how much air to inflate endotracheal tube cuff

The complaints sought in this study included sore throat, dysphagia, dysphonia, and cough. The patient was maintained on isoflurane (11.8%) mixed with 100% oxygen flowing at 2L/min. 28, no. The incidence of postextubation airway complaints after 24 hours was lower in patients with a cuff pressure adjusted to the 2030cmH2O range, 57.1% (56/98), compared with those whose cuff pressure was adjusted to the 3040cmH2O range, 71.3% (57/80). "Aire" indicates cuff to be filled with air. S. Stewart, J. The study groups were similar in relation to sex, age, and ETT size (Table 1). Sao Paulo Med J. This cookie is set by Youtube. Conventional high-volume, low-pressure cuffs may not prevent micro-aspiration even at cuff pressures up to 60 cm H2O [2], although some studies suggest that only 25 cm H2O is sufficient [3]. However you may visit Cookie Settings to provide a controlled consent. In the early years of training, all trainees provide anesthesia under direct supervision. Upon inflation, folds form along the cuff surface, and colonized oropharyngeal secretions may leak through these folds. Cuff pressure should be measured with a manometer and, if necessary, corrected. Anesth Analg. Nordin U, Lindholm CE, Wolgast M: Blood flow in the rabbit tracheal mucosa under normal conditions and under the influence of tracheal intubation. A) Normal endotracheal tube with 10 ml of air instilled into cuff. In general, the cuff inflates properly for adults, but physicians often over-inflate the cuff during . leaking cuff: continuous air insufflation through the inflation tubing has been describe to maintain an adequate pressure in the perforated cuff; . The entire process required about a minute. The ASA recommends checking all ETT cuffs prior to their use.1 While rare, endotracheal tube cuff defects are a known cause of endotracheal tube leaks which often necessitate endotracheal tube exchange. Every patient was wheeled into the operating theater and transferred to the operating table. This cookies is set by Youtube and is used to track the views of embedded videos. Continuous data are presented as the mean with standard deviation and were compared between the groups using the t-test to detect any significant statistical differences. On the other hand, overinflation may cause catastrophic complications. statement and This method is cheap and reproducible and is likely to estimate cuff pressures around the normal range. Endotracheal Tube Cuff Inflation The Gurney Room 964 subscribers Subscribe 7.2K views 2 years ago Learn how to inflate an endotracheal tube cuff the right way, including a trick to do it. Note: prolonged over-inflation of the cuff can cause pressure necrosis of the tracheal mucosa. Frontiers | Evaluation of Endotracheal Tube Cuff Pressure and the Use The poster can be accessed by following the link: https://pdfs.semanticscholar.org/c12e/50b557dd519bbf80bd9fc60fb9fa2474ce27.pdf. 32. The cookie is used to calculate visitor, session, campaign data and keep track of site usage for the site's analytics report. Anesthesia was maintained with a volatile aesthetic in a combination of air and oxygen; nitrous oxide was not used during the study period. Previous studies suggest that this approach is unreliable [21, 22]. Background. Our primary outcomes were 1) measured endotracheal tube cuff pressures as a function of tube size, provider, and hospital; and 2) the volume of air required to produce a cuff pressure of 20 cmH2O as a function of tube size. 1992, 49: 348-353. The cookies store information anonymously and assign a randomly generated number to identify unique visitors. Inject 0.5 cc of air at a time until air cannot be felt or heard escaping from the nose or mouth (usually 5 to 8 cc). AW contributed to protocol development, patient recruitment, and manuscript preparation. 87, no. The compliance of the tube was determined from the measured cuff pressure (cmH2O) and the volume of air (ml) retrieved at complete deflation of the cuff; this showed a linear pressure-volume relationship: Pressure= 7.5. LoCicero J: Tracheo-carotid artery erosion following endotracheal intubation. We designed this study to observe the practices of anesthesia providers and then determine the volume of air required to optimize the cuff pressure to 20 cmH2O for various sizes of endotracheal tubes. 769775, 2012. Springer Nature. Air | Appendix | Environmental Guidelines | Guidelines Library P. Biro, B. Seifert, and T. Pasch, Complaints of sore throat after tracheal intubation: a prospective evaluation, European Journal of Anaesthesiology, vol. Analytics cookies help us understand how our visitors interact with the website. Cuff pressure in . COPD, head injury, ARDS), Rapid sequence induction (RSI) intubation, Procedural variation using rapid anaesthetisation with cricoid pressure to prevent aspiration while airway is quickly secured, Used for patients at risk of aspiration e.g. What are the . Figure 2. All authors have read and approved the manuscript. 