Why should we measure tracheostomy tube cuff pressure
Evidence base
Figure 2
Definition
The cuff pressure is defined as the pressure in the cuff of a tracheal tube, exerted against the mucosal tissue of the trachea to hold the tube in place (Figure 2).
Figure 3
The tracheostomy cuff is an inflatable balloon near the end of the tube that creates a seal against the tracheal wall (Figure 3). This seal assists with airway protection and effective ventilation.
Tracheostomy tube cuff pressure must be measured regularly to prevent complications associated with tracheostomy tube placement. If the pressure is too low, air and pressure may be lost from the lungs, leading to an increased risk of aspiration of saliva or gastric contents because the patient’s airway is unprotected. If the pressure is too high, the patient has an increased risk of tissue damage and necrosis, tracheal stenosis and tracheoesophageal fistulas (Sengupta et al 2004).
Risks and safety measures
The tracheal mucosa blood supply is occluded at a tracheostomy tube cuff pressure of 30-32mmHg (Mallett et al 2013). Such high pressures prevent the delivery of oxygen to the small capillaries supplying the tracheal mucosa, resulting in ischaemia and necrosis. This suggested maximum pressure of 30mmHg was based on healthy volunteers (Lowthian 1997). Critically ill patients are more likely to have a lower blood pressure, resulting in underperfusion of the tracheal mucosa. Therefore, a maximum pressure of 25mmHg is considered a safer upper limit for all patients, with a recommended tracheal pressure range of 20-25mmHg for tracheostomy tube cuff inflation (Lorente et al 2007).
If a high cuff pressure is required to create and maintain a seal with the tracheal mucosa, this can indicate malposition of the tracheostomy tube, tracheomalacia or use of an inappropriately sized tube. If a persistent cuff leak is identified, it is essential to assess for tube displacement; a practitioner who has advanced airway management skills should assess the patient and a chest X-ray should be taken and reviewed. Cuff leaks and loss of cuff pressure can be distressing for a conscious patient. If a persistent cuff leak is identified, practitioners should prepare the patient for tracheostomy removal and replacement of the tracheostomy tube, and support them to minimise distress.
A variety of tracheostomy tubes are available. Low-volume, high-pressure cuffs are generally not used because the pressure exerted on the trachea is high and the risk of damage is increased. Tracheostomy tubes with a high-volume, low-pressure cuff are the safest option. These allow a larger area of the trachea wall to come into contact with the cuff, while exerting less pressure.
Cuff pressure manometers are hand-held devices that are used to measure tracheostomy tube cuff pressures in the trachea. These pressures should be checked after placement of the tracheostomy tube, at any time if a cuff leak is suspected, whenever air is added to or removed from the cuff, following anaesthesia and during patient assessment. The Department of Health (2011) recommends tracheostomy tube cuff pressure assessment every 4 hours.
Learning points
- If the tracheostomy cuff pressure is too high, the patient’s risk of tissue damage and necrosis, tracheal stenosis and tracheoesophageal fistulas is increased.
- If the cuff pressure is too low, air and pressure may be lost from the lungs, leading to an increased risk of aspiration of saliva or gastric contents.
- Persistent cuff leaks and loss of cuff pressure can be distressing for a conscious patient and tracheostomy removal and replacement of the tracheostomy tube may be necessary.
- The Department of Health recommends that tracheostomy tube cuff pressure should be assessed every 4 hours to avoid complications.
Disclaimer: please note that information provided by RCNi Learning is not sufficient to make the reader competent to perform the task. All clinical skills should be formally assessed at the bedside by a nurse educator or mentor. It is the nurse’s responsibility to ensure their practice remains up to date and reflects the latest evidence.
Useful resources
- National Confidential Enquiry into Patient Outcome and Death (2014) On the Right Trach? A Review of the Care Received by Patients Who Underwent a Tracheostomy. NCEPOD, London.
- National Tracheostomy Safety Project: www.tracheostomy.org.uk
- The Global Tracheostomy Collaborative: www.globaltrach.org
References
Department of Health (2011) High Impact Intervention: Care Bundle to Reduce Ventilation-Association Pneumonia. tinyurl.com/m2aw6qz (Last accessed: September 8 2015.)
Mallett J, Albarran JW, Richardson A (2013) Critical Care Manual of Clinical Procedures and Competencies. Wiley-Blackwell, Oxford.
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