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Nov.23.2020View related content

Endotracheal Tube and Tracheostomy Tube Cuff Care - CE

ALERT

If the patient is sedated, paralyzed, on pressure support, or receiving high oxygen delivery, do not disconnect him or her from the ventilator.

Keep the cuff pressure at a level that maintains a seal between the cuff and the tracheal wall; the volume necessary to create the seal depends on tube size and cuff configuration.

Potential complications of cuff inflation include tracheal stenosis, necrosis, tracheoesophageal fistulas, and tracheomalacia; these complications are more likely to occur in conditions that adversely affect tissue response to mucosal injury, such as hypotension.

OVERVIEW

The tube cuff helps stabilize the endotracheal or tracheostomy tube and maintains an adequate airway seal so that air moves through the tube into the lungs. The cuff is an inflatable “balloon” that surrounds the shaft of the tube near its distal end. When inflated, the cuff presses against the tracheal wall to prevent air leakage and pressure loss from the lungs. A cuff prevents the escape of air between the tube and the walls of the trachea and reduces aspiration when a patient is receiving mechanical ventilation. The goals of correctly inflating the cuff on an artificial airway are to promote lung inflation for mechanical ventilation and prevent aspiration of gastric contents, while at the same time allowing drainage of secretions that accumulate between the epiglottis and the cuff. The amount of air inserted in a cuff is based on several factors, including the size of the patient’s trachea and the external diameter of the artificial airway. If the cuff pressure is too high, permanent damage to the tracheal mucosa occurs.

Appropriate cuff care helps prevent major pulmonary aspirations, helps prepare for tracheal extubation, decreases the risk of inadvertent extubation, provides a patent airway for ventilation and removal of secretions, and decreases the risk of health care–associated infections. Although a variety of endotracheal and tracheostomy tubes exists, the most desirable tube provides a maximum airway seal with minimal tracheal wall pressure, using a high-volume, low-pressure cuff (Figure 1)Figure 1 .

High-volume, low-pressure cuffs allow a large surface area to come into contact with the tracheal wall, thus distributing the pressure over a much greater area. The amount of pressure and volume necessary to obtain a seal and prevent mucosal damage depends on tube size and design, cuff configuration, mode of ventilation, and the patient’s arterial blood pressure.

Several devices are available to measure cuff pressure, including bedside sphygmomanometers, special aneroid cuff manometers (Figure 2)Figure 2, and electronic cuff pressure devices. Ideally, the cuff pressure should be between 20 and 30 cm H2O.1 Higher cuff pressure may compress tracheal capillaries, limit blood flow, and predispose the patient to tracheal necrosis. Lower cuff pressure may predispose the patient to aspiration of oropharyngeal secretions and the development of ventilator-associated pneumonia.1 Cuff pressure should be measured at least once per shift to maintain the pressure in the safe range to avoid injury to the trachea and minimize the risk of aspiration.

SUPPLIES

Click here for a list of supplies.

EDUCATION

  • Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
  • Provide the patient and family with an explanation of the equipment and the procedure.
  • Explain the patient’s role in assisting with cuff care.
  • Explain to the patient and family that the procedure may be uncomfortable and cause the patient to cough.
  • Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

  1. Perform hand hygiene before patient contact.
  2. Introduce yourself to the patient.
  3. Verify the correct patient using two identifiers.
  4. Assess for the presence of bilateral breath sounds.
  5. Assess for signs and symptoms of cuff leakage.
    1. Audible or auscultated inspiratory leak over the larynx
    2. The patient’s ability to vocalize audibly
    3. Deflation of inflation (pilot) valve balloon
    4. Loss of inspiratory and expiratory volume in a mechanically ventilated patient
  6. Assess for signs and symptoms of inadequate ventilation.
    1. Rising arterial carbon dioxide tension
    2. Chest–abdominal asynchrony
    3. Patient–ventilator asynchrony
    4. Dyspnea
    5. Headache
    6. Restlessness
    7. Confusion
    8. Lethargy
    9. Increasing (early sign) or decreasing (late sign) arterial blood pressure
    10. Activation of expiratory or inspiratory volume alarms on mechanical ventilator
  7. Assess the amount of air or pressure previously used to inflate the cuff.
  8. Assess the size of the tracheal tube and the size of the patient.

