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Endotracheal Tube and Tracheostomy Cuff Care
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If the patient is sedated, paralyzed, on pressure support, or receiving high oxygen delivery, do not disconnect the patient 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.
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).
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. A commercial electronic tracheal cuff pressure manometer can be attached directly to the inflation port to measure the cuff pressure (Figure 2). Other devices include bedside sphygmomanometers or special aneroid cuff manometers. Ideally, the cuff pressure should be between 20 and 30 cm H2O.undefined#ref1">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 once per shift or per the organization’s practice to maintain the pressure in the safe range to avoid injury to the trachea and minimize the risk of aspiration.
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Rationale: Clearing secretions decreases the risk of aspiration.
Rationale: A manometer allows measurement of air pressure in the cuff.
Adjust cuff pressure after attaching the manometer due to the evacuation of air volume from the cuff that may occur during attachment.
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.
Rationale: Clearing secretions decreases the risk of aspiration.
If the patient is sedated, paralyzed, on pressure support, or receiving high oxygen delivery, do not disconnect the patient from the ventilator.
Rationale: Ventilating the lungs reoxygenates the patient and allows for further assessment of proper cuff inflation and elimination of the air leak.
Rationale: If the trachea is sealed and the air leak has been corrected, the patient will not be able to vocalize.
Rationale: Replacing oxygen and ensuring secure connections provides oxygen flow and prevents oxygen desaturation.
Rationale: A cuff that repeatedly deflates after air is instilled indicates a faulty inflation valve; repair is needed. There are commercial cuff inflation-valve repair kits available.
If the inflation valve has become faulty and reintubation is undesirable, institute emergency cuff inflation (Figure 3).
Rationale: A three-way stopcock provides control of airflow in and out of the inflation valve.
Rationale: If an air leak is no longer detected, this indicates that the seal between the tracheal wall and the cuff is restored.
Rationale: Clamping the inflation tube maintains air in the cuff and provides a quick occlusion of the inflating tube.
Rationale: Turning the stopcock off to the inflation valve allows temporary use of the tube while maintaining cuff pressure.
Make plans to change the tube as a more permanent solution.
Rationale: Cutting off the faulty end prepares the inflation tube for repair.
Rationale: The cannula provides access for inflation.
Use caution to avoid puncturing or severing the inflation line or skin.
Rationale: A three-way stopcock provides control of airflow in and out of the inflating line.
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.
Rationale: Turning the stopcock off allows temporary use of the tube while maintaining cuff pressure.
Rationale: Securing the device with tape to a tongue depressor provides stabilization and protection.
Rationale: Inadequate interface between the tube cuff and tracheobronchial mucosa decreases inspiratory flow.
Reportable conditions: Rising arterial carbon dioxide (CO2) 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
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.
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
Rationale: Removing secretions reduces the chance for partial or complete airway obstruction.
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
Rationale: Changes in altitude alter the volume of gas in the cuff; therefore, volume and pressure must be reevaluated during and after transport.
Rationale: Elevating the head of the bed prevents secretions from pooling on top of the balloon and decreases the risk of ventilator-associated pneumonia.1
Adapted from Wiegand, D.L. (Ed.). (2017). AACN procedure manual for high acuity, progressive, and critical care (7th ed.). St. Louis: Elsevier.
Clinical Review: Genevieve L. Hackney, MSN, RN
Published: February 2024
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