[Changes in intracuff pressure of endotracheal tubes permeable or resistant to nitrous oxide and incidence of postoperative sore throat].
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Abstract:
We assessed the nitrous oxide (N2O) gas-barrier properties of a new endotracheal tube cuff, the Profile Soft-Seal Cuff (Resistant: R) (Sims Portex, Kent, UK).The tracheas of randomly selected patients were intubated with the Profile Cuff (Permeable: P) (Sims Portex) tuble or with Portex Soft-Seal Cuff (R) (n=20 each) endotracheal tube. Cuffs were inflated with air, and intracuff pressure was measured during anesthesia using 67% N2O. Postoperative sore throat was assessed. In addition, the volume-pressure relationship of the cuff was determined in vitro.Cuff pressure increased gradually during anesthesia in both groups. The mean cuff pressure of the group R was significantly lower than that of the group P from 10 minutes to 230 minutes. The inflated gas and the deflated gas were not significantly different in both groups. The incidence of postoperative sore throat was not significantly different between the two groups. In vitro, the mean cuff pressure of the group R was significantly lower than that of the group P.The difference of cuff pressure is considered due to the difference in cuff compliance.Keywords:
Sore throat
Cuff
Nitrous oxide
Endotracheal tube
Tracheal tube
Throat
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BACKGROUND: Although minor, a sore throat after endotracheal intubation can adversely affect patient satisfaction and postoperative function. We compared the effects of 2 endotracheal tube cuff shapes on postoperative sore throat. METHODS: One hundred ninety-one adult patients were included in the study. After induction of anesthesia, patients were randomized to endotracheal intubation with a conventional cylindrical-shaped cuff (Group C, n = 95) or a tapered-shaped cuff (Group T, n = 96). The number of intubation attempts, time to achieve endotracheal intubation, and duration of intubation were recorded. Postoperative sore throat and hoarseness were assessed at 1, 6, and 24 hours after surgery. A 0- to 100-mm visual analog scale was used to evaluate sore throat severity. The primary outcome of this study was the overall cumulative incidence of postoperative sore throat in the 24-hour evaluation period in the 2 groups. RESULTS: The overall incidence of postoperative sore throat was lower in Group T than in Group C (32% vs 54%; relative risk = 0.60, 95% confidence interval: 0.43–0.85; P = .003). At 6 hours after surgery, the incidence and severity of postoperative sore throat were lower in Group T compared with Group C (Bonferroni-corrected P < .05). Postoperative hoarseness also occurred less frequently in Group T compared with Group C (19% vs 37%; P = .006). Group T had lower incidence of hoarseness at 1 and 6 hours after surgery than Group C (Bonferroni-corrected P < .05), but the incidence of hoarseness at 24 hours after surgery did not differ between groups. CONCLUSIONS: Intubation using an endotracheal tube with a tapered cuff reduced the incidence and severity of postoperative sore throat and the incidence of hoarseness after surgery when compared with an endotracheal tube with a cylindrical cuff.
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Sore throat and hoarseness following tracheal intubation is common. The aetiology may include high tracheal cuff pressures. We performed a double-blind, randomized controlled trial in 126 intubated patients to compare the incidence and severity of sore throat and hoarseness following inflation of the cuff using air or saline. Intra-cuff pressures were compared to assess any change due to inward diffusion of nitrous oxide. The incidence of significant sore throat and/or hoarseness overall was 15.0%. There was no statistically significant difference between the groups (air 15.9%, saline 14.5%). In the air group mean intra-cuff pressure increased significantly (start 14.0 mmHg, end 40.9 mmHg), while in the saline group there was no significant increase (start 12.7 mmHg, end 14.6 mmHg). The substitution of saline reliably results in sustained low intra-cuff pressures but high tracheal cuff pressure is not an important factor in the development of sore throat or hoarseness postoperatively within the pressure range and duration of operation studied.
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To reduce the incidence of postoperative pharyngolaryngeal adverse events, laryngeal mask airway (LMA) manufacturers recommend maximum cuff pressures not exceeding 60 cmH₂O. We performed a prospective randomised study, comparing efficacy and adverse events among patients undergoing laparoscopic surgical procedures who were allocated randomly into low (limiting 25 cmH₂O, L group) and high (at 60 cmH₂O, H group) LMA cuff pressure groups with LMA Supreme. Postoperative pharyngolaryngeal adverse events were evaluated at discharge from postanaesthetic care unit (PACU) (postoperative day 1, POD 1) and 24 hours after discharge from PACU (postoperative day 2, POD 2). All patients were well tolerated with LMA without ventilation failure. Before pneumoperitoneum, cuff volume and pressure and oropharyngeal leak pressure (OLP) showed significant differences. Postoperative sore throat at POD 2 (3 versus 12 patients) and postoperative dysphagia at POD 1 and POD 2 (0 versus 4 patients at POD 1; 0 versus 4 patients at POD 2) were significantly lower in L group, compared with H group. In conclusion, LMA with cuff pressure limiting 25 cmH₂O allowed both efficacy of airway management and lower incidence of postoperative adverse events in laparoscopic surgical procedures. This clinical trial is registered with KCT0000334.