22, no. Cuff pressure adjustment: in both arms, very high and very low pressures were adjusted as per the recommendation by the ethics committee. Luna CM, Legarreta G, Esteva H, Laffaire E, Jolly EC: Effect of tracheal dilatation and rupture on mechanical ventilation using a low-pressure cuff tube. C. Stein, G. Berkowitz, and E. Kramer, Assessment of safe endotracheal tube cuff pressures in emergency care - time for change? South African Medical Journal, vol. Outcomes were compared by tube size, provider, and hospital with either an ANOVA (if the values were normally distributed) or the Kruskal-Wallis statistic (if the values were skewed). 1985, 87: 720-725. CONSORT 2010 checklist. We recorded endotracheal tube size and morphometric characteristics including age, sex, height, and weight. Patients who were intubated with sizes other than these were excluded from the study. There was a linear relationship between measured cuff pressure (cmH2O) and volume (ml) of air removed from the cuff: Pressure = 7.5. However, a full hour was plenty of time for the provider to have checked and adjusted cuff pressure to a suitable level. However, there was considerable variability in the amount of air required. It is however difficult to extrapolate these results to the human population since the risk of aspiration of gastric contents is zero while working with models when compared with patients. 10.1007/s00134-003-1933-6. The magnitude of effect on the primary outcome was computed for 95% CI using the t-test for difference in group means. Cite this article. 21, no. (States: would deflate the cuff, pull tube back slightly -1 cm, re-inflate the cuff, and auscultate for bilateral air entry). This cookie is set by Google analytics and is used to store the traffic source or campaign through which the visitor reached your site. Reduces risk of creasing on inflation and minimises pressure on tracheal wall. A limitation of this study is that cuff pressure was evaluated just once 60 minutes after induction of anesthesia. This cookie is used by the WPForms WordPress plugin. Pressure was recorded at end-expiration after ensuring that the patient was paralyzed. Circulation 122,210 Volume 31, No. PBP group (active comparator): in this group, the anesthesia care provider was asked to reduce or increase the pressure in the ETT cuff by inflating with air or deflating the pilot balloon using a 10ml syringe (BD Discardit II) while simultaneously palpating the pilot balloon until a point he or she felt was appropriate for the patient. However, complications have been associated with insufficient cuff inflation. It is used to either assist with breathing during surgery or support breathing in people with lung disease, heart failure, chest trauma, or an airway obstruction. Pelc P, Prigogine T, Bisschop P, Jortay A: Tracheoesophageal fistula: case report and review of literature. PM, SW, and AV recruited patients and performed many of the measurements. The data collected including the number visitors, the source where they have come from, and the pages visited in an anonymous form. P. Sengupta, D. I. Sessler, P. Maglinger et al., Endotracheal tube cuff pressure in three hospitals, and the volume required to produce an appropriate cuff pressure, BMC Anesthesiology, vol. However, these are prohibitively expensive to acquire and maintain in many operating theaters, and as such, many anesthesia providers resort to subjective methods like pilot balloon palpation (PBP) which is ineffective [1, 2, 1620]. Chest. Interestingly, there was also no significant or important difference as a function of provider measured cuff pressures were virtually identical whether filled by CRNAs, residents, or attending anesthesiologists. Students were under the supervision of a senior anesthetic officer or an anesthesiologist. This is the routine practice in all three hospitals. Young, and K. K. Duk, Usefulness of new technique using a disposable syringe for endotracheal tube cuff inflation, Korean Journal of Anesthesiology, vol. 10.1055/s-2003-36557. As newer manufacturing techniques have decreased the occurrence of ETT defects, routine assessments of the ETT cuff integrity prior to use have become increasingly less common among providers. 8184, 2015. Manage cookies/Do not sell my data we use in the preference centre. Underinflation increases the risk of air leakage and aspiration of gastric and oral pharyngeal secretions [4, 5]. The study comprised more female patients (76.4%). 1: anesthesia resident; 2: anesthesia officer; 3: anesthesia officer student; 4: anesthesiologist. 