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 http://www.derangedphysiology.com/main/core-topics-intensive-care/mechanical-ventilation-0/Chapter%201.2.3/endotracheal-tube-detail

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.

Summary:

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

https://www.utmb.edu/policies_and_procedures/4230146

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

Procedure
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.

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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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