2O. In the other group (SmartCuff group), the SmartCuff was used to maintain the cuff pressure to be 20 cmH2O. The mechanical ventilation (tidal volume of 8 ml.kg-1 and 12 breaths per min) was started. The incidence and percentage of gas leakage, and the proportion of adequate seal (defined as gas leakage of < 10%) between the groups were compared. RESULTS: The incidence of audible gas leakage was significantly higher in the Syringe group (10 of 35 patients (28%)) than in the SmartCuff group (none of 35 patients (0%)) (P = 0.00046, 95%CI for difference: 15-43%), and the proportion of adequate seal was significantly lower in the Syringe group (19 of 35 patients (54%)) than in the Smart cuff group (33 of 35 patients (94%)) (P = 0.0001, 95% CI for difference: 20-58%). CONCLUSION: Gas leakage may frequently occur after tracheal intubation, and the use of the SmartCuff can effectively maintain the sealing effect of the cuff.

Efficacy and safety of three inflation methods of the laryngeal mask airway Ambu® Auraonce™: a randomized controlled study.

The laryngeal mask airway (LMA) is commonly used for airway management. Cuff hyperinflation has been associated with complications, poor ventilation and increased risk of gastric insufflation. This study was designed to determine the best cuff inflation method of AuraOnce™ LMA during bronchoscopy and EBUS (Endobronquial Ultrasound Bronchoscopy) procedure. We designed a Randomized controlled, doble-blind, clinical trial to compare the efficacy and safety of three cuff inflation methods of AuraOnce™ LMA. 210 consenting patients scheduled for EBUS procedure under general anesthesia, using AuraOnce™ LMA were randomized into three groups depending on cuff insufflation: residual volume (RV), half of the maximum volume (MV), unchanged volume (NV). Parameters regarding intracuff pressure (IP), airway leak pressure (OLP), leakage volume (LV) were assessed, as well as postoperative complications (PC). 201 (95.7%) patients completed the study. Mean IP differed between groups (MV: 59.4 ± 32.4 cm H2O; RV: 75.1 ± 21.1 cm H2O; NV: 83.1 ± 25.5 cmH20; P < 0.01). The incidence of IP > 60 cmH2O was lower in the MV group compared to the other two (MV: 20/65(30.8%); RV:47/69 (68.1%); NV 48/67 (71.6%); p < 0.01). The insertion success rate was 89,6% (180/201) at first attempt, with no difference between groups (p = 0.38). No difference between groups was found either for OLP (p = 0.53), LV (p = 0.26) and PC (p = 0.16). When a cuff manometer is not available, a partial inflation of AuraOnce™ LMA cuff using MV method allows to control intracuff pressure, with no significant changes of OLP and LV compared to RV and NV insufflation method.Registration clinical trial: NCT04769791.

Tracheal tube cuff pressure during anesthesia for robotic-assisted laparoscopic prostatectomy and the efficacy of an automatic cuff pressure controller (SmartCuff): observational studies of 1-sample paired data.

PURPOSE: The cuff pressure of a tracheal tube may increase during robot-assisted laparoscopic surgery for prostatectomy (RALP), which requires pneumoperitoneum in a steep head-down position, but there have been no studies which confirmed this. METHODS: In study 1, we studied how frequently the cuff pressure significantly increased during anesthesia for the RALP. In study 2, we studied if the SmartCuff (Smiths Medical Japan, Tokyo) automatic cuff pressure controller would minimize the changes in the intracuff pressure. With approval of the study by the research ethics committee (approved number: 20115), we measured the cuff pressures in anesthetized patients undergoing RALP and in those undergoing gynecological laparotomy (as a reference cohort), with and without the use of the SmartCuff. RESULTS: In 21 patients undergoing RALP, a clinically meaningful increase (5 cmH2O or greater) was observed in all the 21 patients (P = 0.00; 95% CI for difference: 86-100%), whereas in 23 patients undergoing gynecological laparotomy, a clinically meaningful decrease (5 cmH2O or greater) was observed in 21 of 23 patients (91%, P < 0.0001; 95% CI for difference: 72-99%). With the use of the SmartCuff, there was no significant increase in the incidence of a clinically meaningful change in the intracuff pressure in either cohort. CONCLUSION: The cuff pressure of a tracheal tube would frequently increase markedly in patients undergoing RALP, whereas it would frequently decrease markedly in patients undergoing gynecological laparotomy. The SmartCuff may inhibit the changes in the cuff pressure during anesthesia.

