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Knowledge and management of endotracheal tube cuffs
International Journal of Nursing Studies 52 (2015) 498–499
Contents lists available at ScienceDirect
International Journal of Nursing Studies journal homepage: www.elsevier.com/ijns
Letters
Knowledge and management of endotracheal tube cuffs Sonia O. Labeau a,b, Marc Bleiman c, Jordi Rello d,e, Dominique M. Vandijck a,f,g, Brigitte Claes h, Stijn I. Blot a,b,i,* a
University College Ghent, Faculty of Education, Health and Social Work, Ghent, Belgium Ghent University, Faculty of Medicine and Health Sciences, Ghent, Belgium c Covidien Belgium BVBA/SPRL, Mechelen, Belgium d Val d’Hebron University Hospital, Intensive Care Unit, Barcelona, Spain e Universitat Autonoma de Barcelona, CIBER Enfermedades Respiratorias (CIBERES), Spain f Hasselt University, Department of Patient Safety and Health Economics, Diepenbeek, Belgium g Ghent University, Department of Public Health, Ghent, Belgium h Antwerp University Hospital, Intensive Care Unit, Antwerp, Belgium i Burns Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Australia b
A R T I C L E I N F O
Article history: Received 15 September 2014 Received in revised form 25 September 2014 Accepted 25 September 2014
Dear Editor, In the intensive care unit (ICU), intubation is a common procedure that requires the insertion of an endotracheal tube, usually equipped with a high-volume low-pressure (HVLP) cuff. Safe cuff pressure ranges between 20 and 30 cmH2O or 15 and 22 mmHg. Overinflation may cause alterations in swallowing, tracheal wall ischemia, stenosis, and tracheo-esophageal fistulae; underinflation may lead to the development of ventilator-associated pneumonia (VAP) through leakage of oropharyngeal and subglottic secretions into the tracheobronchial tree and microaspiration of pathogens from the gastrointestinal tract (Lorente et al., 2010). Although various (patho-)physiological and mechanical factors may alter cuff pressure
* Corresponding author at: Ghent University, Faculty of Medicine and Health Sciences, Ghent, Belgium. Tel.: +32 9 332 62 16; fax: +32 9 332 38 95. E-mail address: [email protected] (S.I. Blot). http://dx.doi.org/10.1016/j.ijnurstu.2014.09.010 0020-7489/ß 2014 Elsevier Ltd. All rights reserved.
significantly (Lizy et al., 2014), irregular pressure measurement and a lack of knowledge about safe ranges have been reported (Spittle and Beavis, 2001). To investigate cuff management and related knowledge among ICU nurses, we distributed a self-administered questionnaire including a survey on daily practice and 10-item multiple choice knowledge questions among all participants of the Flemish Society for Critical Care Nurses annual congress (November 2008). Each multiple choice item was attributed four response alternatives, including ‘‘I do not know’’ to discourage guessing, and one correct answer only. Copies of the questionnaire were included in all congress bags, which were handed to the attendees upon registration. After the chairman’s introductory speech, each question was read aloud and simultaneously projected in the congress hall. Participants were explicitly asked to answer individually. All copies were collected immediately. We collected 591 questionnaires (response rate 82%); 75% of respondents were female, 50% had >10 years of ICU experience, 82% owned a specialized ICU nursing degree.