Preparation

  1. Place the patient in the semi-Fowler position.

PROCEDURE

Measuring Cuff Pressure

  1. Perform hand hygiene and don gloves.
  2. Introduce yourself to the patient.
  3. Verify the correct patient using two identifiers.
  4. Explain the procedure to the patient and ensure that he or she agrees to treatment.
  5. Suction the patient’s airway and oropharynx to clear secretions in the lower airway and above the cuff.
    Rationale: Clearing secretions decreases the risk of aspiration.
  6. Connect the cuff pressure manometer to the inflation port of the endotracheal tube or tracheostomy tube according to the manufacturer’s instructions.
  7. Rationale: A manometer allows measurement of air pressure in the cuff.
  8. Read the cuff pressure displayed on the manometer. Ideally, the cuff pressure should be between 20 and 30 cm H2O.1
  9. Keep the cuff pressure at a level that maintains a seal between the cuff and the tracheal wall; the volume necessary to create the seal depends on the tube size and cuff configuration.
  10. Disconnect the manometer line from the inflation valve.
  11. Discard supplies, remove gloves, and perform hand hygiene.
  12. Document the procedure in the patient’s record.

Correcting an Air Leak

  1. Perform hand hygiene and don gloves, gown, mask, and eye protection or face shield, if indicated.
  2. Introduce yourself to the patient.
  3. Verify the correct patient using two identifiers.
  4. Explain the procedure to the patient and ensure that he or she agrees to treatment.
  5. Suction the patient’s airway and oropharynx to clear secretions in the lower airway and above the cuff.
  6. Rationale: Clearing secretions decreases the risk of aspiration.
    1. Use a fresh, sterile catheter if using an open-suction system for suctioning the tracheobronchial tree. When suctioning of the tracheobronchial tree is complete, use the same catheter to suction the pharynx.
    2. If using a closed-suction system to suction the tracheobronchial tree, use a fresh, sterile catheter to suction the pharynx.
  7. Remove the T-tube (T-piece) or tracheostomy collar from the endotracheal or tracheostomy tube; or, if the patient is on a ventilator, is stable, and is not dependent on pressure support or high levels of oxygen, remove the ventilator tubing. Attach a self-inflating manual resuscitation bag (MRB) device for ventilation.
  8. If the patient is sedated, paralyzed, on pressure support, or receiving high oxygen delivery, do not disconnect him or her from the ventilator.
  9. Instill air into the cuff.
    1. Insert an air-filled syringe tip into the inflation valve (also referred to as the pilot balloon valve).
    2. Gradually add air to the cuff until the leak is eliminated.
    3. Ventilate the lungs with an MRB.
    4. Rationale: Ventilating the lungs reoxygenates the patient and allows for further assessment of proper cuff inflation and elimination of the air leak.
    5. If the patient is awake and alert, ask him or her to vocalize.
    6. Rationale: If the trachea is sealed and the air leak has been corrected, the patient will not be able to vocalize.
  10. Remove the syringe from the inflation valve.
  11. Reconnect the T-tube, tracheostomy collar, or ventilator tubing to the endotracheal or tracheostomy tube. Check and secure ventilator connections as needed.
  12. Rationale: Replacing oxygen and ensuring secure connections provides oxygen flow and prevents oxygen desaturation.
  13. Reassess the patient’s airway and respiratory status.
  14. Measure the cuff pressure.
  15. Discard supplies, remove personal protective equipment (PPE), and perform hand hygiene.
  16. Document the procedure in the patient’s record.

Troubleshooting Cuff Problems

  1. Perform hand hygiene and don gloves.
  2. Introduce yourself to the patient.
  3. Verify the correct patient using two identifiers.
  4. Explain the procedure to the patient and ensure that he or she agrees to treatment.

Faulty Inflation Valve

  1. Check whether the cuff repeatedly deflates despite the addition of air.
  2. Rationale: A cuff that repeatedly deflates after air is instilled indicates a faulty inflation valve; repair is needed.
  3. If the inflation valve has become faulty and reintubation is undesirable, institute emergency cuff inflation (Figure 3)Figure 3.
    1. Insert a three-way stopcock into the distal opening of the inflation valve.
    2. Rationale: A three-way stopcock provides control of airflow in and out of the inflation valve.
    3. Inflate the cuff until an air leak is no longer detected.
    4. Rationale: If an air leak is no longer detected, this indicates that the seal between the tracheal wall and the cuff is restored.
    5. Clamp the inflation tube by applying a padded hemostat distal to the inflation valve.
    6. Rationale: Clamping the inflation tube maintains air in the cuff and provides a quick occlusion of the inflating tube.
    7. Turn the stopcock off to the inflation valve and leave it in place; remove the clamp.
    8. Rationale: Turning the stopcock off to the inflation valve allows temporary use of the tube while maintaining cuff pressure.
  4. Reassess the patient’s airway and respiratory status.
  5. Discard supplies, remove gloves, and perform hand hygiene.
  6. Document the procedure in the patient’s record.

