Performance of the cuff leak test in adults in predicting post-extubation airway complications: a systematic review and meta-analysis

Abstract

Background Clinical practice guidelines recommend performing a cuff leak test in mechanically ventilated adults who meet extubation criteria to screen those at high risk for post-extubation stridor. Previous systematic reviews demonstrated excellent specificity of the cuff leak test but disagreed with respect to sensitivity. We conducted a systematic review and meta-analysis to assess the diagnostic accuracy of the cuff leak test for predicting post-extubation airway complications in intubated adult patients in critical care settings. Methods We searched Medline, EMBASE, Scopus, ISI Web of Science, the Cochrane Library for eligible studies from inception to March 16, 2020, without language restrictions. We included studies that examined the diagnostic accuracy of cuff leak test if post-extubation airway obstruction after extubation or reintubation was explicitly reported as the reference standard. Two authors in duplicate and independently assessed the risk of bias using the Quality Assessment for Diagnostic Accuracy Studies-2 tool. We pooled sensitivities and specificities using generalized linear mixed model approach to bivariate random-effects meta-analysis. Our primary outcomes were post-extubation airway obstruction and reintubation. Results We included 28 studies involving 4493 extubations. Three studies were at low risk for all QUADAS-2 risk of bias domains. The pooled sensitivity and specificity of cuff leak test for post-extubation airway obstruction were 0.62 (95% CI 0.49–0.73; I2 = 81.6%) and 0.87 (95% CI 0.82–0.90; I2 = 97.8%), respectively. The pooled sensitivity and specificity of the cuff leak test for reintubation were 0.66 (95% CI 0.46–0.81; I2 = 48.9%) and 0.88 (95% CI 0.83–0.92; I2 = 87.4%), respectively. Subgroup analyses suggested that the type of cuff leak test and length of intubation might be the cause of statistical heterogeneity of sensitivity and specificity, respectively, for post-extubation airway obstruction. Conclusions The cuff leak test has excellent specificity but moderate sensitivity for post-extubation airway obstruction. The high specificity suggests that clinicians should consider intervening in patients with a positive test, but the low sensitivity suggests that patients still need to be closely monitored post-extubation.

Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 2. Planning and implementing safe management of the patient with an anticipated difficult airway

“…For example, the patient considered at risk of supraglottic or glottic airway edema might be assessed with a cuff leak test. 221,[226][227][228] In a recent systematic review, the authors concluded that the absence of a cuff leak in an at-risk patient is associated with post-extubation stridor or need for re-intubation, but the presence of a leak does not necessarily rule out the occurrence of stridor or need for re-intubation. 228 Further assessment of the at-risk patient can occur by indirect visual evaluation of the glottis and supraglottic area using a VL 229 or FB before emergence from anesthesia or sedation begins.…”

The cuff leak test in critically ill patients: An international survey of intensivists

“…However, intubation can be associated with serious complications such as laryngeal edema that may result in a life‐threatening upper airway obstruction postextubation. A recent systematic review and meta‐analysis of 4493 patients in 28 observational studies reported that approximately 9% of all patients will develop postextubation laryngeal edema, and 3% of patients will require reintubation for an upper airway obstruction 1 . Reintubation has been associated with significant morbidity and mortality 2‐7 …”

“…The diagnostic accuracy of a CLT is debatable. To date, three systematic reviews and meta‐analyses have examined the diagnostic accuracy of the CLT 1,9,10 . All found that a failed CLT was a predictor of laryngeal edema but may not predict reintubation 1,9,10 .…”

“…To date, three systematic reviews and meta‐analyses have examined the diagnostic accuracy of the CLT 1,9,10 . All found that a failed CLT was a predictor of laryngeal edema but may not predict reintubation 1,9,10 . Therefore, the CLT may lead to an unnecessary prolongation of mechanical ventilation, deconditioning, ventilator associated pneumonia, and an extended stay in the ICU.…”

False-positive Cuff Leak Test Due to Glossoptosis: A Case Report

“…Laryngeal edema and post-exubation stridor are related to reintubation, and the incidence of postextubation stridor is reported to be 2-26% [1]. The cuff leak test (CLT) is conducted to predict the presence of laryngeal edema and post-extubation stridor [2,3], and the sensitivity and speci city of the CLT were reported as 0.62 and 0.87 [3], respectively. The CLT can sometimes be falsely positive.…”