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Allergy and Airway |

Endotracheal Cuff Diameter on Plain Film: A Marker of Tracheal Injury?

Mark Valdez, MD; Vincent Cunanan, MD; Luke White, DO
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University of Southern California, Los Angeles, CA


Chest. 2013;144(4_MeetingAbstracts):5A. doi:10.1378/chest.1704038
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Abstract

SESSION TITLE: Airway Case Report Posters

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Measurement of endotracheal cuff pressures has been recommended to avoid overinflation, which can contribute to tracheal ischemia and tracheomalacia. We report the case of an intubated patient who suffered tracheal wall dehiscence after prolonged cuff overinflation. Retrospective review of plain chest films revealed a trend of increasing cuff diameter that could potentially highlight patients at risk for tracheal damage.

CASE PRESENTATION: A 46 year old man with morbid obesity, diabetes, and hypertension was admitted with hypercarbic respiratory failure. The patient was intubated and failed daily weaning trials. On his 15th day of intubation, blood was noted in the endotracheal tube. This quickly progressed to massive hemoptysis. Bronchoscopy revealed a posterior tracheal tear with active bleeding. Cuff pressure obtained via manometry was 70 cmH2O (recommended range: 20-40 cmH2O) (1) despite a leak around the cuff. A tracheostomy revealed severe tracheomalacia with a dehiscent posterior tracheal wall. A chest film prior to tracheostomy revealed gross dilatation of the endotracheal balloon cuff. Films dating from admission revealed a gradual increase in dilatation. The initial width of the trachea at the cuff was 1.55 cm and increased to 3.86 cm on the day prior to tracheostomy. This trend was preserved after adjusting for roentographic technique by indexing the tracheal width to the known diameter of the endotracheal tube.

DISCUSSION: Overinflation of the endotracheal cuff beyond 20-40 cm H2O causes ischemia of the tracheal vasculature (2). This, in turn, can lead to tracheomalacia, tracheal stenosis, tracheal dehiscence and perforation. Previous studies have shown poor correlation between radiographic findings and cuff pressure (3). Differences in film technique can hinder objective interpretation. While cuff diameter varies, the diameter of the endotracheal tube is fixed. By using this known diameter as a correction factor, measurement of the trachea at the cuff may offer an early sign of tracheomalacia due to cuff overinflation.

CONCLUSIONS: Routine measurement of endotracheal cuff pressures has not yet been implemented in many ICUs. While direct manometry remains the only reliable method of ensuring therapeutic cuff pressures, trending of chest films in the intubated patient may prove a useful adjunct for identifying at-risk patients before they manifest potentially catastrophic complications.

Reference #1: Stewart, S., et al. “A Comparison of Endotracheal Tube Cuff Pressures Using Estimation Techniques and Direct Intracuff Measurement.” AANA Journal. December 2003. 71(6): 443-7.

Reference #2: Seegobin, R. and van Hasselt, G. “Endotracheal cuff pressure and tracheal mucosal blood flow: endoscopic study of effects of four large volume cuffs.” Br Med J. 1984. 288(6422): 965-8.

Reference #3: Valentino, J., et al. “Utility of portable chest radiographs as a predictor of endotracheal tube cuff pressure.” Otolaryngology - Head and Neck Surgery. 1999. 120(1): 51-6.

DISCLOSURE: The following authors have nothing to disclose: Mark Valdez, Vincent Cunanan, Luke White

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