Prevention of complications from prolonged tracheal intubation

doi:10.1016/0002-9610(78)90083-1

The American Journal of Surgery

Volume 135, Issue 3, March 1978, Pages 452-457

https://doi.org/10.1016/0002-9610(78)90083-1 Get rights and content

Abstract

Eight commercially available soft cuff endotracheal tubes were studied to determine the relationship between inflation pressure distention of the cuff. Although the balloon cuff may be easily distensible in open air, when confined within the trachea small increments in the inflation volume may produce high pressures. This means that continuous external control of cuff pressure is required to prevent ischemia of the tracheal wall.

Major tracheal complications in a busy ICU were examined before and after the introduction of a controlled pressure tube. Control of intratracheal cuff pressures decreased major tracheal complications tenfold and eliminated complications specifically related to the cuff.

References (10)

GTG Knowlson et al.
The pressures exerted on the trachea by endotracheal inflatable cuffs
Br J Anaesthesiol
(1970)
TEB Dane et al.
A prospective study of complications after tracheostomy for assisted ventilation
Chest
(1975)
FR Lewis et al.
Incidence and outcome of posttraumatic respiratory failure
Arch Surg
(1977)
AN Thomas
The diagnosis and treatment of tracheo-esophageal fistula caused by cuffed tracheal tubes
J Thorac Cardiovasc Surg
(1973)
S Engel
Lung Structure

There are more references available in the full text version of this article.

Cited by (121)