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Summary Background: The incidence of postoperative sore throat (POST) following intubation is not well defined in the pediatric population. The etiology is multifactorial and includes impairment of subglottic mucosal perfusion and edema as a result of the pressures exerted by cuffed or uncuffed tubes. Aim: To determine the incidence of, and risk factors for, POST in intubated children undergoing elective day‐case surgery. Methods: Five hundred patients aged 3–16 years were studied prospectively. Endotracheal tube (ETT) choice (cuffed or uncuffed) was left to the anesthetist. The cuff was inflated either until loss of audible leak or to a determined pressure using a cuff manometer. The research team then measured the cuff pressure (CP). POST incidence and intensity was determined by interviewing patients prior to discharge from the same day procedure unit. Chi‐square testing and stepwise logistic regression were used to determine the predictors of POST. Results: Of the 111 (22%) children developed a sore throat, 19 (3.8%) a sore neck, and 5 (1%) a sore jaw. 19% of patients with cuffed ETTs complained of sore throat compared with 37% of those intubated with an uncuffed ETT. The incidence of POST increased with CP; 0–10% at 0 cmH 2 O, 4% at 11–20 cmH 2 O, 20% at 21–30 cmH 2 O, 68% at CP 31–40 cmH 2 O, and 96% at CP >40 cmH 2 O. The ETT CP and use of uncuffed ETTs were univariate predictors of POST. Conclusions: Children intubated with uncuffed ETTs are more likely to have POST. ETT CP is positively correlated with the incidence of POST. When using cuffed ETTs, CP should be routinely measured intraoperatively.
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A patient with an artificial airway in place, pulmonary aspiration is a serious complication. A prospective study was conducted to investigate the incidence of pulmonary aspiration in patients with all kinds of modern artificial airways with high-volume low-pressure cuffs. In ICU and NSCU (neurosurgery care unit), 40 patients with a tracheostomy or endotracheal tube were included. Before study, cuff pressure was checked and remained at 25 cmH2 O if possible. Then, 0.2 ml of 1% methylene blue was applied on the tongue of each patient every 4 hours. Routine tube care was performed including frequent suction at least once an hour. Any evidence of the blue dye-marker obtained on suctioning was considered positive. The duration of study was 24 hours. Among these 40 patients, the procedure was performed in 50 episodes because some of the patients were evaluated with different kinds of artificial airways. Thirty episodes were evaluated with endotracheal tube, including 7 oral and 23 nasotracheal tubes. No episode of aspiration could be found (0/30). With tracheostomy tubes, 5 of 20 episodes showed positive result (5/20). The difference of incidence between these 2 groups was statistically significant (p less than 0.01). Some possible contributing factors were evaluated between positive and negative episodes, including age, sex, respiration rate, different brands of tracheostomy tubes, modes of ventilation, PEEP level, cuff pressure, nasogastric tubes, coma scale, posture, and ratio of tube and tracheal diameters in tracheostomy group.(ABSTRACT TRUNCATED AT 250 WORDS)
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Maintaining the cuff pressure of endotracheal tubes (ETTs) within 20–30 cmH2O is a standard practice. The aim of the study was to evaluate the effectiveness of standard practice in maintaining cuff pressure within the target range. This was a prospective observational study conducted in a tertiary-care intensive care unit, in which respiratory therapists (RTs) measured the cuff pressure 6 hourly by a handheld manometer. In this study, a research RT checked cuff pressure 2–4 h after the clinical RT measurement. Percentages of patients with cuff pressure levels above and below the target range were calculated. We identified predictors of low-cuff pressure. We analyzed 2120 cuff-pressure measurements. The mean cuff pressure was 27 ± 2 cmH2O by the clinical RT and 21 ± 5 cmH2O by the research RT (p < 0.0001). The clinical RT documented that 98.0 % of cuff pressures were within the normal range. The research RT found the cuff pressures to be within the normal range in only 41.5 %, below the range in 53 % and above the range in 5.5 %. Low cuff pressure was found more common with lower ETT size (OR, 0.34 per 0.5 unit increase in ETT size; 95 % CI, 0.15–0.79) and with lower peak airway pressure (OR per one cm H2O increment, 0.93; 95 % CI, 0.87–0.99) on multivariate analysis. Cuff pressure is frequently not maintained within the target range with low-cuff pressure being very common approximately 3 h after routine measurements. Low cuff pressure was associated with lower ETT size and lower peak airway pressure. There is a need to redesign the process for maintaining cuff pressure within the target range.