8, pp. You also have the option to opt-out of these cookies. Only 27% of pressures were within 2030 cmH2O; 27% exceeded 40 cmH2O. Endotracheal Tube Cuff Leaks: Causes, Consequences, and Mana - LWW Inflation of the cuff of . Copyright 2017 Fred Bulamba et al. El-Orbany M, Salem MR. Endotracheal tube cuff leaks: causes, consequences, and management. However, this could be a site-specific outcome. Categorical data are presented in tabular, graphical, and text forms and categorized into PBP and LOR groups. Methods With IRB approval, we studied 93 patients under general anesthesia with an ET tube in place in one teaching and two private hospitals. Symptoms of a severe air embolism might include: difficulty breathing or respiratory failure. In addition, most patients were below 50 years (76.4%). 1, pp. laryngeal mask airway [LMA], i-Gel), How to insert a nasopharyngeal airway (NPA), Common hypertensive emergencyexam questions for medical finals, OSCEs and MRCP PACES, Guedel Airway Insertion Initial Assessment of a Trauma Patient, Haemoptysis case study with questions and answers, A fexible plastic tube with cuff on end which sits inside the trachea (fully secures airway the gold standard of airway management), Ventilation during anaesthetic for surgery (if muscle relaxant is required, long case, abdominal surgery, or head positing may be required), Patient cant protect their airway (e.g. If the silicone cuff is overinflated air will diffuse out. General anesthesia was induced by intravenous bolus of induction agents, and paralysis was achieved with succinylcholine or a non-depolarizing muscle relaxant. 408413, 2000. These included an intravenous induction agent, an opioid, and a muscle relaxant. If the tracheal lumen is in the appropriate position (i.e., it has not been placed too deeply), bilateral breath sounds will. 1, p. 8, 2004. An anesthesia provider inserted the endotracheal tubes, and the intubator or the circulating registered nurse inflated the cuff. The cookie is set by Google Analytics and is deleted when the user closes the browser. 617631, 2011. LOR group (experimental): in this group, the research assistant attached a 7ml plastic, luer slip loss of resistance syringe (BD Epilor, USA) containing air onto the pilot balloon. In case of a very low pressure reading (below 20cmH, https://pdfs.semanticscholar.org/c12e/50b557dd519bbf80bd9fc60fb9fa2474ce27.pdf. - Manometer - 3- way stopcock. R. J. Hoffman, V. Parwani, and I. H. Hahn, Experienced emergency medicine physicians cannot safely inflate or estimate endotracheal tube cuff pressure using standard techniques, American Journal of Emergency Medicine, vol. A) Dye instilled into the normal endotracheal tube travels all the way to the cuff. Comparison of distance traveled by dye instilled into cuff. The allocation sequence was concealed from the investigator by inserting it into opaque envelopes (according to the clocks) until the time of the intervention. In contrast, newer ultra-thin cuff membranes made from polyurethane effectively prevent liquid flow around cuffs inflated only to 15 cm H2O [2]. Product Benefits. Step 10: Inflate cuff - Elentra However, there was considerable patient-to-patient variability in the required air volume. Underinflation increases the risk of air leakage and aspiration of gastric and oral pharyngeal secretions [4, 5]. This study set out to determine the efficacy of the loss of resistance syringe method at estimating endotracheal cuff pressures. Reed MF, Mathisen DJ: Tracheoesophageal fistula. M. L. Sole, X. Su, S. Talbert et al., Evaluation of an intervention to maintain endotracheal tube cuff pressure within therapeutic range, American Journal of Critical Care, vol. The groups were not equal for the three different types of practitioners; however, determining differences of practice between different anesthesia providers was not the primary purpose of our study. CAS C) Pressure gauge attached to pilot balloon of normal cuff reading 30 mmHg with cuff inflated. Article The rate of optimum endotracheal tube cuff pressure was 90.5% in the group guided by manometer and 31.8% in the conventional procedure group (p < 0.001 . 101, no. Choosing endotracheal tube size in children: Which formula is best? 111, no. An intention-to-treat analysis method was used, and the main outcome of interest was the proportion of cuff pressures in the range 2030cmH2O in each group. Managing endotracheal tube cuff pressure at altitude: a comparison of Interestingly, the amount of air required to achieve a cuff pressure of 20 cmH2O was similar with each tube size (Table 3). The cuff pressure was measured once in each patient at 60 minutes after intubation. This has been shown to cause severe tracheal lesions and morbidity [7, 8]. There are a number of strategies that have been developed to decrease the risk of aspiration, but the most important of all is continuous control of cuff