|Ahead of print publication
Study of tracheal cuff pressure variation in adult tracheostomized patients in the intensive care unit
Manohar Suryavanshi1, Anil Kaul1, Dilip Raghavan2
1 Department of ENT, INHS Asvini, Mumbai, Maharashtra, India
2 Prof & HOD ENT AFMC, Pune, Maharashtra, India
|Date of Submission||26-Aug-2019|
|Date of Acceptance||03-Feb-2020|
|Date of Web Publication||12-Sep-2020|
INHS Asvini, Colaba, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Tracheostomy tube cuff pressure requires to be maintained within the acceptable range in ICU patients to prevent complications like tracheal stenosis, aspiration pneumonia etc. However tracheal cuff pressure monitoring is still not being strictly followed in many medical centres. Aim: To evaluate variation in Tracheal Cuff pressure over 24 hours once inflated to recommended pressure in adult tracheotomised patients. Setting and Design: Prospective observational study. Methods and Material: This study was carried out on 82 tracheostomised adult patients in ICU of a tertiary care hospital. Tracheal cuff pressure was monitored by Manometer every six hourly over 24 hours for 4 days. Statistical Analysis Used: Student's t- test. Result: Tracheal cuff pressure showed significant variation in tracheal cuff pressure within 24 hours period of daily monitoring with all cases showing fall in cuff pressure below the acceptable range. Conclusion: Regular Manometric monitoring of tracheal cuff pressure is recommended in Tracheotomised patients in ICU setting to avoid associated complications.
Keywords: Tracheostomy, Tracheal cuff pressure, Manometer
| Introduction|| |
Tracheostomy can be a lifesaving procedure. Tracheostomy tube with inflatable cuff helps to prevent air leak around the tube and aspiration of upper airway secretions. Excessive or prolonged pressure of the tracheal tube cuffs may cause acute catastrophic airway injury, such as tracheal rupture, or may cause subacute or chronic injury, such as tracheal necrosis, tracheal stenosis, tracheoesophageal fistula, or laryngeal nerve palsy.,,
Microaspiration of oropharyngeal contents caused by underinflation of the tracheal cuff in intubated patients can lead to aspiration pneumonia causing morbidity and mortality. It is recommended that cuff pressure (CP) levels be kept at 20–30 cm of H2O.,, When the CP falls to below 20 cm of H2O, the risk of aspiration pneumonia increases fourfold; on the other hand, tracheal CP ≥30 cm H2O may damage the tracheal mucosa by impairment of capillary mucosal perfusion, whereas critical perfusion pressure is reached at 50 cm H2O which may lead to ischemic necrosis of tracheal mucosa.,
Most studies of variation and regulation of CP have been performed using intubated and mechanically ventilated patients, but studies on CP in tracheostomized patients are scarce. Further, the optimal frequency of monitoring endotracheal tube CPs too has not been standardized. Motoyama et al. in a recent study of mechanically ventilated adult patients found that tracheal CP decreased to <20 cm H2O within 2 h after adjusting to it to 24 cm H2O. Sole et al. concluded that intervention was effective in maintaining endotracheal tube CP within the optimal range and CP decreased over time without intervention.
The aim of this study was to evaluate variation in tracheal CP over 24 h, once inflated to recommended pressure, and to assess the requirement of reinflation of the tracheal cuff to maintain the recommended CP in adult tracheostomized patients in intensive care unit (ICU). The topic may not be new; however, tracheal CP inflation based on recommended CP range is still not widely practiced in our country at least. This is mainly due to ignorance of its significance and lack of equipment.
| Methodology|| |
This was designed as a prospective observational study. After obtaining the institutional ethical committee clearance and written consent of patients, 82 consecutive tracheostomized adult patients in ICU with cuffed tracheostomy tubes of either sex were enrolled with age between 18 years and above.
Portex tracheostomy tubes of size 7–8.5 mm were used. Before tracheostomy, the tubes selected for the study were checked for any leaks in the cuff system. CP was assessed every 6 h over 24 h for 4 days with Portex CP manometer (by connecting it to pilot balloon). Regular calibration of CP manometer was ensured before the measurement.
The CP was readjusted to 25 cm of H2O by a manometer whenever the pressure recorded was beyond the acceptable range (20–30 cm of H2O).
