Endotracheal Tube Cuff Pressures Health, Medicine, Nursing Essay

ENDOTRACHEAL TUBE CUFF PRESSURES
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ENDOTRACHEAL TUBE CUFF PRESSURES
Introduction
Intubation is a crucial procedure in the management of patients who need urgent and sustained critical care. Intubation is a way of providing artificial airway. However, there are a lot of pitfalls that negatively influence the role of intubation in healthcare; one such problem revolves around endotracheal tube cuff pressures whose lack of control can lead to health complications as a result of either over-inflation or under-inflation. Endotracheal tube (ETT) cuff pressure-related challenges include risk of aspiration, ventilated associated pneumonia, and tracheal mucosal injury and stenosis. There is an alarming concern on the concept of ETT cuff pressure despites its deleterious consequences when its evidenced-based practices are violated. This paper is a culmination of guidelines, protocols, and literature review, which provide a concise explanation of ETT cuff pressure concepts from diverse standpoints.
I find the research on endotracheal cuff pressure highly relevant because it touches on perioperative care and anesthesia, which are my areas of interest. I perceived the concept of ETT cuff pressures as a largely ignored aspect, yet it plays a critical role in ensuring better health outcomes for the patients.
Overview
Intubation is a common medical practice in healthcare setups that host critically ill patients. It is a process that is well pronounced in intensive care units, anesthesia, and perioperative units. The endotracheal tube (ETT) is a flexible tube that is passed through the mouth into the trachea. The insertion process of ETT into a patient’s tracheas is defined as intubation. The purpose of ETT is to aid a patient in breathing mainly by maintaining the patency of the trachea. The ETT is connected to the ventilator; thus, it acts as a passageway that delivers oxygen from the ventilator to the patient’s lungs. Intubation is ordinarily done during trauma, surgery under general anesthesia, upper respiratory airway diseases, partial or complete airway obstruction, and any other severe illness that can impair blood oxygenation. Patients undergoing surgery often require the insertion of an endotracheal tube (ETT) for airway management. The first documented case of ETT was brought to the fore by Hippocrates (460–380 BC) (Sultan et al., 2011, pp.379). Patients undergoing surgery do require the insertion of ETT for airway management. Patients undergoing surgery often require the insertion of an endotracheal tube (ETT) for airway management. One area of interest relating to ETT is over-inflation due to its associated adverse effects.
Intraoperative ETT cuff Pressures and why it is an issue of Concern
One outstanding challenge that is associated with ETT intraoperative cuff pressures is excess pressures in supra-glottic airway and cuffs, especially during general anesthesia. The excess pressures can predispose a patient to pharyngo-laryngotracheal complications. The cuff pressures are poorly monitored in most operating theatres, this contrasts with what usually happens in intensive-care units, where ETT pressures are given sufficient attention by doing close monitoring and constant adjustments. The concerns on ETT pressures in intraoperative theatres and lack of adequate attention to cuff pressure details call for a need to do more research, interest, and development of elaborate protocols.
The endotracheal tubes have undergone tremendous development and the currents ones can offer better sealing properties than the earlier ones. But there is a challenge regarding their use; this is shown by the gap that exists between sophisticated equipment for ventilation and cuffed ETT. Cuffed ETT does no match the complexity of other ventilator accessories and this partly explains the problem of ETT cuff pressures (Efrati, Deutsch and Gurman, 2012.pp 54).
Pathophysiology of ETT Cuff Pressure and Adverse Health Consequences
Inflation and monitoring of endotracheal (ET) tube cuff pressure is often ignored. In many instances, it is not perceived as a crucial practice in perioperative surgical patients in surgical patients. Over-inflation of ETT cuff pressure has been highlighted in many studies and some of the adverse clinical outcomes of over-inflation include mucosal ulceration, and vocal cord paralysis (Grant, 2013 pp.198). Tennyson et al. (2016, PP.721) cited an increased risk for tracheal mucosa injury, and lumen scarring as a result of suppressed capillary blood flow in the mucosa. Over-inflation of the ETT cuff pressure can lead to more serious complications like tracheal mucosal necrosis, tracheal ruptures, and trachea-esophageal fistula formations (Almarakbi and Kaki, 2014, pp.328). Despite this overwhelming evidence of tracheal damage due to limited attention given to ETT pressure, no bold step has been taken to boost attention on pressures.
