Utility of Endotracheal Tube Cuff Pressure Monitoring in Mechanically Ventilated (MV) Children in Preventing Post-extubation Stridor (PES)
Farhan Shaikh, Yeshwanth R Janaapureddy, Shashwat Mohanty, Preetham K Reddy, Kapil Sachane, Parag S Dekate, Anupama Yerra, Dinesh Chirla
Citation Information :
Shaikh F, Janaapureddy YR, Mohanty S, Reddy PK, Sachane K, Dekate PS, Yerra A, Chirla D. Utility of Endotracheal Tube Cuff Pressure Monitoring in Mechanically Ventilated (MV) Children in Preventing Post-extubation Stridor (PES). Indian J Crit Care Med 2021; 25 (2):181-184.
Objective: To study if protocolized monitoring of endotracheal tube (ETT) cuff pressure every 6 hours is better than adjusting endotracheal tube cuff inflation by the only bedside clinical assessment. Materials and methods: This was a single-center prospective randomized controlled study done between July 1, 2017 and March 31, 2019. Children between 1 month and 18 years, intubated with cuffed ETT by our trained doctors were included. After obtaining consent, patients were randomized into two groups, standard group (SG) and cuff pressure monitoring group (MG). Sample size was calculated with 80 patients in each group with a power of 80%, significance level (alpha 0.05 and beta 0.2). In the SG, ETT cuff inflation was adjusted by clinical assessment (bedside minimal leak technique and monitoring the percentage of leak displayed on ventilator display) at 6 hours interval. In the MG, cuff pressures were monitored by the device every 6 hours to maintain between 20 and 25 mm Hg. Results: Out of 543 mechanically ventilated children during the study period, 266 were eligible and randomized for study. During the study, 89 patients died and 17 were left against medical advice, leaving 80 patients in each group. Incidence of post-extubation stridor (PES), re-intubation rate, ventilator-associated pneumonia (VAP) rate, ventilator days, and length of pediatric intensive care unit (PICU) stay were analyzed and found no advantage of protocolized monitoring of cuff pressures in the reduction of any of the above variables. Conclusion: Our findings if confirmed by large multicentric studies can bring an end to routine ETT cuff pressure measurements and emphasize more on clinical assessment. Clinical trial registry (CTRI/2019/05/019098).
Koka BV, Jeon IS, Andre JM, McKay I, Smith RM. Postintubation croup in children. Anesth Analg 1977;56(4):501–505. DOI: 10.1213/00000539-197707000-00008.
Kurachek SC, Newth CJ, Quasney MW, Rice T, Sachdeva RC, Patel NR, et al. Extubation failure in pediatric intensive care: a multiple-center study of risk factors and outcomes. Crit Care Med 2003;31(11):2657–2664. DOI: 10.1097/01.CCM.0000094228.90557.85.
Tellez DW, Galvis AG, Storgion SA, Amer HN, Hoseyni M, Deakers TW. Dexamethasone in the prevention of postextubation stridor in children. J Pediatr 1991;118(2):289–294. DOI: 10.1016/s0022-3476(05)80505-0.
Deakers TW, Reynolds G, Stretton M, Newth CJ. Cuffed endotracheal tubes in pediatric intensive care. J Pediatr 1994;125(1):57–62. DOI: 10.1016/s0022-3476(94)70121-0.
Newth CJL, Rachman B, Patel N, Hammer J. The use of cuffed versus uncuffed endotracheal tubes in pediatric intensive care. J Pediatr 2004;144(3):333–337. DOI: 10.1016/j.jpeds.2003.12.018
Edmunds S, Weiss I, Harrison R. Extubation failure in a large pediatric ICU population. Chest 2001;119(3):897–900. DOI: 10.1378/chest.119.3.897.
Zuckerberg AL, Nichols DG. Airway management in pediatric critical care. In: Rogers MC, ed. Textbook of Pediatric Intensive Care, 3rd edition, Maryland: Williams & Wilkins; 1996. p. 51–76.
Thompson AE. Pediatric airway management. In: Fhurman B, Zimmerman JJ, eds. Pediatric Critical Care, 3rd edition, St Louis: Mosby; 2006. p. 492.
American Heart Association. Part 12: pediatric advanced life support. Circulation 2005;112(24):IV-167–IV-187. DOI: 10.1161/CIRCULATIONAHA.105.166573.
