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Paramedics Overinflate Endotracheal Tube Cuffs

Every paramedic in this study inflated the cuff above the safe limit, and 87% could not detect an overinflated cuff by palpation of the pilot balloon.

Overinflation of an endotracheal tube (ETT) cuff can lead to severe complications, including tracheal necrosis, laryngeal nerve palsy, and tracheo-esophageal fistula, whereas underinflation can lead to inadequate ventilation from air leaks and aspiration. In a prospective, observational, cross-sectional simulation study, researchers assessed paramedics’ ability to inflate an ETT cuff to a safe pressure and to estimate the pressure of previously inflated cuffs by palpation of the pilot balloon.

After performing a simulated intubation, each participant assessed cuff pressure, and then a researcher measured actual pressure using a cuff inflation device. In a second phase of the study, participants palpated, in random order, nine ETT pilot balloons with pressures ranging from 0 to 120 cm H₂O and indicated whether the pressure was too low, appropriate, or too high.

The 53 participating paramedics had an average career length of 6.6 years and performed endotracheal intubation an average of 3.6 times per year. Every participant inflated the ETT cuff above the safe pressure limit of 25 cm H₂O, and, in 66% of cases, ETT cuff pressure was greater than the upper limit of measurement (120 cm H₂O). Most participants (87%) could not detect an overinflated ETT cuff by palpation, and no participant identified all overinflated cuffs. The authors suggest that clinicians consider using a commercial ETT cuff inflator to achieve optimal pressures and a manometer to assess for safe results.

Comment: Although these dismal results might not be reproduced in larger samples or in an emergency department setting, they should remind us to pay attention to the dangers of overinflation or underinflation of an endotracheal tube cuff. Next time you intubate a patient or receive a patient who was intubated in the field, add assessment of the intracuff pressure to your postintubation algorithm of checking breath sounds, end-tidal carbon dioxide, and chest x-ray!

— Kristi L. Koenig, MD, FACEP

Published in Journal Watch Emergency Medicine August 30, 2007

Citation(s):

Parwani V et al. Practicing paramedics cannot generate or estimate safe endotracheal tube cuff pressure using standard techniques. Prehosp Emerg Care 2007 Jul-Sep; 11:307-11.

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