The changes of endotracheal tube intracuff pressures after ear and head and neck surgery-related positions: a prospective observational study / Alterações na pressão intracuff do tubo endotraqueal após posições cirúrgicas nas cirurgias de orelha e cabeça e pescoço: estudo observacional prospectivo

Abstract Introduction The cuff of an endotracheal tube seals the airway to facilitate positive-pressure ventilation and reduce subglottic secretion aspiration. However, an increase or decrease in endotracheal tube intracuff pressure can lead to many morbidities. Objective The main purpose of this study is to investigate the effect of different head and neck positions on endotracheal tube intracuff pressure during ear and head and neck surgeries. Methods A total of 90 patients undergoing elective right ear (Group 1: n = 30), left ear (Group 2: n = 30) or head and neck (Group 3: n = 30) surgery were involved in the study. A standardized general anesthetic was given and cuffed endotracheal tubes by the assistance of video laryngoscope were placed in all patients. The pilot balloon of each endotracheal tube was connected to the pressure transducer and standard invasive pressure monitoring was set to measure intracuff pressure values continuously. The first intracuff pressure value was adjusted to 18.4 mmHg (25 cm H2O) at supine and neutral neck position. The patients then were given appropriate head and neck positions before related-surgery started. These positions were left rotation, right rotation and extension by under-shoulder pillow with left/right rotation for Groups 1, 2 and 3, respectively. The intracuff pressures were measured and noted after each position, at 15th, 30th, 60th, 90th minutes and before the extubation. If intracuff pressure deviated from the targeted value of 20-30 cm H2O at anytime, it was set to 25 cm H2O again. Results The intracuff pressure values were increased from 25 to 26.73 (25-28.61) cm H2O after left neck rotation (p = 0.009) and from 25 to 27.20 (25.52-28.67) cm H2O after right neck rotation (p = 0.012) in Groups 1 and 2, respectively. In Group 3, intracuff pressure values at the neutral position, after extension by under-shoulder pillow and left or right rotation were 25, 29.41 (27.02-36.94) and 34.55 (28.43-37.31) cm H2O, respectively. There were significant differences between the neutral position and extension by under-shoulder pillow (p < 0.001), and also between neutral position and rotation after extension (p < 0.001). However, there was no statistically significant increase of intracuff pressure between extension by under-shoulder pillow and neck rotation after extension positions (p = 0.033). Conclusion Accessing the continuous intracuff pressure value measurements before and during ear and head and neck surgeries is beneficial to avoid possible adverse effects/complications of surgical position-related pressure changes.

