The Science Journal of the American Association for Respiratory Care

2002 OPEN FORUM Abstracts

Delayed Airway Replacement in the Presence of Persistent Cuff Leak

Bob Estetter RRT, Dean Holland RRT, Grant O?Keefe M.D. Parkland Health and Hospital System Dallas, Texas

Introduction: Cuff leaks may present in 10 to 25% all patients with endotracheal or tracheostomy tubes.1,2 Possible solutions have been offered to address the various types of leaks.3,4 We propose a method providing continuous inflation of the cuff. The device consists of a flow meter attached to a variable length of O2 tubing attached to a small-bore ?T? connector. The 90-degree portion of the connector is then attached to a seven-foot length of kink resistant O2 tubing open to ambient air. A variable length of tubing is connected to the ?T? connector and then to a male to male I.V. connection attached to the pilot balloon of the ETT. Cuff pressure is regulated with O2 flow meter adjustments and set to minimal occluding volume.

Methods: Our device was attached to a # 8.0 ETT which connected a ventilator set at AC 15, VT 720, I:E 1:2 and Flow 70 Lpm with a Michigan lung (compliance 36 cc/cmH2O). A twenty three-gauge needle was used to introduce leaks (holes) into the cuff of the ETT. Tidal volumes and intra-cuff pressures were captured via ventilator display and a pressure transducer respectively. Data was collected and recorded as leaks were added to the system.

Results: All study parameters were obtained using 6-15 lpm O2 flow.

Parameter 1 hole

2 holes

3 holes 4 holes 5 holes 6 holes 7 holes 20 holes 30 holes
Cuff pressure 18-66 mmHg 11-48 mmHg 4-40 mmHg 2-34 mmHg 0-25 mmHg 0-20 mmHg 0-20 mmHg 0-17 mmHg 0-11 mmHg
VT exhaled 675-720 cc’s 600-710 cc’s 50-710 cc’s 0-695 cc’s 0-690 cc’s 0-660 cc’s 0-660 cc’s 0-500 cc’s 0-280 cc’s
Vmin exhaled 10.2-11 liters 8.7-11 liters 1.4-10.9 liters 0-10.5 liters 0-10.3 liters 0-10.1 liters 0-9.9 liters 0-7.5 liters 0-4.1 liters

Discussion: We have successfully employed our device in three unstable patients and postponed airway replacement for as much as three weeks. This presents an important alternative to emergent reintubation when presented with loss of cuff integrity. When incorporating this design in the clinical arena the clinician should rule out other causes of persistent cuff leaks (i.e. T-E fistula, ETT position). Also of note, cuff pressures measured at the pilot balloon do not reflect actual cuff pressure. This necessitates frequent monitoring of cuff with the minimal occlusive volume technique.

References:

1. Rashkin MC, Davis T. Acute complications of endotracheal intubation: Relationship to reintubation, route, urgency, and duration. Chest 89:165, 1986.

2. Crofts SL, Alzeer A, Mcguire GP, Wong DT, Charles D; A comparison of percutaneous and operative tracheostomies in intensive care patients. Can J Anaesth 42:775-9, 1995

3. Ho AMH, Contardi LAH. What to do when an endotracheal tube cuff leaks. J Trauma 40;3: 486-7, 1996

4. Sprung J, letter, Anesthesiology 81:790-1, 1994

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