S.O. Labeau et al. / International Journal of Nursing Studies 52 (2015) 498–499
As targeted cuff pressure in the ICU of employment, a median of 25 cmH2O (IQR 10) was reported by 36% and of 30 mmHg (IQR 7.5) by 32%; 66% indicated not to know. Pressure was measured by auditive determination of the minimal occlusive volume in 10%, by manometer in 76%, by finger palpation of the balloon in 41%, and continuously in 0.3%. Audibly leakage was the most frequently reported indication for pressure check (79%). Without indication, 53% checked pressure every 8 h. In 46% there was no registration in the patient’s charts. The median score on the knowledge test was 6 (IQR 2). Correct pressure was known by 52%, and 84% was aware that a calibrated manometer measures pressure most accurately. It is well known that cuffs seal the extraluminal airway (95%), that subinflation can lead to aspiration (94%) and overinflation to tracheal injury (98%). Only 15% knew that overinflation can cause alterations in swallowing, and 7% that cuffs can be filled with sterile water. Although paucity of related data hampers extensive comparison, two previous surveys conducted in the United Kingdom are worthwhile mentioning. A survey in 32 general ICUs (Spittle and Beavis, 2001) revealed that cuff pressure was never measured in 13 of the 30 participating units, and of the 17 ICUs that did measure it, only four did so regularly. In only two units, cuff pressure was measured regularly after intubation, tube change, or admission of a patient already intubated. Of the senior nurses in charge, from whom the survey data were obtained, 20 indicated not to know the acceptable maximum cuff pressure. Second, a survey was conducted in a 13-bed ICU and 10bed high-dependency unit (Bhatta and Greer, 2007). Of 21 nurses questioned, only 15 were aware of cuff pressure monitoring in their unit, and of them, only nine knew what the maximum cuff pressure was. In the same study, 18 physicians were surveyed. Of these, only nine knew about cuff pressure monitoring, and of them, only six knew the maximum recommended cuff pressure (Bhatta and Greer, 2007). Differences in questionnaire and survey design do not allow a direct comparison between the results of both surveys (Bhatta and Greer, 2007; Spittle and Beavis, 2001) and ours. Generally, nevertheless, the variety in cuff management reported is striking, and regularity in measuring pressure appears to be missing. Moreover, all three studies indicate a poor to moderate knowledge of safe and evidence-informed cuff pressure practices among ICU clinicians. Thereby, their results are in line with these of previous surveys on ICU nurses’ knowledge of evidencebased guidelines (Labeau et al., 2007, 2008a,b). Considering the harmful effects associated with both cuff over- and underinflation, maintaining accurate cuff pressure is indispensable. As the hectic ICU environment does not allow checking cuff pressure constantly, automatic
499
devices that control and adjust cuff pressure continuously have been developed. These devices succeed in maintaining pressure between safe ranges and demonstrate a significant reduction in the risk of VAP (Lorente et al., 2014; Nseir et al., 2011). Classically, HVLP cuffs are manufactured of polyvinyl chloride (thickness 50 mm). More recently however, endotracheal tubes with ultrathin polyurethane cuff membranes of 7 mm only have been introduced to prevent the formation of folds within the cuff and fluid and air leakage. These devices have shown to reduce the frequency of early postoperative pneumonia in cardiac surgical patients (Poelaert et al., 2014). In spite of these technical advances, basic requirements such as consistent evidence-based, or at least evidenceinformed, guidelines for managing endotracheal cuffs, and a raised awareness of the importance of safe cuff pressure are still lacking. Remedying these shortcomings could contribute to improve the quality of care and hence the safety of critically ill intubated patients. References Bhatta, K., Greer, R., 2007. Awareness and monitoring of tracheal tube cuff pressure in a multidisciplinary intensive care unit. Anaesth. Intens. Care 35 (2), 302–303. Labeau, S., Vandijck, D.M., Claes, B., Van Aken, P., Blot, S.I., on behalf of the Executive Board of the Flemish Society for Critical Care Nurses, 2007. Critical care nurses’ knowledge of evidence-based guidelines for preventing ventilator-associated pneumonia: an evaluation questionnaire. Am J. Crit. Care 16 (4), 371–377. Labeau, S., Vandijck, D., Rello, J., Adam, S., Rosa, A., Wenisch, C., Ba¨ckman, C., Agbaht, K., Csomos, A., Seha, M., Dimopoulos, G., Vandewoude, K.H., Blot, S., 2008a. Evidence-based guidelines for the prevention of ventilator-associated pneumonia: results of a knowledge test among European intensive care nurses. J. Hosp. Infect. 