pressures. These data suggest that tube size is not an important determinant of appropriate cuff inflation volume. This study was not powered to evaluate associated factors, but there are suggestions that the levels of anesthesia providers with varying skill set and technique at direct laryngoscopy may be associated with a high incidence of complications. Acta Otorhinolaryngol Belg. 70, no. How to insert an endotracheal tube (ETT) Equipment required for ET tube insertion Laryngoscope (check size - the blade should reach between the lips and larynx - size 3 for most patients), turn on light Cuffed endotracheal tube Syringe for cuff inflation Monitoring: end-tidal CO2 monitor, pulse oximeter, cardiac monitor, blood pressure Tape Suction Anesthesia services are provided by different levels of providers including physician anesthetists (anesthesiologists), residents, and nonphysician anesthetists (anesthetic officers and anesthetic officer students). protects the lung from contamination from gastric contents and nasopharyngeal matter such as blood. The cuff is inflated with air via a one-way valve attached to the cuff through a separate tube that runs the length of the endotracheal tube. ETT exchange could pose significant risk to patients especially in the case of the patient with a difficult airway. Cuff Pressure Measurement Check the cuff pressure after re-inflating the cuff and if there are any concerns for a leak. Basic routine monitors were attached as per hospital standards. Daniel I Sessler. Also, at the end of the pressure measurement in both groups, the manometer was detached, breathing circuit was attached to the ETT, and ventilation was started. Pediatr Pathol Lab Med. Dullenkopf A, Gerber A, Weiss M: Fluid leakage past tracheal tube cuffs: evaluation of the new Microcuff endotracheal tube. Anesthetists were blinded to study purpose. To achieve the optimal ETT cuff pressure of 2030cmH2O [3, 8, 1214], ETT cuffs should be inflated with a cuff manometer [15, 16]. 795800, 2010. 1990, 18: 1423-1426. We did not collect data on the readjustment by the providers after intubation during this hour. Investigators measured the cuff pressure at 60 minutes after induction of anesthesia using a manometer (VBM, Sulz, Germany) that was connected to the pilot balloon of the endotracheal tube cuff via a three-way stopcock. Google Scholar. How much air is injected into the cuff is not a major concern for almost all anaesthetists and they usually depend on palpating the external cuff tense to judge is it too much, accurate or not enough? When should tracheostomy cuff be inflated deflated? Study participants were randomized to have their endotracheal cuff pressures estimated by either loss of resistance syringe or pilot balloon palpation. Comparison of normal and defective endotracheal tubes. We tested the hypothesis that the tube cuff is inadequately inflated when manometers are not used. 18, no. Experienced emergency medicine physicians cannot safely inflate or estimate endotracheal tube cuff pressure using standard techniques. The cookie is used to store information of how visitors use a website and helps in creating an analytics report of how the website is doing. The AAFP recommends inflating the cuff using air in 0.5-mL increments from a 3-mL syringe until no leak can be heard when the rebreathing bag is squeezed and the pressure in . Endotracheal intubation: MedlinePlus Medical Encyclopedia 23, no. The cookie is created when the JavaScript library executes and there are no existing __utma cookies. PubMed Don't Forget the Routine Endotracheal Tube Cuff Check! Compared with the cuff manometer, it would be cheaper to acquire and maintain a loss of resistance syringe especially in low-resource settings. Our first goal was thus to determine if cuff pressure was within the recommended range of 2030 cmH2O, when inflated using the palpation method. Measuring actual cuff pressure thus appears preferable to injecting a given volume of air. The total number of patients who experienced at least one postextubation airway symptom was 113, accounting for 63.5% of all patients. 1984, 288: 965-968. By clicking Accept, you consent to the use of all cookies. Independent anesthesia groups at the three participating hospitals provided anesthesia to the participating patients. 