Resumo Introdução O manguito ou cuff de um tubo endotraqueal sela as vias aéreas para facilitar a ventilação com pressão positiva e reduzir a aspiração de secreção subglótica. Entretanto, o aumento ou diminuição da pressão intracuff do tubo endotraqueal pode levar a muitas morbidades. Objetivo Investigar o efeito de diferentes posições da cabeça e pescoço da pressão intracuff do tubo endotraqueal durante cirurgias de orelha e cabeça e pescoço. Método Participaram do estudo 90 pacientes submetidos à cirurgia eletiva na orelha direita (Grupo 1: n = 30), orelha esquerda (Grupo 2: n = 30) ou cabeça e pescoço (Grupo 3: n = 30). Um anestésico geral padronizado foi administrado e o tubo endotraqueal com cuff foi colocado em todos os pacientes através de videolaringoscopia. O balão-piloto de cada tubo endotraqueal foi conectado ao transdutor de pressão e o monitoramento-padrão da pressão invasiva foi estabelecido para medir continuamente os valores da pressão intracuff. O primeiro valor de pressão intracuff foi ajustado para 18,4 mmHg (25 cm H2O) na posição supina e neutra do pescoço. Em seguida, os pacientes foram colocados nas posições cirúrgicas apropriadas de cabeça e pescoço antes do início da cirurgia. Essas posições foram rotação esquerda, rotação direita e extensão por rotação esquerda/direita com almofada sob o ombro, para os grupos 1, 2 e 3, respectivamente. As pressões intracuff s foram medidas e anotadas após cada posição, aos 15, 30, 60, 90 minutos e antes da extubação. Se a pressão intracuff saísse do valor desejado de 20 ~ 30 cm H2O a qualquer momento, ela era definida em 25 cm H2O novamente. Resultados Os valores de pressão intracuff aumentaram de 25 para 26,73 (25-28,61) cm H2O após a rotação do pescoço para a esquerda (p = 0,009) e de 25 a 27,20 (25,52-28,67) cm H2O após rotação do pescoço para a direita (p = 0,012) nos grupos 1 e 2, respectivamente. No Grupo 3, os valores da pressão intracuff na posição neutra, após extensão com almofada sob o ombro e rotação para a esquerda ou direita, foram 25, 29,41 (27,02-36,94) e 34,55 (28,43-37,31) cm H2O, respectivamente. Houve diferenças significativas entre a posição neutra e a extensão com almofada sob o ombro (p < 0,001) e também entre a posição neutra e a rotação após a extensão (p < 0,001). Entretanto, não houve aumento estatisticamente significante da pressão intracuff entre extensão com almofada sob o ombro e rotação do pescoço após as posições de extensão (p = 0,033). Conclusão As medições contínuas do valor da pressão intracuff antes e durante cirurgias de orelha e cabeça e pescoço são benéficas para evitar possíveis efeitos adversos/complicações de alterações de pressão relacionadas à posição cirúrgica.

The changes of endotracheal tube intracuff pressures after ear and head and neck surgery-related positions: a prospective observational study.

INTRODUCTION: The cuff of an endotracheal tube seals the airway to facilitate positive-pressure ventilation and reduce subglottic secretion aspiration. However, an increase or decrease in endotracheal tube intracuff pressure can lead to many morbidities. OBJECTIVE: The main purpose of this study is to investigate the effect of different head and neck positions on endotracheal tube intracuff pressure during ear and head and neck surgeries. METHODS: A total of 90 patients undergoing elective right ear (Group 1: n=30), left ear (Group 2: n=30) or head and neck (Group 3: n=30) surgery were involved in the study. A standardized general anesthetic was given and cuffed endotracheal tubes by the assistance of video laryngoscope were placed in all patients. The pilot balloon of each endotracheal tube was connected to the pressure transducer and standard invasive pressure monitoring was set to measure intracuff pressure values continuously. The first intracuff pressure value was adjusted to 18.4mmHg (25cm H2O) at supine and neutral neck position. The patients then were given appropriate head and neck positions before related-surgery started. These positions were left rotation, right rotation and extension by under-shoulder pillow with left/right rotation for Groups 1, 2 and 3, respectively. The intracuff pressures were measured and noted after each position, at 15th, 30th, 60th, 90th minutes and before the extubation. If intracuff pressure deviated from the targeted value of 20-30cm H2O at anytime, it was set to 25cm H2O again. RESULTS: The intracuff pressure values were increased from 25 to 26.73 (25-28.61) cm H2O after left neck rotation (p=0.009) and from 25 to 27.20 (25.52-28.67) cm H2O after right neck rotation (p=0.012) in Groups 1 and 2, respectively. In Group 3, intracuff pressure values at the neutral position, after extension by under-shoulder pillow and left or right rotation were 25, 29.41 (27.02-36.94) and 34.55 (28.43-37.31) cm H2O, respectively. There were significant differences between the neutral position and extension by under-shoulder pillow (p<0.001), and also between neutral position and rotation after extension (p<0.001). However, there was no statistically significant increase of intracuff pressure between extension by under-shoulder pillow and neck rotation after extension positions (p=0.033). CONCLUSION: Accessing the continuous intracuff pressure value measurements before and during ear and head and neck surgeries is beneficial to avoid possible adverse effects/complications of surgical position-related pressure changes.