International Liaison Committee on Resuscitation. The International Liaison Committee on Resuscitation (ILCOR) consensus science with treatment recommendations for pediatric and neonatal patients: pediatric basic and advanced life support. Pediatrics 2006;117(5):e955–e977. DOI: 10.1542/peds.2006-0206.
Stauffer JL, Olson DE, Petty TL. Complications and consequences of endotracheal intubation and tracheotomy. A prospective study of 150 critically ill adult patients. Am J Med 1981;70(1):65–76. DOI: 10.1016/0002-9343(81)90413-7.
Sengupta P, Sessler DI, Maglinger P, Wells S, Vogt A, Durrani J, et al. Endotracheal tube cuff pressure in three hospitals, and the volume required to produce an appropriate cuff pressure. BMC Anesthesiol 2004;4(1):8. DOI: 10.1186/1471-2253-4-8.
Pilbeam SP. Mechanical ventilation: physiological and clinical applications, 6th ed.; 2016. p. 131.
Mhanna MJ, Zamel YB, Tichy CM, Super DM. The ‘air leak’ test around the endotracheal tube, as a predictor of postextubation stridor, is age-dependent in children. Crit Care Med 2002;30(12):2639–2634. DOI: 10.1097/00003246-200212000-00005.
Schneider J, Mulale U, Yamout S, Pollard S, Silver P. Impact of monitoring endotracheal tube cuff leak pressure on post extubation stridor in children. J Crit Care 2016;36:173–177. DOI: 10.1016/j.jcrc.2016.06.033.
American Heart Association. Pediatric advanced life support provider manual. American Heart Association; 2016. p. 282.
Tobias J. Pediatric airway anatomy may not be what we thought: implications for clinical practice and the use of cuffed endotracheal tubes. Paediatr Anaesth 2015;25(1):9–19. DOI: 10.1111/pan.12528.
Sultan P, Carvalho B, Rose BO, Cregg R. Endotracheal tube cuff pressure monitoring: a review of the evidence. J Perioper Pract 2011;21(11):379–386. DOI: 10.1177/175045891102101103.
Colice G, Stukel T, Dain B. Laryngeal complications of prolonged intubation. Chest 1989;96(4):877–884.
Khemani RG, Hotz J, Morzov R, Flink R, Kamerkar A, Ross PA, et al. Evaluating risk factors for pediatric post-extubation upper airway obstruction using a physiology-based tool. Am J Respir Crit Care Med 2016;193(2):198–209. DOI: 10.1164/rccm.201506-1064OC.
Epstein SK, Ciubotaru RL. Independent effects of etiology of failure and time to reintubation on outcome for patients failing extubation. Am J Respir Crit Care Med 1998;158(2):489–493. DOI: 10.1164/ajrccm.158.2.9711045.
American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005;171(4):388–416. DOI: 10.1164/rccm.200405-644ST.
Safdar N, Dezfulian C, Collard HR, Saint S. Clinical and economic consequences of ventilator-associated pneumonia: a systematic review. Crit Care Med 2005;33(10):2184–2193. DOI: 10.1097/01.ccm.0000181731.53912.d9.
Rello J, Sonora R, Jubert P, Artigas A, Rue M, Valles J. Pneumonia in intubated patients: role of respiratory airway care. Am J Respir Crit Care Med 1996;154(1):111–115. DOI: 10.1164/ajrccm.154.1.8680665.
Joshi VV, Mandavia SG, Stern L, Wiglesworth FW. Acute lesions induced by endotracheal intubation. Occurrence in the upper respiratory tract of newborn infants with respiratory distress syndrome. Am J Dis Child 1972;124(5):646–649. DOI: 10.1001/archpedi.1972.02110170024003.
Hartley M, Vaughan RS. Problems associated with tracheal extubation. Br J Anaesth 1993;71(4):561–568. DOI: 10.1093/bja/71.4.561.
Letvin A, Kremer P, Silver PC, Samih N, Reed-Watts P, Kollef MH. Frequent versus infrequent monitoring of endotracheal tube cuff pressures. Respir Care 2018;63(5):495–501. DOI:10.4187/respcare.05926.
Khemani RG, Schneider JB, Morzov R, Markovitz B, Newth CJ. Pediatric upper airway obstruction: Interobserver variability is the road to perdition. J Crit Care 2013;28(4):490–497. DOI: 10.1016/j.jcrc.2012.11.009.