Life-threatening high tracheal tube cuff pressure
2023, Asian Journal of Surgery
Efficacy of Automatic Retention Pressure of a Double-Lumen Tube Cuff: An Artificial Intubation Model
2021, Journal of Surgical Research
Citation Excerpt :
We found that the bronchial cuff pressure of DLT temporarily increased when traction was applied to the bronchus in our experiments. The high pressure of the intubation cuff may lead to several respiratory tract complications.9-11 An automatic retention pressure control device for a DLT intubation cuff continuously controls pressure and prevents unexpected high pressures.
The movement of a double-lumen endotracheal tube (DLT) out of its appropriate position during thoracic surgery can result in the loss of one-lung ventilation (OLV), especially during pulmonary resection and node dissection. Our study aimed to validate the efficacy of automatic retention pressure control of the DLT bronchial cuff in maintaining OLV in an artificial intubation model.
A 35-Fr left-sided DLT was intubated to the left main bronchus in an intubation simulator and connected to an anesthesia machine. The inspiratory volume, respiratory rate, and inspiratory-expiratory ratio were set at 500 mL, 12 times/min, and 1:2, respectively. A 1-kg right main bronchial traction in the lateral right was provided after OLV was established. SmartCuff (Smiths Medical, Minneapolis, Minnesota, USA) was used to maintain cuff pressure. The efficacy of retention pressure with SmartCuff (Group S) and without SmartCuff (Group WS) was compared. The primary outcome was the rate of tidal volume (TV) reduction following bronchial traction in the two groups.
The TVs were 289.8 ± 28.9 mL and 242.8 ± 31.9 mL in Group S and Group WS, respectively (P = 0.003). The rate of TV reduction after bronchial traction was significantly lower in Group S (29 ± 5%) than in Group WS (43 ± 6%) (P < 0.001).
Automatic retention pressure control of the DLT bronchial cuff improves the rate of TV reduction during right main bronchial traction in an artificial intubation model. Continuous retention cuff pressure may be useful in maintaining OLV during thoracic surgery.
Laryngotracheal injuries after intubation in pediatric seizure patients: A case series and a review of the literature
2020, International Journal of Pediatric Otorhinolaryngology
Acute management of seizures may require intubation with an endotracheal tube (ETT) in addition to benzodiazepine administration. Although necessary for management at times, intubation can lead to laryngotracheal injury as has been reported at length in both the adult and pediatric populations. A review of the literature shows no prior reports of laryngotracheal injuries following intubation in actively seizing pediatric patients. We share our experience with two pediatric patients who had laryngotracheal injuries after being emergently intubated with large ETT's during management of their seizures. We describe two unique cases in the pediatric seizure population associated with laryngotracheal injuries with the goal of emphasizing appropriate ETT sizing for intubation.
Bronchial blockers under pressure: In vitro model and ex vivo model
2016, British Journal of Anaesthesia
Pressures (P_e) exerted by bronchial blockers on the inner wall of the bronchi may cause mucosal ischaemia. Our aims were as follows: (i) to compare the intracuff pressure (P_i) and P_e exerted by commercially available bronchial blockers in an in vitro and an ex vivo model; (ii) to investigate the influence of both the inflated intracuff volume and cuff diameter on P_e; and (iii) to estimate the minimal sealing volume (V_Smin) and the corresponding P_e for each bronchial blocker studied.
The P_e exerted by seven commercial bronchial blockers was measured at different inflation volumes using a custom-designed system using in vitro and ex vivo animal models with two internal diameters (12 and 15 mm).
In the same conditions, P_i was significantly lower than P_e (P<0.05), and P_e was higher in the in vitro model than in the ex vivo model. The P_e increased with the inflated volume, with use of the small-diameter model (P<0.05). Ex vivo models needed a higher minimal sealing volume than the in vitro models, and this volume increased with the diameter (e.g. the V_Smin at a positive pressure of 25 cm H₂O required a P_e ranging from 12 to 78 mm Hg on the 15 mm ex vivo model and from 66 to 110 mm Hg on the 12 mm ex vivo model).
The P_i cannot be used to approximate P_e. The diameter of the model, the inflated volume, and the bronchial blocker design all influence P_e. A pressure higher than the critical ischaemic threshold (i.e. 25 mm Hg) was needed to prevent air leak around the cuff in the in vitro and ex vivo models.
In vitro evaluation of the method effectiveness to limit inflation pressure cuffs of endotracheal tubes
2016, Brazilian Journal of Anesthesiology
Os balonetes das cânulas traqueais protegem as vias aéreas inferiores da aspiração de conteúdo gástrico e facilitam a ventilação pulmonar, mas podem provocar diversas complicações, principalmente quando a pressão do balonete supera 30 cm H₂O. Isto ocorre em mais de 30% das insuflações convencionais, sendo recomendada a limitação desta pressão. Neste estudo avaliou‐se in vitro a eficácia de um método para limitar a pressão dos balonetes à faixa entre 20 e 30 cm H₂O.