AARC Clinical Practice Guideline: Management of Pediatric Patients With Tracheostomy in the Acute Care Setting.

Children requiring a tracheostomy to maintain airway patency or to facilitate long-term mechanical ventilatory support require comprehensive care and committed, trained, direct caregivers to manage their complex needs safely. These guidelines were developed from a comprehensive review of the literature to provide guidance for the selection of the type of tracheostomy tube (cuffed vs uncuffed), use of communication devices, implementation of daily care bundles, timing of first tracheostomy change, type of humidification used (active vs passive), timing of oral feedings, care coordination, and routine cleaning. Cuffed tracheostomy tubes should only be used for positive-pressure ventilation or to prevent aspiration. Manufacturer guidelines should be followed for cuff management and tracheostomy tube hygiene. Daily care bundles, skin care, and the use of moisture-wicking materials reduce device-associated complications. Tracheostomy tubes may be safely changed at postoperative day 3, and they should be changed with some regularity (at a minimum of every 1-2 weeks) as well as on an as-needed basis, such as when an obstruction within the lumen occurs. Care coordination can reduce length of hospital and ICU stay. Published evidence is insufficient to support recommendations for a specific device to humidify the inspired gas, the use of a communication device, or timing for the initiation of feedings.

Time to consider supraglottic airway device oropharyngeal leak pressure measurement more objectively.

Oropharyngeal leak pressure (OLP) is considered a measure of successful placement, adequate performance and is a useful comparator between supraglottic airway devices (SADs). OLP measurement is based on the premise that the SAD is sited properly in the hypopharynx after blind placements, but the evidence suggests otherwise. Several limitations and controversies surround OLP. This editorial addresses the uses and pitfalls of OLP, the rationale for and methods of ascertaining OLP, the pros and cons of OLP measurement and newer modalities to improve its accuracy.

Clinical Outcomes of a Modified Laryngeal Mask Airway (LMA® Gastro™ Airway) During Esophagogastroduodenoscopy in Children and Adolescents: A Randomized Study.

INTRODUCTION: During esophagogastroduodenoscopy (EGD), general anesthesia (GA) may be provided using a laryngeal mask airway (LMA) with the endoscope inserted behind the cuff of the LMA into the esophagus. Passage of the endoscope may increase the intracuff of the LMA. We evaluated a newly designed LMA (LMA® Gastro™ Airway) which has an internal channel exiting from its distal end to facilitate EGD. The current study compared the change of LMA cuff pressure between this new LMA and a standard clinical LMA (Ambu® AuraOnce™) during EGD. METHODS: Patients less than 21 years of age and weighing more than 30 kg were randomized to receive airway management with one of the two LMAs during EGD. After anesthetic induction and successful LMA placement, the intracuff pressure of the LMAs was continuously monitored during the procedure. The primary outcome was the change of intracuff pressure of the LMAs. RESULTS: The study cohort included 200 patients (mean age 13.6 years and weight 56.6 kg) who were randomized to the LMA® Gastro™ Airway (n=100) or the Ambu® AuraOnce™ LMA (n=100). Average intracuff pressures during the study period (before and after endoscope insertion) were not different between the two LMAs. Ease of the procedure was slightly improved with the LMA® Gastro™ Airway (p<0.001). DISCUSSION: The LMA® Gastro™ Airway blunted, but did not prevent an increase in intracuff pressure during EGD when compared to the Ambu® AuraOnce™ LMA. Throat soreness was generally low, and complications were infrequent in both groups. The ease of the procedure was slightly improved with the LMA® Gastro™ Airway compared to the Ambu® AuraOnce™ LMA.

Correlation and variation of cuff inflating volumes and pressures in different adult models of laryngeal mask: a prospective randomized trial.