70 (2), 180–185. Labeau, S., Vereecke, A., Vandijck, D.M., Claes, B., Blot, S., on behalf of the Executive Board of the Flemish Society for Critical Care Nurses, 2008b. Critical care nurses’ knowledge of evidence-based guidelines for preventing infections associated with central venous catheters: an evaluation questionnaire. Am. J. Crit. Care 17 (1), 65–71. Lizy, C., Swinnen, W., Labeau, S., Poelaert, J., Vogelaers, D., Vandewoude, K., Dulhunty, J., Blot, S., 2014. Cuff pressure of endotracheal tubes after changes in body position in critically ill patients treated with mechanical ventilation. Am. J. Crit. Care 23 (1), e1–e8. Lorente, L., Blot, S., Rello, J., 2010. New issues and controversies in the prevention of ventilator-associated pneumonia. Am. J. Respir. Crit. Care Med. 182 (7), 870–876. Lorente, L., Lecuona, M., Jimenez, A., Lorenzo, L., Roca, I., Cabrera, J., Llanos, C., Mora, M.L., 2014. Continuous endotracheal tube cuff pressure control system protects against ventilator-associated pneumonia. Crit. Care 18 (2), R77. Nseir, S., Zerimech, F., Fournier, C., Lubret, R., Ramon, P., Durocher, A., Balduyck, M., 2011. Continuous control of tracheal cuff pressure and microaspiration of gastric contents in critically ill patients. Am. J. Respir. Crit. Care Med. 184 (9), 1041–1047. Poelaert, J., Haentjens, P., Blot, S., 2014. Association among duration of mechanical ventilation, cuff material of endotracheal tube, and postoperative nosocomial pneumonia in cardiac surgical patients: a prospective study. J. Thorac. Cardiovasc. Surg., http://dx.doi.org/10.1016/ j.jtcvs.2014.05.085 (e-pub ahead of print). Spittle, C.N.S., Beavis, S.E., 2001. Do you measure tracheal cuff pressure? A survey of clinical practice. Brit. J. Anaesth. 87 (2), 344P–345P.
Contents lists available at ScienceDirect
International Journal of Nursing Studies journal homepage: www.elsevier.com/ijns
Letters
Knowledge and management of endotracheal tube cuffs Sonia O. Labeau a,b, Marc Bleiman c, Jordi Rello d,e, Dominique M. Vandijck a,f,g, Brigitte Claes h, Stijn I. Blot a,b,i,* a
University College Ghent, Faculty of Education, Health and Social Work, Ghent, Belgium Ghent University, Faculty of Medicine and Health Sciences, Ghent, Belgium c Covidien Belgium BVBA/SPRL, Mechelen, Belgium d Val d’Hebron University Hospital, Intensive Care Unit, Barcelona, Spain e Universitat Autonoma de Barcelona, CIBER Enfermedades Respiratorias (CIBERES), Spain f Hasselt University, Department of Patient Safety and Health Economics, Diepenbeek, Belgium g Ghent University, Department of Public Health, Ghent, Belgium h Antwerp University Hospital, Intensive Care Unit, Antwerp, Belgium i Burns Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Australia b
A R T I C L E I N F O
Article history: Received 15 September 2014 Received in revised form 25 September 2014 Accepted 25 September 2014
Dear Editor, In the intensive care unit (ICU), intubation is a common procedure that requires the insertion of an endotracheal tube, usually equipped with a high-volume low-pressure (HVLP) cuff. Safe cuff pressure ranges between 20 and 30 cmH2O or 15 and 22 mmHg. Overinflation may cause alterations in swallowing, tracheal wall ischemia, stenosis, and tracheo-esophageal fistulae; underinflation may lead to the development of ventilator-associated pneumonia (VAP) through leakage of oropharyngeal and subglottic secretions into the tracheobronchial tree and microaspiration of pathogens from the gastrointestinal tract (Lorente et al., 2010). Although various (patho-)physiological and mechanical factors may alter cuff pressure
* Corresponding author at: Ghent University, Faculty of Medicine and Health Sciences, Ghent, Belgium. Tel.: +32 9 332 62 16; fax: +32 9 332 38 95. E-mail address: [email protected] (S.I. Blot). http://dx.doi.org/10.1016/j.ijnurstu.2014.09.010 0020-7489/ß 2014 Elsevier Ltd. All rights reserved.