Utilizando um adaptador para conectar a cânula testada ao aparelho de anestesia, regulou‐se a válvula limitadora deste a 30 cm H₂O, insuflando o balonete por meio do acionamento do botão de fluxo rápido de oxigênio. Realizaram‐se 33 testes para cada cânula de três fabricantes, de cinco tamanhos (6.5 a 8.5), utilizando três tempos para insuflação (10, 15 e 20 segundos), totalizando 1485 testes. Terminada a insuflação, mediu‐se a pressão obtida com um manômetro. Pressões >30 cm H₂O ou < 20 cm H₂O foram consideradas falhas.
Ocorreram oito falhas (0,5%; IC 95%: 0,1‐0,9%), sendo todas por pressões <20 cm H₂O e após insuflações de 10 segundos (1,6%; IC 95%: 0,5‐2,7%). Uma falha ocorreu com cânula 6.5 (0,3%; IC 95%: –0,3‐0,9%), seis com cânulas 7.0 (2%; IC 95%: 0,4‐3,6%), e uma com cânula 7.5 (0,3%; IC 95%: –0,3‐0,9%).
Este método mostrou‐se eficaz para insuflar os balonetes de cânulas traqueais de diferentes tamanhos e fabricantes limitando sua pressão à faixa entre 20 e 30 cm H₂O, com incidência de sucesso de 99,5% (IC 95%: 99,1‐99,9%).
Cuffs of tracheal tubes protect the lower airway from aspiration of gastric contents and facilitate ventilation, but may cause many complications, especially when the cuff pressure exceeds 30 cm H₂O. This occurs in over 30% of conventional insufflations, so it is recommended to limit this pressure. In this study we evaluated the in vitro effectiveness of a method of limiting the cuff pressure to a range between 20 and 30 cm H₂O.
Using an adapter to connect the tested tube to the anesthesia machine, the relief valve was regulated to 30 cm H₂O, inflating the cuff by operating the rapid flow of oxygen button. There were 33 trials for each tube of three manufacturers, of five sizes (6.5 to 8.5), using three times inflation (10, 15 and 20 seconds), totaling 1485 tests. After inflation, the pressure obtained was measured with a manometer. Pressure >30 cm H₂O or <20 cm H₂O were considered failures.
There were eight failures (0.5%, 95% CI: 0.1‐0.9%), with all by pressures <20 cm H₂O and after 10 seconds inflation (1.6%, 95% CI: 0 5‐2.7%). One failure occurred with a 6.5 tube (0.3%, 95% CI: –0.3‐0.9%), six with 7.0 tubes (2%, 95% CI: 0.4 to 3.6%), and one with a 7.5 tube (0.3%, 95% CI: –0.3‐0.9%).
This method was effective for inflating tracheal tube cuffs of different sizes and manufacturers, limiting its pressure to a range between 20 and 30 cm H₂O, with a success rate of 99.5% (95% CI: 99.1‐99.9%).
Management of benign dynamic "a-shape" tracheal stenosis: A retrospective study of 60 patients
2015, Annals of Thoracic Surgery
Benign tracheal stenosis complicates tracheal intubation or tracheostomy in 0.6% to 65% of cases. Surgical resection is the standard treatment. Endoscopic management is used for inoperable patients with 17% to 69% success. Dynamic “A-shape” tracheal stenosis (DATS) results in a dynamic stenosis with anterior fracture of tracheal cartilage and frequently associated posterior malacia. We report the results of our multidisciplinary management.
Sixty patients with DATS were included. Management decision was made during initial bronchoscopy. When suitable, patients were referred to thoracic surgery for tracheal resection. Posterior localized tracheomalacia was treated with laser photocoagulation of the posterior tracheal wall. Tracheal stents were placed if the stenosis persisted after laser treatment. The choice of stent (straight silicone, hour-glass shaped silicone, T-tube, or fully-covered self-expandable metallic stent) was based on operator's judgment. After 12 to 18 months, stents were removed. If the stenosis persisted after stent removal, surgery was reconsidered. If surgery was not possible, a stent was replaced. In case of satisfactory result, a stent was replaced only after recurrence. Stable patients after treatment were considered as success, requirement of long-term tracheostomy or T tube as failure, and long-term stent as partial success.
All patients developed DATS after tracheostomy. Thirty-three patients had posterior tracheomalacia. In 13 patients, mild stenosis required only endoscopic surveillance. Two patients were referred to thoracic surgery for tracheal resection surgery. Endoscopic management was the initial therapy in 45 patients (75%) and was considered successful in 23 patients (51%), partially successful in 10 (22%), and failed in 12 (27%). Five patients with successful outcomes required only laser therapy. Overall 70 stents were placed in 35 patients, with a migration rate of 31%.
The DATS management was successful in 63%. Stent migration was frequent. Posterior tracheomalacia was successfully treated in selected cases, avoiding stent placement.

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^☆: This work was supported by USPHS Contract #1-HR-42915.

¹: From the Departments of Surgery and Anesthesiology, University of California School of Medicine, San Francisco General Hospital.

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Prevention of complications from prolonged tracheal intubation☆

Abstract

Br J Anaesthesiol

Chest

Incidence and outcome of posttraumatic respiratory failure

Arch Surg

The diagnosis and treatment of tracheo-esophageal fistula caused by cuffed tracheal tubes

J Thorac Cardiovasc Surg

Lung Structure