Evaluating the Knowledge of Endotracheal Cuff Pressure Monitoring Among Critical Care Providers by Palpation of Pilot Balloon and By Endotracheal Tube Cuff Manometer

Abstract

Introduction Mishandled endotracheal cuff pressure may either make ventilation difficult or cause damage to the airway. Therefore, the aim of this audit was to assess the knowledge about endotracheal cuff pressure monitoring with a manometer and manual palpation of pilot balloon among critical care providers. Methods This audit includes 150 critical care providers having experience of handling endotracheal tube (ETT) cuff at critical care area of National Institute of Cardiovascular Diseases (NICVD), Karachi from April 2017 to June 2017. Knowledge about endotracheal cuff pressure monitoring with the manometer and deleterious effects of mishandled ETT cuff was assessed using a self-reported questionnaire. Enrolled healthcare providers were asked to palpate the patient and cuff pressure was recorded and categorized. Results Out of 150 participants, 66 (44.0%) were doctors. Only 46 (30.67%) participants had prior knowledge about ETT cuff manometer and 110 (73.33%) had never used a manometer. Similarly only 42 (28.0%) had knowledge of hazardous effects of mishandled ETT cuff. Kappa coefficient of 0.155 with p=0.015 showed significant yet low agreement between participant prediction and the actual amount of air in cuff balloon. Agreement level was comparatively higher for staff as compared to doctors with a Kappa coefficient of 0.210 (p=0.018) vs. 0.133 (p=0.099). Conclusion In this study of knowledge and practice of ETT tube cuff pressure monitoring, we observed low levels of knowledge (30.67%), poor adherence to standard practice (73.33%) and were able to demonstrate poor agreement (Kappa coefficient 0.155; p=0.015) between the palpation method and cuff manometer measurements for assessing cuff pressure.

Improving nurses’ knowledge of managing endotracheal tube cuff pressure in intensive care units: A quasi-experimental study

“…Strategies in the form of educational programmes should be implemented to enhance the nurses’ knowledge. This is especially important as previous studies conducted on nurses’ knowledge regarding ETT cuff pressure revealed differences in ICU nurses’ knowledge, leading to varying practices (Abubaker et al 2019 ; Jordan 2011 ; Jordan, Van Rooyen & Venter 2012 ; Mohammed et al 2016 ; Mwakanyanga, Masika & Tarimo 2018 ). A study by Mohammed et al ( 2016 ) showed that an educational programme including discussion groups and formal lectures accompanied by suitable teaching aids, such as handouts, posters, coloured pictures and a programme booklet, improved the knowledge of the nurses regarding ETT cuff pressure.…”

Knowledge acquisition and retention among nurses after an educational intervention on endotracheal cuff pressure

“…These recommendations are also part of the preventive measures emphasized in the VAP prevention guidelines 10,11 . Despite the existence of such guidelines, evidence shows that variation in cuff maintenance practices and compliance with such guidelines are still suboptimal in some of the ICUs in developed countries like the United States, 6 Australia, and New Zealand 12,13 and in developing countries like Pakistan, 14 Sri Lanka, 5,15 and South Africa 16 …”

“…Variations in practice were noted in the frequency of monitoring, 14,17 technique of cuff pressure measurements, 5,12,18 and documentation 16 . Diversity in the frequency of monitoring endotracheal cuff pressure among nurses and ICUs was reported in international literature, with some monitoring every 2 to 4 hours; some every 6 to 12 hours; and others only if the need arose, such as when air leakage was noted 12,17,18 .…”

“…Although ETT cuff pressure management techniques include the predetermined volume technique, palpation technique, syringe technique, and minimal occlusive volume technique, the gauge manometer is the most reliable manual measurement and is widely recommended 5,6,19 (Siamdous et al, 2015AQ4). However, a gauge manometer is not routinely used in actual practice in some ICUs, 19 and previous studies highlighted that the subjective practice of estimation using finger palpation still exists among practitioners, for example, in Pakistan, 14 Sri Lanka, 5 Egypt (Khalil et al, 2018), Malaysia, 20 Italy, 21,22 India, 23 South Africa, 24 and the United States, 6 among others. An observational cross‐sectional study in Melbourne, Australia, which assessed the minimal leak test and cuff manometer techniques, noted that the minimal leak test results in a cuff pressure outside the recommended range; thus, the authors suggested the use of the cuff manometer technique for reliable practice 25 …”

“…Evidence from the literature on possible reasons for variation in practice and poor adherence to cuff pressure management practice suggests that practitioners' lack of scientific knowledge and awareness were the main contributors to failure to comply with their responsibilities 6,26 . Studies on knowledge and management of ETT cuff pressure reported that ICU practitioners had poor to moderate knowledge on safe practice for endotracheal cuff management 14,27,28 . Akhtar 29 pointed out that a lack of awareness among practitioners and non‐availability of gauge manometers in most of the critical care areas in government and private hospitals in Pakistan were some reasons for severe post‐intubation complications among intubated patients.…”