BACKGROUND: Hyperinflation of laryngeal mask cuffs may carry the risk of airway complications. The manufacturer recommends inflating cuff until the intracuff pressure reaches 60 cmH2O, or inflate with the volume of air to not exceed the maximum recommended volume. We prospectively assessed the correlation of cuff inflating volumes and pressures, and the appropriated the cuff inflating volumes to generate an intracuff pressure of 60 cmH2O in the adult laryngeal masks from different manufacturers. METHODS: Two groups of 80 patients requiring laryngeal mask size 3 and 4 during general anesthesia were randomized into 4 subgroups for each size of the laryngeal mask: Soft Seal® (Portex®), AuraOnce™ (Ambu®), LMA-Classic™ (Teleflex®) and LMA-ProSeal™ (Teleflex®). After insertion, the cuff was inflated with 5-ml increments of air up to the maximum recommended volume. After each 5-ml intracuff pressure was measured, the volume of air that generated the intracuff pressure of 60 cmH2O was recorded. RESULTS: Mean (SD) volume of air required to achieve the intracuff pressure of 60 cmH2O in Soft Seal®, AuraOnce™, LMA-Classic™, LMA-ProSeal™ laryngeal mask size 3 were 11.80(1.88), 9.20(1.88), 8.95(1.50) and 13.50(2.48) ml, respectively, and these volumes in laryngeal mask size 4 were 14.45(4.12), 12.55(1.85), 11.30(1.95) and 18.20(3.47) ml, respectively. The maximum recommended volume resulted in high intracuff pressures (> 60 cmH2O) in all laryngeal mask types and sizes studied. CONCLUSION: Pressure-volume curves of adult laryngeal masks are all in sigmoidal shape. Cuff designs and materials can effect pressure and volume correlation. Approximately half of the maximum recommended volume is required to achieve the intracuff pressure of 60 cmH2O except LMA-ProSeal™ which required two-thirds of the maximum recommended volume. TRIAL REGISTRATION: Thai Clinical Trials Registry, TCTR20150602001, May 28, 2015.

Choosing endotracheal tube size in children: Which formula is best?

OBJECTIVES: Various formulae have been suggested to calculate the appropriate sized endotracheal tube in children. The current study prospectively compares three commonly used formulae for selection of cuffed endotracheal tubes in children. METHODS: Patients were randomized to one of three formulae (Duracher, Cole, or Khine) to determine the size of the cuffed endotracheal tube for endotracheal intubation. The fit of the tube was noted and intracuff pressure was measured using a manometer. The postoperative incidence of stridor, throat pain/soreness, and hoarseness was noted in the post-anesthesia care unit at 2, 4 and 24 h after the procedure. RESULTS: The study cohort included 135 patients less than or equal to 8 years, equally divided into three groups based on age, weight, and gender. There was no difference in the intracuff pressure, the volume required to seal the airway, or the number of times in which the intracuff pressure was greater than or equal to 20 or 30 cm H2O among the three groups. Six tube changes were required in the Cole group while no tube changes were required in the Duracher group (p < 0.05). The postoperative incidence of adverse events (throat pain, hoarseness, and stridor) at 0-2 h, 2-4 h, and 24 h was higher in the Cole group when compared to the Duracher group. CONCLUSION: When using an endotracheal tube with a polyurethane cuff, the Duracher formula provided the best estimate for choosing the correct size.

Comparison and evaluation of single-use LMA supreme versus the reusable proseal LMA in paralyzed patients undergoing surgery with controlled ventilation.

BACKGROUND AND AIMS: The objective of this prospective randomized blinded study was to assess the safety and efficacy of the laryngeal mask airway (LMA) Supreme as compared with the LMA Proseal. MATERIAL AND METHODS: A total of 60 patients were randomised into two groups to either receive a Proseal LMA (PLMA) or Supreme LMA (SLMA) for airway management. The primary outcome was to measure oropharyngeal leak pressure (OLP) in both groups. The secondary outcomes were the measurement of insertion time, insertion success rate, fibreoptic grading, intracuff pressure, ease of ventilation, and airway pressure on standard ventilatory settings and postoperative complications. RESULTS: Intracuff pressure increase after 60 minutes of induction was significantly higher in the PLMA group (PLMA 97.43 ± 11.03 cm of H2O and SLMA 75.17 ± 8.95 cm of H2O). OLP was recorded after device insertion, after 30 min and after 60 min in each group and was found to be 28.71 ± 2.97, 30.93 ± 2.87, and 31.93 ± 2.72 cm of H2O in PLMA and 24.84 ± 2.08, 26.73 ± 2.26, and 27.95 ± 2.55 cm of H2O in SLMA group, respectively. The mean OLP with the SLMA was significantly (p=<.001) lower than PLMA. All the other parameters were comparable in both groups. CONCLUSION: PLMA is better than SLMA as airway device to ventilate at higher airway pressure in paralyzed adult patients. On the basis of our study, we recommend Proseal over Supreme LMA.