10, pp. 2006;24(2):139143. demonstrate the presence of legionellae in aerosol droplets associated with suspected bacterial reservoirs. Placement of a Double-Lumen Endotracheal Tube | NEJM Our results are consistent in that measured cuff pressure exceeded 30 cmH2O in 50% of patients and were less than 20 cmH2O in 23% of patients. It is also likely that cuff inflation practices differ among providers. Chest Surg Clin N Am. Google Scholar. Accuracy 2cmH2O) was attached. One such approach entails beginning at the patient and following the circuit to the machine. A newer method, the passive release technique, although with limitations, has been shown to estimate cuff pressures better [2124]. This however was not statistically significant ( value 0.053) (Table 3). M. H. Bennett, P. R. Isert, and R. G. Cumming, Postoperative sore throat and hoarseness following tracheal intubation using air or saline to inflate the cuffa randomized controlled trial, Anesthesia and Analgesia, vol. The cookie is updated every time data is sent to Google Analytics. First, inflate the tracheal cuff and deflate the bronchial cuff. One study, for instance, found that cuff pressure exceeded 40 cm H2O in 40-to-90% of tested patients [22]. The anesthesia providers were either physician anesthetists (anesthesiologists or residents) or nonphysicians (anesthetic officer or anesthetic officer student). 4, no. This cookies is installed by Google Universal Analytics to throttle the request rate to limit the colllection of data on high traffic sites. Out of these cookies, the cookies that are categorized as necessary are stored on your browser as they are essential for the working of basic functionalities of the website. Measured cuff pressures averaged 35.3(21.6)cmH2O; only 27% of the patients had measured pressures within the recommended range of 2030 cmH2O. This cookie is installed by Google Analytics. . The pressure reading of the VBM was recorded by the research assistant. The cookie is updated every time data is sent to Google Analytics. 10, no. If using a neonatal or pediatric trach, draw 5 ml air into syringe. Anaesthesist. It was nonetheless encouraging that we observed relatively few extremely high values, at least many fewer than reported in previous studies [22]. 2003, 13: 271-289. Compliance of the cuff system was evaluated by linear regression of measured cuff pressure vs. measured cuff volume. B) Defective cuff with 10 ml air instilled into cuff. 6, pp. trachea, bronchial tree and lung, from aspiration. - 20-25mmHg equates to between 24 and 30cmH2O. Copyright 2013-2023 Oxford Medical Education Ltd. Myasthenia Gravis (MG) Neurological Examination, Questions about DVT (Deep Vein Thrombosis), Endotracheal tube (ETT) insertion (intubation), Supraglottic airway (e.g. 6, pp. Incidence of postextubation airway complaints in the study population. ETTs were placed in a tracheal model, and mechanical ventilation was performed. This single-blinded, parallel-group, randomized control study was performed at Mulago National Referral Hospital, Uganda. Consecutive available patients were enrolled until we had recruited at least 10 patients for each endotracheal tube size at each participating hospital. Necessary cookies are absolutely essential for the website to function properly. These were adopted from a review on postoperative airway problems [26] and were defined as follows: sore throat, continuous throat pain (which could be mild, moderate, or severe), dysphagia, uncoordinated swallowing or inability to swallow or eat, dysphonia, hoarseness or voice changes, and cough (identified by a discomforting, dry irritation in the upper airway leading to a cough). 1992, 74: 897-900. 20, no. Google Scholar. Novel ETT cuffs made of polyurethane,158 silicone, 159 and latex 160 have been developed and . This was a randomized clinical trial. A caveat, though, is that tube sizes were chosen by clinicians in our study and presumably matched patient size; results may well have differed if tube size had been randomly assigned. The chamber is set to an altitude of 25,000 feet, which gives a time of useful consciousness of around three to five minutes. We similarly found that the volume of air required to inflate the cuffs to 20 cmH2O did not differ significantly as a function of endotracheal tube size. 21, no. Part of The cookies collect this data and are reported anonymously. Liu H, Chen JC, Holinger LD, Gonzalez-Crussi F: Histopathologic fundamentals of acquired laryngeal stenosis. The regression equation indicated that injected volumes between 2 and 4 ml usually produce cuff pressures between 20 and 30 cmH2O independent of tube size for the same type of tube. 87, no. Also to note, most cuffs in the PBP group were inflated to a pressure that exceeded the recommended range in the PBP group, and 51% of the cuff pressures attained had to be adjusted compared with only 12% in the LOR group (Table 2). The study would be discontinued if 5% of study subjects in one study group experienced an adverse event associated with the study interventions as determined by the DSMB, or if a value of <0.001 was obtained on an interim analysis performed halfway through patient accrual. How do you measure endotracheal cuff pressure? - Studybuff If the patient is able to talk, the cuff is not inflated adequately (air is vibrating the vocal cords). The cookie is set by CloudFare. Bernhard WN, Yost L, Joynes D, Cothalis S, Turndorf H: Intracuff pressures in endotracheal and tracheostomy tubes. Hahnel J, Treiber H, Konrad F, Eifert B, Hahn R, Maier B, Georgieff M: [A comparison of different endotracheal tubes. The cookie is set by Google Analytics. All patients who received nondepolarizing muscle relaxants were reversed with neostigmine 0.03mg/kg and atropine 0.01mg/kg at the end of surgery. Free Respiratory Therapy Flashcards about RCP111 A research assistant (different from the anesthesia care provider) read out the patients group, and one of the following procedures was followed. 