Don’t put 10 cc air in the cuff of any endo-tracheal tube

Use the minimal-leak method instead. Described below.

parts of an endo-tracheal tube. (this is of a newer variety with built-in suction port to prevent micro-aspiration). from

In a recent blog, I got lots of hits but very few clicks on the actual video. I decided to rewrite this to focus only on this one specific issue.


Here is a policy and procedure from a major teaching hospital in Texas, USA.

UTMB RESPIRATORY CARE SERVICES PROCEDURE – Minimal Occluding Volume (MOV) or Minimal Leak Technique Policy 7.3.49 Page 1 of 4 Minimal Occluding Volume (MOV) or Minimal Leak Technique Formulated: 11/92 Effective: 11/02/94 Revised: 11/03/14

Continued next page

Minimal Occluding Volume (MOV) Purpose To standardize the method of minimal volume of air in the endotracheal/tracheal cuff that will allow optimal sealing of the airway.
Scope  All intubated patients will be assessed for proper volume/pressure in endotracheal cuffs with each ventilator assessment.

 All tracheostomy patients not utilizing a foam-filled (bivona type) cuff volume/pressures will be monitored on a routine basis.

 The acceptable intra-cuff pressure is less than 25 mmHg.

Audience Respiratory Care Practitioners employed by the Respiratory Care Services Department with the understanding of age specific requirements of the patient population.
Equipment  10cc syringe

 Stethoscope

 Cuff pressure manometer

 Three-way stop cock

 OR Cufflator cuff inflation device

 Manual resuscitator and mask

Step Action
1 Technique for MOV

 Suction the patient airway and oral pharynx to prevent possible aspiration of retained secretions.

 Place your stethoscope diaphragm over the laryngeal area and inflate cuff until all air leak is gone.

 For Positive Pressure Ventilation, remove small increments (0.25-0.50cc) of air from the cuff until a small leak is heard at the point of peak inspiratory pressure (PIP). Check tidal volume to insure adequate ventilation and inflate cuff until all air leak is gone.

 For spontaneous ventilation or CPAP, remove small increments of air (0.25-0.50cc) from cuff until a small expiratory leak is heard (usually in early or mid exhalation). Inflate until all air leakage is gone.

Here is a video showing exactly how to do it:

What if you use too much air?

Using the 10 cc is wrong because it causes “tracheal malacia” and post-extubation stridor. the trachea gets stretched at the point of balloon contact and collapses when air moves out. It can also contribute to tracheal-esophageal fistula. In other words, too much air in the cuff will harm the patient.


About Joe Niemczura, RN, MS

These blogs, and my books, and videos are written on the principle that any person embarking on something similar to what I do will gain more preparation than I first had, by reading them. I have fifteen years of USA nursing faculty background. Add to it fifteen more devoted to adult critical care. In Nepal, I started teaching critical care skills in 2011. I figure out what they need to know in a Nepali practice setting. Then I teach it in a culturally appropriate way so that the boots-on-the-ground people will use it. One theme of my work has been collective culture and how it manifests itself in anger. Because this was a problem I incorporated elements of "situational awareness" training from the beginning, in 2011.
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2 Responses to Don’t put 10 cc air in the cuff of any endo-tracheal tube

  1. Usman says:

    This is indeed a timely demo . I gained a lot through your write ups ( this one and others ). Perhaps you may need to expand ur educational sojourns to Nigeria. They’re loads of people that would benefit from ur vast skills and unique expertise. I happened to be one of ur tens of thousands students across the globe. I was in ur class for 3 days seminar at PADMASHREE INSTITUTE OF NURSING, BANGALORE , INDIA 2015.

    • I remember you, and those sessions. I think there were four or five Nigerian guys in the sessions and I appreciated what you added to the mix! I had fun and the students were terrific. I am glad to hear that you found value in the class. Maybe I will go to Nigeria, if you can be my local contact and help me find a teaching venue.

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