December Journal Club

[katevaughn]

This month's journal club is presented by Vania Milnes. She chose an important article that discusses the effectiveness of interventions that can increase provider monitoring of endotracheal tube and LMA cuff pressures. This is definitely a measure we should all be doing with every case but is often something bypassed. 

A common postoperative complaint after an endotracheal tube or a laryngeal mask airway is throat pain and/or hoarseness. It's so common that many providers include this in their consent and discussion of potential risks of anesthesia. Other more significant complications can also occur such as lingual nerve damage, necrosis, dysphagia, bleeding and ulceration to name a few, which are mostly associated with higher than suggested cuff pressures. We do not routinely monitor this variable and manometers are not easily obtained in the OR. In pediatrics we often test for a "leak" for our smaller intubated patients by auscultation and setting the pop-off at 20, but that is also inconsistently performed. Interestingly, checking cuff pressures was routine in the PICU where I worked, yet this doesn't happen in the OR, even for longer cases.

This article addresses the need for routine monitoring and evaluates the efficacy of a quality improvement project that was implemented. The project was focused on increasing monitoring and assessing whether or not this made a difference by decreasing postoperative complications. It's interesting how some of our common practices such as manual cuff palpation are very inaccurate, so this warrants a more definitive measure.

Here is a link to the article. 

1. Have you ever routinely monitored cuff pressures in the OR here or any other institution? If so, how did you access manometers?

2. Do you think this is a valid concern based on the article? Do you have a story to share about a postoperative complication potentially related to excessive cuff pressures? How would you propose we institute a similar quality improvement project and do you think it be difficult to do in such a large institution?

[Kristen Horsman]

1. I have never routinely monitored cuff pressures in the OR here or any other institution I rotated to during my clinical rotations in school.

2. I do believe excessive cuff pressures is a valid concern for pharyngeal complications- sore throat, hoarseness, lingual nerve smsage, ulceration, bleeding, tracheal stenosis/necrosis, dysphagia,etc. The article states that manometers are only $200-500 which is a very reasonable cost for the anesthesia budget. During the next update of EPIC, a row for cuff pressure could be easily added to our screen where we document temp/BIS/TOF to make it a standard of documentation.

[nanci]

1)Have you ever routinely monitored cuff pressures in the OR here or any other institution? If so, how did you access manometers? No I have never routinely monitored cuff pressures in the OR here or at any other institution. There were no manometers routinely (if ever) available for use. That being said, a few years ago at Hopkins in the Weinberg OR's there were a group of our Residents doing research on this subject and they would routinely come into cases throughout the day with their manometer and do cuff pressure checks on patients at a variety of times (ie... post intubation, intra-op, pre-extubation). I recall them doing this with ETT's but do not recall them ever having done it on a patient I was taking care of with use of LMA- so can not comment to that. I also do not know where their research took them, where they obtained or kept their isntrumentation, or if their findings were ever published.

2 Do you think this is a valid concern based on the article? Sure, sore throat and hoarseness definitely happen as well as other complications mentioned in the article.
Do you have a story to share about a postoperative complication potentially related to excessive cuff pressures? No
How would you propose we institute a similar quality improvement project and do you think it be difficult to do in such a large institution? Since the Residents already did a similar project (pre-EPIC charting- we were using Metavision at the time) I can not see why it can not be done for the greater good of the department overall and all patients. One would have to speak to whomever puts in for obtaining equipment for the anesthesia department and work it into the budget. Maybe they can also purchase an accompanying holder for the front of each anesthesia machine to hold the device so that they do not get lost or thrown away as easily. I'm sure that purchases in such bulk can be made if given enough notice. Speak with Dr. Rivers or whomever updates EPIC and put in a request to have Cuff reading placed and I am sure that can be accommodated as well. An email to go out to all staff (including CCT's) on the specifics (so all know how to use/chart/clean/store/maintain/etc...) and a periodic reminder (to include results which hopefully would show greater patient safety achieved) would also be helpful for compliance.

[Moishe Mayer]

1. Have you ever routinely monitored cuff pressures in the OR here or any other institution? If so, how did you access manometers?

I have never worked used a manometer or any device to directly measure cuff pressure. The only methods I saw used were palpating the pilot balloon. Another method I often use when I am not sure how much air was placed in the balloon, is to deflate completely, and reinflate while applying positive pressure. I will then cease to inflate beyond the minimal occlusive pressure; assuming I am achieving good Vt.

2. Do you think this is a valid concern based on the article? Do you have a story to share about a postoperative complication potentially related to excessive cuff pressures? How would you propose we institute a similar quality improvement project and do you think it be difficult to do in such a large institution?