An inflated cuff puts pressure on the tracheal wall. Thus, the within the cuff depicts the extent of pressure exertion on the tracheal walls. The pressure on tracheal walls creates a seal, which improves the possibility of delivery of ventilator volume to the patient, being accompanied by accurate end-tidal volume (Grant, 2013 pp.198). Grant (2013 pp.199) further shows that the seal is intended to prevent fluids from leaking out of the cuff into the lungs; these fluid leakages have always been associated with postoperative complications such as nosocomial infections such as pneumonia. The fundamental roles of (ETT) cuff are to sustain sufficient sealing of airway, prevent gastro-pharyngeal contents aspiration, and facilitate effective lung ventilation (Almarakbi and Kaki, 2014, pp.328) The amount of pressure emanating from the cuff and is sufficient enough to occlude the trachea is measured in centimeters of water (cmH2O) and it is between can range from 20-50cmH2O (Grant, 2013 pp.199). Over-inflation of an ET tube cuff is characterized by the injection of a volume of air that exceeds the normal recommended values that are necessary for the creation of a seal between the cuff and the tracheal wall (Sultan et al., 2011, pp.379).
The cuff pressure against the tracheal wall relies on the compliance of the trachea and cuff. The pressure of the ET cuff is an estimate of pressure on tracheal mucosa. There is a correlation between the measured cuff pressure and the volume of air infused into the cuff. Sultan et al., (2011, pp.379) found no correlation between the measured ETT cuff pressure and sex, age, and height amongst the patients. The authors also observed that there was no difference between the measured ETT cuff pressure and the size of the tube. However, the patient position, head position, cuff position, temperature, cuff volume, and nitrous oxide anesthesia, were observed to increase the pressure in ETT cuff (Sultan et al., 2011, pp.379). Findings indicate that the infused cuff volumes between 2- 4ml lead to cuff pressures between 20 and 30cmH2O regardless of tube size but there is a variation amongst the patients relating to volume of air that is necessary to attain cuff pressures (Sultan et al., 2011, pp.379).
The pathophysiology of high cuff pressures that results from over-inflation originates from the excess volume of air. The excess air causes a corresponding increase in the pressure within the ETT cuff, which is deflected onto the mucosal tracheal wall and nearby anatomical structures. The degree of tracheal damage is determined by the amount of wall pressures and the duration of intubation. The profound impact of cuff pressures is experienced anteriorly but less posteriorly. The anterolateral aspect of the tracheal wall endures severely comprised blood flow but the membranous posterior walls, indicate less impairment in blood flow. The anterior and posterior wall disparities on the concept of mucosal damage result from structural difference; the membranous posterior wall is more distensible than the anterolateral wall, which is anatomically cartilaginous.
Guidelines for Endotracheal Cuff Pressure
There is scarce literature on protocols and guidelines that revolve around the concept of endotracheal cuff pressure during the perioperative period. There have been limited or no standardized ways of measuring, monitoring, and adjusting endotracheal cuff pressure, that have been advanced by a professional organization. Letvin et al., (2018 pp.1) shared similar sentiments that contemporary healthcare do not have an accepted standard of practice that acts as a blueprint for the optimal frequency of ETT cuff pressure monitoring in mechanically ventilated patients. The inability to come up with specific guidelines and protocols is due to the diversity in the category of patients, features, and type of endotracheal tube, the extent of patient stay in the hospital, amongst other reasons. Even in cases where there are some guidelines, such guidelines are limited to a specific group of patients, for example, pediatrics or adults. The instances, where there have been elements of protocols and guidelines, such directions or guidelines are not treated as forms of minimum standards of practice, or as a replacement for clinical judgment. Thus, ETT cuff pressure dynamics do not have an elaborate and concise body of protocols that national and professional bodies have advanced. The available guidelines e.g. those presented by Difficulty Airway Society (DAS, 2015) in the United Kingdom (UK). According, to DAS, the UK guidelines are broad; they encompass everything from intensive critical care unit, intra-operative room to other settings where there is care administers to critically ill patients e.g. emergency theatres. Thus, there is no specificity, since the available literature on protocols is highly extensive. For example, an article posted in the British Journal of Anesthesia has guidelines on the management of intubation process but relatively little data has been accorded to endotracheal tube cuff pressures (Higss et al., 2018, pp.323-352). DAS (2015) UK guidelines are constructed based on common sense but aided by evidence. However, it is noted that even if a particular expert uses a certain approach and its outcomes are exemplary, such skill may not be classified as a core skill or method, which can act as a prototype.
The guidelines in the UK are informed by the available resources for ETT, culture, and skills. The UK guidelines in airway management are synthesized in a way that they can be used as a basis for developing skills that can address diverse clinical scenarios during intubations. The UK guidelines on intubation are not specific like the protocols for management of HIV/ADS or tuberculosis; this is due to skill mix, differences in the available ETT equipment, and the uniqueness of each clinical case that need intubation. For example, supra-glottic devices are sold based on commercial reasons rather than what they can perform and this makes it difficult for anesthetists to come up with a common set of skills; each supra-glottic device requires a different approach of skill use.
Proper management of endotracheal cuff pressure can involve adequate assessment of clinical symptoms. There is a range of symptoms that may indicate poor control of ETT cuff pressures. These parameters include the absence or change of capnograph waveform when ventilating, altered chest wall movement, an increase of airway pressure, reduced tidal volume, visible leaks, an...