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Original Research: Critical Care |

Endotracheal Tubes for Critically Ill PatientsEndotracheal Tube-Associated Tracheal Injury: An In Vivo Analysis of Associated Tracheal Injury, Mucociliary Clearance, and Sealing Efficacy

Gianluigi Li Bassi, MD, PhD; Nestor Luque, MD; Joan Daniel Martí, PhD, RPT; Eli Aguilera Xiol, MSc; Marta Di Pasquale, MD; Valeria Giunta, MD; Talitha Comaru, PhD, RPT; Montserrat Rigol, DVM, PhD; Silvia Terraneo, MD; Francesca De Rosa, MD; Mariano Rinaudo, MD; Ernesto Crisafulli, MD, PhD, FCCP; Rogelio Cesar Peralta Lepe, MD; Carles Agusti, MD, PhD; Carmen Lucena, MD; Miguel Ferrer, MD, PhD; Laia Fernández, PhD; Antoni Torres, MD, PhD, FCCP
Author and Funding Information

From the Division of Animal Experimentation (Drs Li Bassi, Luque, Martí, Di Pasquale, Giunta, Comaru, Rigol, Terraneo, De Rosa, Rinaudo, Crisafulli, Peralta Lepe, Ferrer, Fernández, and Torres and Ms Aguilera Xiol), Department of Pulmonary and Critical Care Medicine, Thorax Institute, Hospital Clínic, Barcelona, Spain; Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (Drs Li Bassi, Rigol, Ferrer, Fernández, and Torres), Barcelona, Spain; Centro de Investigación Biomedica En Red-Enfermedades Respiratorias (CIBERES) (Drs Li Bassi, Martí, Rigol, Ferrer, Fernández, and Torres and Ms Aguilera Xiol), Barcelona, Spain; University of Milan (Drs Di Pasquale, Giunta, Terraneo, and De Rosa), Milan, Italy; Division of Bronchoscopy (Drs Agusti and Lucena), Department of Pulmonary Medicine, Thorax Institute, Hospital Clínic, Barcelona, Spain; and University of Barcelona (Dr Torres), Barcelona, Spain.

CORRESPONDENCE TO: Antoni Torres, MD, PhD, FCCP, Department of Pulmonary and Critical Care Medicine, Hospital Clínic, Calle Villarroel 170, Esc 6/8 Planta 2, 08036 Barcelona, Spain; e-mail: atorres@clinic.ub.es


Drs Li Bassi and Luque contributed equally to this work.

FUNDING/SUPPORT: Support was provided by Covidien Ltd.

Part of this article has been presented in abstract form [De Rosa F, Li Bassi G, Martí JD, et al. Histological evaluation of the recovery of cuff-induced tracheal injury: assessment at 72 hours from extubation. Intens Care Med. 2013;39(suppl 2):0680; Li Bassi G, Marti JD, Aguilera Xiol E, et al. Effects of high-volume low-pressure cuff designs and materials on mucociliary clearance. Crit Care Med. 2012;40(12)(suppl 1):440; and Li Bassi G, Aguilera Xiol E, Marti JD, et al. Assessment of cuff-induced tracheal injury by commercially available endotracheal tubes. Crit Care Med. 2012;40(12 suppl 1):443].

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;147(5):1327-1335. doi:10.1378/chest.14-1438
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BACKGROUND:  Improvements in the design of the endotracheal tube (ETT) have been achieved in recent years. We evaluated tracheal injury associated with ETTs with novel high-volume low-pressure (HVLP) cuffs and subglottic secretions aspiration (SSA) and the effects on mucociliary clearance (MCC).

METHODS:  Twenty-nine pigs were intubated with ETTs comprising cylindrical or tapered cuffs and made of polyvinylchloride (PVC) or polyurethane. In specific ETTs, SSA was performed every 2 h. Following 76 h of mechanical ventilation, pigs were weaned and extubated. Images of the tracheal wall were recorded before intubation, at extubation, and 24 and 96 h thereafter through a fluorescence bronchoscope. We calculated the red-to-green intensity ratio (R/G), an index of tracheal injury, and the green-plus-blue (G+B) intensity, an index of normalcy, of the most injured tracheal regions. MCC was assessed through fluoroscopic tracking of radiopaque markers. After 96 h from extubation, pigs were killed, and a pathologist scored injury.

RESULTS:  Cylindrical cuffs presented a smaller increase in R/G vs tapered cuffs (P = .011). Additionally, cuffs made of polyurethane produced a minor increase in R/G (P = .012) and less G+B intensity decline (P = .022) vs PVC cuffs. Particularly, a cuff made of polyurethane and with a smaller outer diameter outperformed all cuffs. SSA-related histologic injury ranged from cilia loss to subepithelial inflammation. MCC was 0.9 ± 1.8 and 0.4 ± 0.9 mm/min for polyurethane and PVC cuffs, respectively (P < .001).

CONCLUSIONS:  HVLP cuffs and SSA produce tracheal injury, and the recovery is incomplete up to 96 h following extubation. Small, cylindrical-shaped cuffs made of polyurethane cause less injury. MCC decline is reduced with polyurethane cuffs.

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