I would like to see manometers here at Hopkins for my own education, and to help me better identify with how much pressure I am inflating the balloon. I am not thoroughly convinced from this article alone that manometers should become a standard of care. The numbers did not seem all that significant, coupled with a relatively small sample size.

[Ben Waldbaum]

1. No as we do not have manometer

2. I wouldn't base any changes in our hospital on this study as it was quite small, not statistically significant, and the confidence intervals overlapped. Additionally, they did not follow the patients postoperatively to record instances of sore throat, tracheal injury, or other injuries. Manometery of ETT/LMA cuff pressures may be beneficial, but that cannot be concluded in any way from this study. Our practice needs to be evidence based. While $200-$500 per manometer may not seem like a lot, when you consider that the purchase would be around 200 of them, the cost becomes $40,000 to $100,000, which is hardly a small expense. What I'd like to see is clear evidence of benefit. Many times articles present a statistical value called the "NNT" which stands for the "Number needed to treat." This is a number that states how many patients the intervention needs to be done on in order to help a single patient. The lower the number the better. This is the ultimate number that could be used to justify the capital expense of acquiring manometers. It's an interesting topic so I did a brief literature search and found an article regarding LMA cuff pressure which is a RCT and follows the patients post operatively. There is some evidence for LMAs. here is the link:

link.springer.com/article/10.1007%2Fs00101-016-0160-9

I couldn't find a RCT for cuff manometry of ETT's and it's relationship to posteropative tracheal/pharyngeal injury. Can anyone find one?

[Fara Lekhnych]

I have not worked with a manometer or other device to monitor cuff pressures.

I definitely think the article presents a very valid concern. I am curious to know why it is such commonplace in our profession not to monitor cuff pressures. If it is beneficial for patients I think it is worth considering but many factors have to be considered, including cost and if the benefits outweigh all of the other factors. In the study the incidence of sore throat was 34% in the manometer group compared to 44% in the control group. In my opinion, it would be challenging to not only have all providers change their practice, but also to budget for this, so a method that would be easier to implement that would mitigate some of the concerns may be worth considering. Patients will have a sore throat simply for the fact that a foreign object was placed into the oropharynx or trachea. I have not seen in my practice that patients are routinely getting tracheal stenosis or lingual nerve damage from routine procedures. This does not mean that it is not a concern, because it is significant when it actually happens. If the major concern is a sore throat, LTA's can be an alternative. I have used them before and it was a good way to prevent emergence coughing and post-operative sore throat.

[Jennifer Hannon]

1. We used them in Virginia and in Boston. They are just a little hand-held squeeze-gauge, and so I see them disappearing at Hopkins like the little TOF stims, until they are better adopted across the board and secured to our vents.

2.I believe excessive cuff pressures is a concern for the complications mentioned in the article:sore throat, hoarseness, lingual nerve damage, tracheal stenosis/necrosis,etc.I agree that Rivers can easily add a entry box (near BIS) for cuff pressures. I don't have a story of complications to share.

[Jessica Switzman]

1. I have not and do not currently monitor cuff pressures.

2. I have left a 5 cc syringe attached to an inflated cuff when the pt remains in Tberg for an extended time. I do believe an over inflated cuff can cause sore throats, hoarseness and nerve injury.    

[Soo-Ok Kim]

1. Have you ever routinely monitored cuff pressures in the OR here or any other institution? If so, how did you access manometers?

I have not monitored cuff pressure routinely since we don't have a manometer in this institution. However, I routinely perform leak test with ETT in pediatric population to inflate the pilot balloon just enough to occlude trachea with about 20cmH2O pressure.


2. Do you think this is a valid concern based on the article? Do you have a story to share about a postoperative complication potentially related to excessive cuff pressures? How would you propose we institute a similar quality improvement project and do you think it be difficult to do in such a large institution?

Although this article describes valid point with complications related to excessive cuff pressure, I agree with Ben's point saying that it is small sample study with a wide range of baseline data.

However, it is true that anesthesia providers' estimation of cuff pressure tend to be inaccurate. I am surprised to read 210mmHg with LMA cuff. So, using manometer to measure accurate pressure can be useful to decrease the known complications.

That should be more research done to prove the point to be standardized.

[Jessica Hadley]

1. Have you ever routinely monitored cuff pressures in the OR here or any other institution? If so how did you access manometers?

No, I have never measured cuff pressures in any of the OR's I have worked in or rotated to as a student.

2. Do you think this is a valid concern based on the article? Do you have a story to share about a postoperative complication potentially related to excessive cuff pressures? How would you propose we institute a similar quality improvement project and do you think it would be difficult to do in such a large institution?