56, no. When considering this primary outcome, the LOR syringe method had a significantly higher proportion compared to the PBP method. APSF President Robert K. Stoelting, MD: A Tribute to 19 Years of Steadfast Leadership, Immediate Past Presidents Report Highlights Accomplishments of 2016, Save the Date! Cuff pressure adjustment: in both arms, very high and very low pressures were adjusted as per the recommendation by the ethics committee. Supported by NIH Grant GM 61655 (Bethesda, MD), the Gheens Foundation (Louisville, KY), the Joseph Drown Foundation (Los Angeles, CA), and the Commonwealth of Kentucky Research Challenge Trust Fund (Louisville, KY). D) Pressure gauge attached to pilot balloon of defective cuff with reading of 30 mmHg with cuff not appropriately inflated. Because nitrous oxide was not used, it is unlikely that the cuff pressures varied much during the first hour of the study cases. This cookie is native to PHP applications. Cuff pressure reading of the VBM manometer was recorded by the research assistant. 6, pp. Standard cuff pressure is 25mmH20 measured with a manometer. Endotracheal tube system and method . Most manometers are calibrated in? Outcomes Research Institute, University of Louisville, 501 E. Broadway, Suite 210, Louisville, KY, 40202, USA, Papiya Sengupta,Daniel I Sessler&Anupama Wadhwa, Department of Anesthesiology and Perioperative Medicine, University of Louisville, 530 S. Jackson St. University Hospital, Louisville, KY, 40202, USA, Daniel I Sessler,Paul Maglinger,Jaleel Durrani&Anupama Wadhwa, School of Medicine, University of Louisville School of Medicine, Louisville, KY, 40292, USA, You can also search for this author in This is used to present users with ads that are relevant to them according to the user profile. After deflating the cuff, we reinflated it in 0.5-ml increments until pressure was 20 cmH2O. These cookies do not store any personal information. Spay/Neuter Patient Care: Inflating an Endotracheal Tube Cuff At the time of the intervention, the study investigator retrieved the next available envelope, which indicated the intervention group, from the next available block envelope and handed it to the research assistant. 5, pp. This outcome was compared between patients with cuff pressures from 20 to 30cmH2O range and those from 31 to 40cmH2O following the initial correction of cuff pressures. chest pain or heart failure. Vet Anaesth Analg. Abstract: An endotracheal tube includes a main tubular portion including a distal end and a proximal end opposite the distal end, the main tubular portion including a central lumen at least in part defined by a wall of the main tubular portion; a . Issue PDF, We are writing to call attention to the often under-appreciated importance of checking the endotracheal tube (ETT) prior to the start of the procedure. 139143, 2006. J. R. Bouvier, Measuring tracheal tube cuff pressurestool and technique, Heart and Lung, vol. An endotracheal tube : provides a passage for gases to flow between a patients lungs and an anaesthesia breathing system . Anyone you share the following link with will be able to read this content: Sorry, a shareable link is not currently available for this article. How to insert an endotracheal tube (intubation) for doctors and medical students, Video on how to insert an endotracheal tube, AnaestheticsIntensive CareOxygenShortness of breath. This website uses cookies to improve your experience while you navigate through the website. (Cuffed) endotracheal tubes seal the lower airway of at the cuff location in the trachea. B) Dye instilled into the defective endotracheal tube stops at the entrance of the pilot balloon tubing into the main tubing (arrow in Figure 2A and 2B). Over-inflation of an endotracheal tube (ETT) cuff may lead to tracheal mucosal irritation, tracheal wall ischemia or necrosis, whereas under-inflation increases the risk of pulmonary aspiration as well as leaking anesthetic gas and polluting the environment. Christina M. Brown, MD, Resident, Department of Anesthesiology, Washington University in St. Louis, MO. The mean volume of inflated air required to achieve an intracuff pressure of 25 cmH2O was 7.1 ml.

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