Why should we measure tracheostomy tube cuff pressure

-

Evidence base

Figure 2
Figure 2. An inflated tracheostomy cuff in place|
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
Figure 3. A tracheostomy tube with the cuff inflated
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).
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.
learningpoints

Learning points

  1. If the tracheostomy cuff pressure is too high, the patient’s risk of tissue damage and necrosis, tracheal stenosis and tracheoesophageal fistulas is increased.
  2. 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.
  3. 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.
  4. 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.)
Lorente L, Lecuona M, Jiménez A, Mora ML, Sierra A (2007) Influence of an endotracheal tube with polyurethane cuff and subglottic secretion drainage on pneumonia. American Journal of Respiratory and Critical Care Medicine. 176, 11, 1079-1083. MEDLINE•CROSSREF
Lowthian P (1997) Notes on the pathogenesis of serious pressure sores. British Journal of Nursing. 6, 16, 907-912. MEDLINE•CROSSREF
Mallett J, Albarran JW, Richardson A (2013) Critical Care Manual of Clinical Procedures and Competencies. Wiley-Blackwell, Oxford.
Sengupta P, Sessler DI, Maglinger P et al (2004) Endotracheal tube cuff pressure in three hospitals, and the volume required to produce an appropriate cuff pressure. BMC Anesthesiology. 4, 1, 8. MEDLINE •CROSSREF

Comentários

Enviar um comentário

Mensagens populares deste blogue

Hemorrhoids (Piles) — Symptoms and Treatment

-
Imagem
Hemorrhoids cushions are normal structures of the lower rectum.  They are very vascular and pathology develops when that vasculature becomes engorged (especially the veins). Itching and pain are common symptoms of hemorrhoid pathology. Hemorrhoids are classified on their origin relative to the dentate line: external (below the dentate line), internal (above the dentate line), and prolapsed internal hemorrhoids. Most hemorrhoids are treated with dietary modification (increase fiber) and stool softeners, but occasionally surgery is required. Table of Contents Definition of Hemorrhoids Epidemiology of Hemorrhoids Etiology of Hemorrhoids Pathology and Pathophysiology of Hemorrhoids Symptoms of Hemorrhoids Diagnosis of Hemorrhoids Differential Diagnoses of Hemorrhoids Therapy of Hemorrhoids Progression and Prognosis of Hemorrhoids Review Questions References Image : “Types of hemorrhoids” by WikipedianProlific and Mikae...
Ler mais

12 Cranial Nerves — Functions and Mnemonics

-
Imagem
Crania l nerves emerge directly via the spinal cord from the bony skull because they supply cranial structures or fulfill specific functions. During medical studies, cranial nerves are an essential element of the subjects of the brain and the nervous system. In the following, you will find a concise overview of the classification, the functions and the course of the 12 cranial nerves. Table of Contents Classification of Cranial Nerves List of Cranial Nerves Cranial nerve I: Olfactory Nerve Cranial nerve II: Optic Nerve Cranial Nerve III: Oculomotor Nerve Cranial Nerve IV: Trochlear Nerve Cranial Nerve V: Trigeminal Nerve Cranial Nerve VI: Abducent Nerve Cranial Nerve VII: Facial Nerve Cranial Nerve VIII: Vestibulocochlear Nerve Cranial Nerve IX: Glossopharyngeal Nerve Cranial Nerve X: Vagus Nerve Cranial Nerve XI: Accessory Nerve Cranial Nerve XII: Hypoglossal Nerve Overview of the 12 cranial nerves Review Questions References Image : “Cranial Nerves” by Br...
Ler mais

Nerve Tissue: Brain

-
Imagem
In LECTURIO :) - Table of Contents Introduction to the Brain The Cerebrum The Cerebellum The Meninges The Spinal Cord References Image :  “Skull and brain normal human diagram”  by Patrick J. Lynch. License:  CC BY 2.5 Introduction to the Brain The brain is the central organ of the human nervous system along with the spinal cord. It is made up of: The cerebrum Diencephalon, consisting of thalamus, hypothalamus and pituitary gland The cerebellum The brainstem- consisting of midbrain, pons and medulla Image :  “Introduction to Brain Structures”  by BruceBlaus. License:  CC BY 3.0 The organ weighs about 1400 grams on average in an adult. It is housed and protected by the skull bones which include the: Parietal Frontal Occipital Ethmoid Sphenoid bone The bones of the face Image :  “Cranial sutures shown from the top of the head”  by Xxjamesxx. License:  CC BY-SA 3.0 At birth, the paired an...
Ler mais