Yes, as the article explained high cuff/lma pressures can cause sore throat, hoarseness, lingual dysfunction, etc. I have had a couple of patients tell me during preop interviews that in previous surgeries they have had sore throats that felt quite severe and lasted multiple days, potentially from excessive cuff pressures although a source is hard to pinpoint after the fact. In order to make improvements regarding this subject we would first need to have manometers available for use. Perhaps a pilot could be done somewhere like JHOC, where there are only 8 OR's so results could be easily measured. Finally, yes I do think that this would be challenging to implement in such a large institution especially since there is relatively rapid turnover in staff due to residents, agency staff, etc.

[Wai-Ling Lo]

1. Have you ever routinely monitored cuff pressures in the OR here or any other institution? If so, how did you access manometers?

No, I didn't routinely monitored cuff pressures in OR. However, for long cases, I do perform leak test after intubation and use the least occlusive pressure.



2. Do you think this is a valid concern based on the article? Do you have a story to share about a postoperative complication potentially related to excessive cuff pressures? How would you propose we institute a similar quality improvement project and do you think it be difficult to do in such a large institution?

Yes, this is a valid concern not just from reading this article, but also from talking to ENT surgeons and doing cases with tracheal stenosis from previous intubation that required repeat tracheal dilatation. It really makes me think twice how much air should I put in the cuff every time I intubate a pt. Other factors that may contribute to cuff pressure changes include the use of N2O, fluid shift, positioning of pts, CO2 insufflation... Some studies showed that cuff pressure elevation of 10-15cm H2O may result from CO2 insufflation and pts in stiff T-berg position. This was associated with higher incidence of postop sore throat and other complications. That being said, too little cuff pressure can also lead to complications like microaspiration. All these complications may be prevented by vigilant cuff pressure measuring. It is already a gold standard to measure ETT cuff pressure in ICU. With the notion of 'do no harm' to pts, and the potential denial payment from insurance for complications caused by the healthcare system, a quality improvement project should be warranted.

[Chuck Eder]

1. No routine monitoring of cuff pressures here at Hopkins or any previous place I have trained.

2. This seems like it could be a valid concern for possible post op complications of ETT/LMA use. It would be interesting to see the results from a larger study. 102 study subjects probably could be obtained at Hopkins in less than 2 days with the amount of cases completed each day. It would be nice to have access to a manometer to evaluate our current practice and make adjustments as needed. The addition of a entry window in EPiC could also lead to provider compliance. A manometer could be very helpful with the different ETTs that we use in the OR. Inflation of each different ETT (NIMS, anode, standard ETT, ETT with gastric suction) has variable amounts of inflation air. Another variable to the sore throat complication is the number of DL's performed or the number of attempts to properly "seat" the LMA, which can be independent of the inflation pressures.

[Mary SH]

1. Have you ever routinely monitored cuff pressures in the OR here or any other institution? If so, how did you access manometers? Routinely, no I have not. Periodically someone does a study on providers guessing volumes and then testing them with a manometer (we were never even close!!), but never seen it in practice in the OR.

2. Do you think this is a valid concern based on the article? Do you have a story to share about a postoperative complication potentially related to excessive cuff pressures? How would you propose we institute a similar quality improvement project and do you think it be difficult to do in such a large institution? Yes, it is a valid concern, especially in pediatrics. We have had kids come in who were intubated in the field, ER or sometimes the OR with tubes that were too big or had too much air in the cuffs and they developed subglottic stenosis. Would it be difficult to do? No. Would it be difficult to get providers to do it? Yes. We can't get providers to measure temperatures and put on warming devices, imagine introducing something new like this. The manometers would need to be purchased for each anesthetic area and tethered to the machines

[klinden]

"Everything old becomes new" .  It was fairly common practice in the 80'same to monitor cuff pressures - everyone had a monometer - we had manual blood pressure cuffs.  Once all tubes became low pressure cuffs it became a non-issue.  So, yes I have monitored cuff pressures but not for about 20 years.

Resp therapy has those cuff pressure attachments to monitor cuff pressures on Ett, no reason why we couldn't use them also. I'm not sure that I'm convinced that this a practice I need to use routinely for LMA'so as I don'the use them for long cases.

[emedina1]

I have not used cuff monitor in my practice here at Hopkins nor other hospital that I worked. However, It was introduced in the early years of my practice.
It didn't gain enough concern . I agree with Ben that for this practice to be observed it will require a big amount of monetary resource . Maybe evidence base study to

convince the powers to implement this