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Postoperative upper airway complications are frequently encountered with the use of supraglottic airway devices (SADs). Cuff pressure is one of the risk factors for upper airway complications with SADs. Among SADs, i-gel has shown lesser incidence. The effect of different cuff pressures on the incidence of postoperative upper airway complications is not known with Ambu AuraGain and nor has Ambu AuraGain been compared with i-gel in this regard. So, we undertook this study.A total of 200 patients undergoing elective laparoscopic surgery were randomised into 3 groups based on the SAD used and intra-cuff pressure: i-gel (IG) (n = 66); Ambu AuraGain at 25 cmH2O cuff pressure (AL) (n = 67); and Ambu AuraGain at 60 cmH2O cuff pressure (AH) (n = 67). The oropharyngeal leak pressures (OLPs) were measured after insertion and generation of carboperitoneum. An observer who was blind to the intraoperative details assessed the patients for two postoperative days for sore throat, dysphagia, dysphonia, or any other upper airway complications.The OLPs before and after carboperitoneum in the 3 groups were (IG-24.22 ± 7.87 and 28.31 ± 8.52, AL-24.40 ± 5.84 and 26.94 ± 5.93, AH-25.02 ± 5.02 and 28.91 ± 5.6) cmH2O (P = 0.747 and P = 0.231). The overall incidence of postoperative sore throat among the 3 groups was: IG-5.7%, AL-14.9%, and AH-17.9%; P = 0.135. Dysphagia was seen only with Ambu AuraGain at high pressure in 4 patients (5.97%) (P = 0.017).Limiting cuff pressure in Ambu AuraGain to 25, as against 60 cmH2O, does not affect the OLP but has the potential of reducing the incidence of dysphagia.
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Many clinical reports have described postoperative hoarseness and sore throat after general anesthesia. In most cases, these symptoms were attributed to high pressure of the endotracheal tube cuff. The recommended cuff pressure is less than 25 mmHg, as excessive pressure produces ischemia of the tracheal mucosa. However, within the safe pressure range, postoperative hoarseness and sore throat are still often observed. In this study, one hundred and ninety patients of ASA classes I or II were allocated randomly to two groups, low cuff pressure group (< 15 mmHg) or high cuff pressure group (15-25 mmHg), using continuous monitoring with a cuff pressure gauge. We investigated the incidence of postoperative hoarseness and sore throat at 24 hours after intubation and on the seventh postoperative day. The incidence of postoperative hoarseness and sore throat was significantly decreased in the low pressure group at 24 hours after intubation as compared with the high pressure group, but there was no significant difference between the two groups on the seventh postoperative day. These results suggest that keeping the cuff pressure under 15 mmHg can prevent postoperative hoarseness or sore throat at 24 hours after intubation, and that a cuff pressure gauge is thought to be one of the indispensable monitors during anesthesia.
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Pharyngolaryngeal discomfort is a significant complication following the use of laryngeal mask airway (LMA). The present study aimed to investigate the relation of LMA cuff pressure and the occurrence of pharyngolaryngeal discomfort during spontaneous ventilation (SV), pressure support (PSV) and pressure control ventilation (PCV).A hundred and twenty patients, ASA I-III, were included in this study. Originally the patients were divided into three groups: the 1st group was left to breath spontaneously, the 2nd group was placed under PSV while PCV was used in the 3rd group. Each group was divided into two subgroups: A) intervention group (maintaining cuff pressure at 60 cmH2O, measurement in 10 min intervals) and B) observation group (no intervention in cuff pressure, measurement in 10 min intervals). Anesthesia was induced with propofol and fentanyl and maintained with sevoflurane in air/oxygen. Patients were assessed 2 and 24 hours post-surgery, for sore throat, dysphonia or dysphagia.A and B subgroup comparison at 24 hours revealed a statistically significant difference in the presence of pharyngolaryngeal discomfort in the PSV group (10% versus 55% respectively, P=0.006). Furthermore, when assessing the effect of maintaining a constant cuff pressure regardless of mode of ventilation, significantly fewer adverse effects were observed (8.3% vs. 35%, P=0.001) when compared to the non-intervention subgroup.Maintaining LMA cuff pressure in values which do not exceed 60 cmH2O probably contributes in decreasing pharyngolaryngeal discomfort independently of ventilation mode. The ventilation mode which leads to the highest incidence of pharyngolaryngeal morbidity when cuff pressures are not closely monitored is PSV.
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