Comparison of four inflation techniques on endotracheal tube cuff pressure using a feline airway simulator.

OBJECTIVES: The aim of this study was to compare four inflation techniques on endotracheal tube cuff (ETC) pressure using a feline airway simulator. METHODS: Ten participants used four different endotracheal cuff inflation techniques to inflate the cuff of a low-pressure, high-volume endotracheal tube within a feline airway simulator. The simulator replicated an average-sized feline trachea, intubated with a 4.5 mm endotracheal tube, connected to a circle breathing system and pressure-controlled ventilation with oxygen and medical air. Participants inflated the ETC: by pilot balloon palpation (P); by instilling the minimum occlusive volume (MOV) required for loss of airway leaks during mechanical ventilation; until a passive release of pressure with use of a loss-of-resistance syringe (LOR); and with use of a syringe with a digital pressure reader (D) specifically designed for endotracheal cuff inflation. Intracuff pressure was measured by a manometer obscured to participants. The ideal pressure was considered to be between 20 and 30 cmH2O. Data were analysed by Shapiro-Wilk, Kruskal-Wallis and χ2 tests, as appropriate. RESULTS: Participants were eight veterinarians and two veterinary nurses with additional training in anaesthesia. Measured median intracuff pressures for P, MOV, LOR and D, respectively, were 25 cmH2O (range 4-74 cmH2O), 41 cmH2O (range 4-70 cmH2O), 31 cmH2O (range 18-64 cmH2O) and 22 cmH2O (range 20-30 cmH2O). D performed significantly better (P <0.001) than all other techniques, with no difference between the other techniques. CONCLUSIONS AND RELEVANCE: Use of D for cuff inflation achieved optimal cuff pressures. There may be high operator-dependent variability in the cuff pressures achieved with the use of P, MOV or LOR inflation techniques. As such, a cuff manometer is recommended when using any of these techniques.

Intracuff pressure during one-lung ventilation in infants and children.

OBJECTIVE: We prospectively evaluated intracuff pressure (IP) during one-lung ventilation (OLV) to characterize potential risk associated with overinflation of the cuff used for OLV. DESIGN: Prospective observational study over a 2-year period, in infants and children undergoing thoracic surgery. The IPs of the tracheal and bronchial balloon were measured using a manometer and compared to a previously recommended threshold of 30 cmH2O. Data were compared by the device type used to achieve OLV. SETTING: Freestanding tertiary-care pediatric hospital. PARTICIPANTS: Patients ≤18 years of age undergoing thoracic procedures requiring OLV. INTERVENTIONS: Measurement of IP. MEASUREMENTS AND MAIN RESULTS: Thirty patients were enrolled (age 5 months-18 years) with a median weight of 28 kg. Median tracheal and bronchial IPs were 32 cmH2O (range: 11, 90) and 44 cmH2O (range: 10, 100), respectively. The tracheal and bronchial IPs exceeded 30 cmH2O in 13 of 20 patients (65%) and 21 of 30 patients (70%), respectively. CONCLUSIONS: IP was high and in excess of recommended levels in most children undergoing OLV. Continuous monitoring of IP may be indicated during OLV to address the risks involved and ensure the prevention of complications related to high IP. TYPE OF STUDY: Prospective comparative study. LEVEL OF EVIDENCE: Level II.

