Intraoperative management of ETT and LMA cuff pressures: a survey of anaesthetists’ knowledge, attitude and current practice

Abstract

Background: Endotracheal tubes and laryngeal mask airway devices are routinely used during anaesthesia. Inappropriate inflation of cuffs has been shown to cause postoperative airway morbidity, and limiting the pressure decreases the incidence of pharyngo-laryngeal complications. Subjective measurements of cuff pressures correlate poorly to actual pressures, yet the use of objective cuff manometry is not routinely practised. The aim of this study was to determine current clinical practice of cuff inflation as well as the knowledge and attitude of anaesthetists in the University of KwaZulu-Natal (UKZN) Discipline of Anaesthesiology and Critical Care. Methods: This was a descriptive, observational study and data were collected using an anonymous self-administered questionnaire from practising anaesthetists in the UKZN Discipline of Anaesthesiology and Critical Care. Results: A total of 160 anaesthetists participated. The minimal occlusive volume test (38.8%) and the pilot balloon palpation technique (36.3%) were most commonly used. Most participants felt it was important to accurately measure ETT (84.8%) and LMA (56.1%) cuff pressures and that using a cuff manometer should be mandatory (76%). Reasons for not using it routinely included manometers not being readily available. Gaps in knowledge and education were also identified. Conclusion: There is increasing importance placed on quality assurance. Clinical practice varies widely among practitioners with the only consistency being the omission of cuff manometers during routine intraoperative management, despite their proven benefit and efficacy. The authors propose recommendations to facilitate the routine intraoperative use of cuff manometers.

Knowledge and practice of tracheal tube cuff pressure monitoring: a multicenter survey of anaesthesia and critical care providers in a developing country

“…In our multicentre study encompassing both anaesthesia and critical care staff only 31.1% of the care providers knew the correct Pcuff, 97% had never used a tracheal cuff manometer, while 81% were aware that improper cuff pressure could harm patients. Meanwhile, a seemingly higher knowledge of the correct tracheal cuff pressure was recorded by 45% of participants in a multicentre questionnaire-based survey conducted among 160 anaesthesiologists practicing in South Africa [ 15 ]. In the South African study the participants were all anaesthesiologists (anaesthesia faculty fellows, residents and diplomates), while in our study and the others, the participants were an admixture of physician and non-physician care providers (nurse anaesthetists, certified registered nurse anaesthetists, student registered nurse anaesthetists, anaesthesia technicians, ICU nurses, etc.)…”

“…This applies to the endotracheal tube, but also the tracheostomy tube and laryngeal mask airway. However, with the reports from the United Kingdom and South Africa, it would appear that beside making the manometer available, deficits in knowledge and attitude regarding Pcuff management need to be addressed too [ 15 – 17 ].…”

Anestesisykepleieres metoder for å kontrollere cufftrykk – en observasjonsstudie

“…Det kan skje gjennom undervisning og økt bevisstgjøring om risiko ved å ikke bruke en cufftrykkmanometer både på larynxmaske og endotrakealtube. Å utarbeide standarder, retningslinjer eller prosedyrer basert på forskning vil også bidra til å styrke en implementering og endre praksis (34,39).…”

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

“…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 …”

“…In addition, another recent study reported that more than 70% of clinicians in Pakistan have never used a manometer in their practice 14 . The unavailability of manometers was also noted as a reason for not using it routinely in studies conducted among anaesthetists in South Africa 24 and India (Balakrishan & Jacob, 2016). Akhtar 29 and Abubaker et al 14 suggested that gauge manometer usage should be made mandatory, and education regarding its use should be disseminated among clinicians for better application in daily practice to safeguard patients against life‐threatening complications.…”