The patients who could not be followed over 4 days either because of mortality or weaned off from ventilator were excluded from the study. Student's t-test was used for statistical analysis of the CP variation from the mean. “P“ values of the CPs recorded were calculated with confidence levels of 95% and degrees of freedom being N-1 (N-sample size).
| Results|| |
Eighty-two tracheostomized adult patients in ICU were enrolled in the study. Demographic profile is given in [Table 1].
Tracheal CP variation pattern, at 6-h intervals over 4 days, for all the cases in this study, is reflected in [Table 2].
From the data in [Table 2], it is observed that after 6 h of inflation of the tracheal cuff, the mean CP, over 4 days of monitoring, was 21.90 ± 0.77 cm of H2O, which was within the acceptable range. After 12 h of inflation, the mean CP was 17.88 ± 0.88 cm of H2O, which was significantly less than the acceptable range.
From the graph [Figure 1], it is seen that after 6 h of tracheal cuff inflation, the mean fall (over a period of 4 days) in tracheal CP was observed to be 3.06–3.18 cm of H2O, and after 12 h, the mean fall in CP noted was 7.11–7.12 cm of H2O.
From the graph [Figure 2], it is observed that, at day 1, after 6 h, not a single case required reinflation. However, after 12 h period, 100% of the cases required reinflation on day 1. The same pattern was seen every 12 h period over 4 days.
|Figure 2: Profile of requirement of reinflation of tracheal cuff after the initial inflation|
Click here to view
| Discussion|| |
Overinflation of the cuff can cause changes in the tracheal mucosa, granuloma, rupture of the trachea, tracheoesophageal fistula or tracheal stenosis, and total blockage of tracheal mucosal blood flow. Underinflation may cause air leakage, risk of pulmonary aspiration, and tracheostomy tube displacements.
In this study, tracheal CP monitoring revealed that post initial cuff inflation to 25 cm of H2O, there was a fall in tracheal CP in all cases at the end of 6 h, but no case showed a fall in CP below the recommended range of 20–30 cm of H2O. However, the tracheal CP was noted to be below the acceptable range of CP in 100% cases at the end of 12 h. A similar pattern of CP variation was observed over the next 12 h, post reinflation of the cuff to recommended acceptable limit, on all 4 days. Sole et al. noted a decrease in tracheal CP within 4–12 h after adjustment to 20 cm of H2O. Sridermma et al. reported that CP reduced to 20 cm of H2O in 4–5 h after initial cuff inflation to 25 cm of H2O.
The frequency of the manometric assessment of CP was kept at 6-h intervals to avoid significant reduction in tracheal CP, due to associated air leak at every measurement, in case the time intervals were further reduced as has also been asserted in a recent study by Motoyama et al.
After 6 h, the mean fall in CP noted over 4 days was 3.18 cm of H2O, and at the end of 12 h, the mean fall in CP noted over 4 days was 7.11 cm of H2O.
The need for precise measurement of tracheal CPs in patients undergoing prolonged ventilation has been previously recommended by Curiel García et al. and recently by Motoyama et al., Precise measurement allows accurate control of CPs within a stipulated range, thus minimizing the negative effects of over- and underinflation of the cuff.
According to the study carried out by Zolfaghari and Wyncoll in 2011, when tracheal CP falls below 20 cm of H2O, there is formation of folds in the inflated cuff leads to microaspiration of pooled oropharyngeal secretions into the trachea which then results in aspiration pneumonia. Hameed et al. showed tracheal mucosa damage due to high intra-CP leading to acquired tracheoesophageal fistula.
In the present study, intermittent CP measurement in adult tracheostomized patients in ICU showed a significant variation in tracheal CP over a period of 24 h. In all cases, the tracheal CP dropped below the recommended range of tracheal CP (20–30 cm of H2O) after 12 h and required cuff reinflation to acceptable level. Granja et al. had recommended to monitor CP 3 times daily. It is essential to maintain CPs in the range of 20–30 cm of H2O to avoid the consequences of decreased or increased CP.
It is recommended that manometric CP monitoring should be done regularly, at least every 6 h, if not automated continuous manometric monitoring, to prevent possible complications due to abnormal CP. Further study needs to be undertaken to compare pressure cuff variation among different types of tracheostomy tubes based on cuff material and design. Mariyaselvam et al. in a recent study concluded that endotracheal tubes showed substantial variation in fluid aspiration relating to cuff material and design.
This study hopes to serve as a wake-up call for all concerned for adopting the recommended standard of care for such patients.
The authors would like to thank the Department of Anesthesia and Critical Care, INHS Asvini, Colaba, Mumbai.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]