Changes in endotracheal tube intracuff pressure and air leak pressure over time in anesthetized Beagle dogs.

OBJECTIVE: To evaluate endotracheal tube intracuff pressure (Pcuff) changes over time and the effect of these changes on air leak pressure (Pleak). STUDY DESIGN: Prospective experimental study. ANIMALS: A group of nine healthy adult Beagle dogs. METHODS: In part I, in vitro measurements of Pcuff were recorded for 1 hour in eight endotracheal tubes subjected to four treatments: room temperature without lubricant (RT0L), room temperature with lubricant (RTWL), body temperature without lubricant (BT0L), and body temperature with lubricant (BTWL). In part II, nine dogs were endotracheally intubated and Pleak was evaluated at Pcuff of 25 mmHg. Subsequently, Pcuff was reset to 25 mmHg (baseline) and Pcuff measurements were recorded every 5 minutes for 1 hour. Subsequently, a second Pleak measurement was recorded at the current Pcuff. The data were analyzed using Wilcoxon signed-rank test, repeated measures anova and Mann-Whitney U test. RESULTS: In part I, Pcuff differed significantly between the RT0L and RTWL treatments at 5-60 minutes, and between the BT0L and BTWL treatments at 5-35, 55 and 60 minutes (p < 0.05). In part II, compared with baseline pressures, mean Pcuff decreased to <18 mmHg at 10 minutes and significant decreases were recorded at 15-60 minutes (Pcuff range: 10.0 ± 4.9 to 13.4 ± 6.3 mmHg, mean ± standard deviation). Significant differences were observed between the first and second Pleak measurements (p = 0.034). Pleak decreased in six of nine dogs, was not changed in two dogs and increased in one dog. CONCLUSIONS AND CLINICAL RELEVANCE: Significant decreases in Pcuff over time were measured. Pleak may decrease during anesthesia and increase the risk for silent pulmonary aspiration. The results indicate the need for testing Pcuff more than once, especially at 10 minutes after the onset of anesthesia.

The effect of user experience and inflation technique on endotracheal tube cuff pressure using a feline airway simulator.

OBJECTIVE: The effect of user experience and inflation technique on endotracheal tube cuff pressure using a feline airway simulator. STUDY DESIGN: Prospective, experimental clinical study. METHODS: Participants included veterinary students at the beginning (group S1) and end (group S2) of their 2-week anaesthesia rotation and veterinary anaesthetists (group A). The feline airway simulator was designed to simulate an average size feline trachea, intubated with a 4.5 mm low-pressure, high-volume cuffed endotracheal tube, connected to a Bain breathing system with oxygen flow of 2 L minute-1. Participants inflated the on-endotracheal tube cuff by pilot balloon palpation and by instilling the minimum occlusive volume (MOV) required for loss of airway leaks during manual ventilation. Intracuff pressures were measured by manometers obscured to participants and ideally were 20-30 cm H2O. Student t, Fisher exact, and Chi-squared tests were used where appropriate to analyse data (p < 0.05). RESULTS: Participants were 12 students and eight anaesthetists. Measured intracuff pressures for palpation and MOV, respectively, were 19 ± 12 and 29 ± 19 cm H2O for group S1, 10 ± 5 and 20 ± 11 cm H2O for group S2 and 13 ± 6 and 29 ± 18 cm H2O for group A. All groups performed poorly at achieving intracuff pressures within the ideal range. There was no significant difference in intracuff pressures between techniques. Students administered lower (p = 0.02) intracuff pressures using palpation after their training. CONCLUSIONS AND CLINICAL RELEVANCE: When using palpation and MOV for cuff inflation operators rarely achieved optimal intracuff pressures. Experience had no effect on this skill and, as such, a cuff manometer is recommended.

Cuffed endotracheal tubes in children: the effect of the size of the cuffed endotracheal tube on intracuff pressure.