significantly (Lizy et al., 2014), irregular pressure measurement and a lack of knowledge about safe ranges have been reported (Spittle and Beavis, 2001). To investigate cuff management and related knowledge among ICU nurses, we distributed a self-administered questionnaire including a survey on daily practice and 10-item multiple choice knowledge questions among all participants of the Flemish Society for Critical Care Nurses annual congress (November 2008). Each multiple choice item was attributed four response alternatives, including ‘‘I do not know’’ to discourage guessing, and one correct answer only. Copies of the questionnaire were included in all congress bags, which were handed to the attendees upon registration. After the chairman’s introductory speech, each question was read aloud and simultaneously projected in the congress hall. Participants were explicitly asked to answer individually. All copies were collected immediately. We collected 591 questionnaires (response rate 82%); 75% of respondents were female, 50% had >10 years of ICU experience, 82% owned a specialized ICU nursing degree.
S.O. Labeau et al. / International Journal of Nursing Studies 52 (2015) 498–499
As targeted cuff pressure in the ICU of employment, a median of 25 cmH2O (IQR 10) was reported by 36% and of 30 mmHg (IQR 7.5) by 32%; 66% indicated not to know. Pressure was measured by auditive determination of the minimal occlusive volume in 10%, by manometer in 76%, by finger palpation of the balloon in 41%, and continuously in 0.3%. Audibly leakage was the most frequently reported indication for pressure check (79%). Without indication, 53% checked pressure every 8 h. In 46% there was no registration in the patient’s charts. The median score on the knowledge test was 6 (IQR 2). Correct pressure was known by 52%, and 84% was aware that a calibrated manometer measures pressure most accurately. It is well known that cuffs seal the extraluminal airway (95%), that subinflation can lead to aspiration (94%) and overinflation to tracheal injury (98%). Only 15% knew that overinflation can cause alterations in swallowing, and 7% that cuffs can be filled with sterile water. Although paucity of related data hampers extensive comparison, two previous surveys conducted in the United Kingdom are worthwhile mentioning. A survey in 32 general ICUs (Spittle and Beavis, 2001) revealed that cuff pressure was never measured in 13 of the 30 participating units, and of the 17 ICUs that did measure it, only four did so regularly. In only two units, cuff pressure was measured regularly after intubation, tube change, or admission of a patient already intubated. Of the senior nurses in charge, from whom the survey data were obtained, 20 indicated not to know the acceptable maximum cuff pressure. Second, a survey was conducted in a 13-bed ICU and 10bed high-dependency unit (Bhatta and Greer, 2007). Of 21 nurses questioned, only 15 were aware of cuff pressure monitoring in their unit, and of them, only nine knew what the maximum cuff pressure was. In the same study, 18 physicians were surveyed. Of these, only nine knew about cuff pressure monitoring, and of them, only six knew the maximum recommended cuff pressure (Bhatta and Greer, 2007). Differences in questionnaire and survey design do not allow a direct comparison between the results of both surveys (Bhatta and Greer, 2007; Spittle and Beavis, 2001) and ours. Generally, nevertheless, the variety in cuff management reported is striking, and regularity in measuring pressure appears to be missing. Moreover, all three studies indicate a poor to moderate knowledge of safe and evidence-informed cuff pressure practices among ICU clinicians. Thereby, their results are in line with these of previous surveys on ICU nurses’ knowledge of evidencebased guidelines (Labeau et al., 2007, 2008a,b). Considering the harmful effects associated with both cuff over- and underinflation, maintaining accurate cuff pressure is indispensable. As the hectic ICU environment does not allow checking cuff pressure constantly, automatic