Faulty Inflation Tube

  1. Check for an air leak in the inflation tube.
  2. If an air leak is found, cut off the faulty end of the inflation tube and valve with scissors.
  3. Rationale: Cutting off the faulty end prepares the inflation tube for repair.
  4. Insert a short, small-gauge blunt cannula into the inflation tube.
  5. Rationale: The cannula provides access for inflation.
    Use caution to avoid puncturing or severing the inflation line or skin.
  6. Attach a three-way stopcock to a blunt cannula.
  7. Rationale: A three-way stopcock provides control of airflow in and out of the inflating line.
  8. Inflate the cuff until an air leak is no longer detected.
  9. Rationale: Inability to detect an air leak after inflation of the cuff indicates that the seal between the tracheal wall and the cuff has been restored.
  10. Turn the stopcock off to the inflation tube.
  11. Rationale: Turning the stopcock off allows temporary use of the tube while maintaining cuff pressure.
  12. Secure the assembled device with tape to a tongue depressor.
  13. Rationale: Securing the device with tape to a tongue depressor provides stabilization and protection.
  14. Notify the practitioner and assemble the equipment for tube replacement.
  15. Reassess the patient’s airway and respiratory status.
  16. Discard supplies, remove gloves, and perform hand hygiene.
  17. Document the procedure in the patient’s record.

MONITORING AND CARE

  1. Assess respiratory status for optimal ventilation.
    Rationale: Inadequate interface between the tube cuff and tracheobronchial mucosa decreases inspiratory flow.
    Reportable conditions: Rising arterial carbon dioxide (CO 2) tension, chest–abdominal dyssynchrony, patient–ventilator dyssynchrony, dyspnea, headache, restlessness, confusion, lethargy, rising (early sign) or falling (late sign) arterial blood pressure, activation of expiratory or inspiratory volume alarms on mechanical ventilator
  2. Measure cuff pressure every shift. Maintain a cuff pressure between 20 and 30 cm H2O.1
    Rationale: Maintaining correct cuff pressure helps prevent tracheal injury and aspiration.
    If the volume of air (milliliters) needed to seal the airway increases, consult with the practitioner regarding the need for a chest radiograph to evaluate the patient for tracheal dilation and to determine the cuff diameter to tracheal diameter ratio. An increasing volume of air required to maintain cuff inflation may also indicate a leak in the cuff, inflation valve, or inflation tube.
  3. Minimize unnecessary tube manipulation to maintain cuff integrity.
    Rationale: Tube manipulation increases the likelihood of cuff disruption. A cuff leak or rupture is evident when the pressure on the manometer continues to decrease.
    Reportable conditions: Inability to maintain cuff inflation, audible air through the patient’s nose or mouth, low-pressure or low-volume alarm sounds on the mechanical ventilator, audible or auscultated inspiratory leak over the larynx, patient’s ability to vocalize audibly, pilot balloon deflation, loss of inspiratory and expiratory volume in a mechanically ventilated patient
  4. Suction secretions from the patient as indicated.
    Rationale: Removing secretions reduces the chance for partial or complete airway obstruction.
  5. Compare the patient’s cardiopulmonary status before and after cuff care.
    Rationale: Comparing the cardiopulmonary status before and after cuff care helps assess the effects of cuff care on the cardiovascular system.
    Reportable conditions: Decreased arterial oxygen saturation, cardiac arrhythmias, bronchospasm, respiratory distress, cyanosis, increased blood pressure or intracranial pressure, anxiety, agitation, changes in level of consciousness
  6. Reassess cuff pressure and volume during and after transporting the patient from one altitude to another (e.g., via air transport) or during hyperbaric therapy without environmental pressurization.
    Rationale: Changes in altitude alter the volume of gas in the cuff; therefore, volume and pressure must be reevaluated during and after transport.
  7. Unless contraindicated, maintain a head-of-bed elevation of greater than 30 degrees.
    Rationale: Elevating the head of the bed prevents secretions from pooling on top of the balloon and decreases the risk of ventilator-associated pneumonia.

EXPECTED OUTCOMES

  • Endotracheal or tracheostomy tube remains in correct position.
  • Cuff pressure is kept at a level that maintains a seal between the cuff and tracheal wall.
  • Cuff remains intact.

UNEXPECTED OUTCOMES

  • Extubation or tube dislodgment
  • Tracheal mucosal ischemia due to cuff overinflation
  • Faulty inflation valve or tube
  • Cuff overinflation and distention over the end of the tube
  • Cuff rupture

DOCUMENTATION

  • Education
  • Date and time procedure was performed
  • Cuff pressure measurement
  • Cardiopulmonary and vital sign assessments before and after procedure
  • Patient’s tolerance of procedure
  • Appearance and characteristics of tracheal secretions, if present
  • Unexpected outcomes and related interventions

REFERENCES

  1. La Vita, C.J. (2021). Chapter 37: Airway management. In R.M. Kacmarek, J.K. Stoller, A.J. Heuer (Eds.), Egan's fundamentals of respiratory care (12th ed., pp. 748-787). St. Louis: Elsevier.

Adapted from Wiegand, D.L. (Ed.). (2017). AACN procedure manual for high acuity, progressive, and critical care (7th ed.). St. Louis: Elsevier.