BACKGROUND: In children, the size of the cuffed endotracheal tube is based on various age-based formulas. However, such formulas may over or underestimate the size of the cuffed endotracheal tube. There are no data on the impact of different-sized cuffed endotracheal tubes (ETT) on the intracuff pressure in children. AIM: The current study measures intracuff pressure with different-sized cuffed ETT. METHOD: The study was conducted in an in vitro and in vivo phase. For the in vitro phase, 10 cuffed ETT of size 4.0, 4.5, and 5 mm internal diameter (ID) each were randomly placed inside a 1.0 cm ID plastic tube (mimicking the trachea), which was in turn connected to a 1 l test lung. After inflation of the cuff using the air leak test at a continuous positive airway pressure of 20 cmH2 O, the intracuff pressure was measured. The in vivo phase was conducted in 100 children (4-8 years) and were randomly divided into two groups to receive either a cuffed endotracheal tube based on the Khine formula (Group R) or a cuffed endotracheal tube that was a half-size (0.5 mm ID) smaller (Group S). Following the inflation of the cuff to seal the trachea, the intracuff pressure was measured. RESULTS: In the in vitro phase, the intracuff pressure was 45 ± 6, 23 ± 1, and 14 ± 6 cmH2 O with size 4.0, 4.5, and 5 mm ID cuffed ETT, respectively (F-test P < 0.001 for difference among three groups). In the in vivo phase, the mean intracuff pressure in Group R was 25 ± 19 cmH2 O vs 37 ± 35 cmH2 O in Group S (95% CI of difference: 1, 23; P = 0.039). CONCLUSION: If the cuffed endotracheal tube is too small, the trachea can still be sealed by inflating the cuff with additional air. However, this transforms the cuff from the intended high-volume, low-pressure cuff to an undesirable high-volume, high-pressure cuff.

Incidence and risk factors of postoperative sore throat after endotracheal intubation in Korean patients.

Objective To investigate the incidence of postoperative sore throat (POST) in Korean patients undergoing general anaesthesia with endotracheal intubation and to assess potential risk factors. Methods This prospective study enrolled patients who underwent all types of elective surgical procedures with endotracheal intubation and general anaesthesia. The patients were categorized into group S (those with a POST) or group N (those without a POST). The demographic, clinical and anaesthetic characteristics of each group were compared. Results This study enrolled 207 patients and the overall incidence of POST was 57.5% ( n = 119). Univariate analysis revealed that significantly more patients in group S had a cough at emergence and hoarseness in the postanaesthetic care unit compared with group N. Receiver operating characteristic curve analysis showed that an intracuff pressure ≥17 cmH2O was associated with POST. Multivariate analysis identified an intracuff pressure ≥17 cmH2O and cough at emergence as risk factors for POST. At emergence, as the intracuff pressure over ≥17 cmH2O increased, the incidence of hoarseness increased. Conclusions An intracuff pressure ≥17 cmH2O and a cough at emergence were risk factors for POST in Korean patients. Intracuff monitoring during anaesthesia and a smooth emergence are needed to prevent POST.

The effect of esophagogastroduodenoscopy probe insertion on the intracuff pressure of airway devices in children during general anesthesia.

Given the size of the esophagogastroduodenoscopy (EGD) probe and the compressibility of the pediatric airway, the EGD probe may increase the intracuff pressure (IP) of an airway device. The current study evaluated IP changes during EGD examination under general anesthesia in pediatric patients. Following the induction of anesthesia, a laryngeal mask airway (LMA) or endotracheal tube (ETT) was placed without neuromuscular blockade. The IP was measured at baseline, during EGD probe insertion, while the EGD probe was in place, and after probe removal. The study cohort included 101 patients (mean age 11.3 years). The airway was secured with an LMA and an ETT in 88 and 13 patients, respectively. The IP increased from 27 ± 15 cmH2O at baseline to 34 ± 17 cmH2O during probe insertion (p < 0.001), remained at 33 ± 16 cmH2O while the probe was in place, and decreased to 26 ± 14 cmH2O after probe removal. The IP of the LMA or ETT increased during EGD probe insertion and remained elevated while the probe was in place. High IP may compromise mucosal perfusion resulting in a sore throat when using an LMA or the potential for airway damage if an ETT is used. Removal of air from the cuff and titration of the IP should be considered after EGD insertion.