499
devices that control and adjust cuff pressure continuously have been developed. These devices succeed in maintaining pressure between safe ranges and demonstrate a significant reduction in the risk of VAP (Lorente et al., 2014; Nseir et al., 2011). Classically, HVLP cuffs are manufactured of polyvinyl chloride (thickness 50 mm). More recently however, endotracheal tubes with ultrathin polyurethane cuff membranes of 7 mm only have been introduced to prevent the formation of folds within the cuff and fluid and air leakage. These devices have shown to reduce the frequency of early postoperative pneumonia in cardiac surgical patients (Poelaert et al., 2014). In spite of these technical advances, basic requirements such as consistent evidence-based, or at least evidenceinformed, guidelines for managing endotracheal cuffs, and a raised awareness of the importance of safe cuff pressure are still lacking. Remedying these shortcomings could contribute to improve the quality of care and hence the safety of critically ill intubated patients. References Bhatta, K., Greer, R., 2007. Awareness and monitoring of tracheal tube cuff pressure in a multidisciplinary intensive care unit. Anaesth. Intens. Care 35 (2), 302–303. Labeau, S., Vandijck, D.M., Claes, B., Van Aken, P., Blot, S.I., on behalf of the Executive Board of the Flemish Society for Critical Care Nurses, 2007. Critical care nurses’ knowledge of evidence-based guidelines for preventing ventilator-associated pneumonia: an evaluation questionnaire. Am J. Crit. Care 16 (4), 371–377. Labeau, S., Vandijck, D., Rello, J., Adam, S., Rosa, A., Wenisch, C., Ba¨ckman, C., Agbaht, K., Csomos, A., Seha, M., Dimopoulos, G., Vandewoude, K.H., Blot, S., 2008a. Evidence-based guidelines for the prevention of ventilator-associated pneumonia: results of a knowledge test among European intensive care nurses. J. Hosp. Infect. 70 (2), 180–185. Labeau, S., Vereecke, A., Vandijck, D.M., Claes, B., Blot, S., on behalf of the Executive Board of the Flemish Society for Critical Care Nurses, 2008b. Critical care nurses’ knowledge of evidence-based guidelines for preventing infections associated with central venous catheters: an evaluation questionnaire. Am. J. Crit. Care 17 (1), 65–71. Lizy, C., Swinnen, W., Labeau, S., Poelaert, J., Vogelaers, D., Vandewoude, K., Dulhunty, J., Blot, S., 2014. Cuff pressure of endotracheal tubes after changes in body position in critically ill patients treated with mechanical ventilation. Am. J. Crit. Care 23 (1), e1–e8. Lorente, L., Blot, S., Rello, J., 2010. New issues and controversies in the prevention of ventilator-associated pneumonia. Am. J. Respir. Crit. Care Med. 182 (7), 870–876. Lorente, L., Lecuona, M., Jimenez, A., Lorenzo, L., Roca, I., Cabrera, J., Llanos, C., Mora, M.L., 2014. Continuous endotracheal tube cuff pressure control system protects against ventilator-associated pneumonia. Crit. Care 18 (2), R77. Nseir, S., Zerimech, F., Fournier, C., Lubret, R., Ramon, P., Durocher, A., Balduyck, M., 2011. Continuous control of tracheal cuff pressure and microaspiration of gastric contents in critically ill patients. Am. J. Respir. Crit. Care Med. 184 (9), 1041–1047. Poelaert, J., Haentjens, P., Blot, S., 2014. Association among duration of mechanical ventilation, cuff material of endotracheal tube, and postoperative nosocomial pneumonia in cardiac surgical patients: a prospective study. J. Thorac. Cardiovasc. Surg., http://dx.doi.org/10.1016/ j.jtcvs.2014.05.085 (e-pub ahead of print). Spittle, C.N.S., Beavis, S.E., 2001. Do you measure tracheal cuff pressure? A survey of clinical practice. Brit. J. Anaesth. 87 (2), 344P–345P.