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The cuff shadow
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Daren Herrick, RN RRT Oxnard, Calif.
Send letter to journal:
darenah{at}verizon.net Daren Herrick
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As a Critical Care RN and a Registered Respiratory Therapist, I have taken a special interest in assessing and monitoring endotracheal tube application and complications in the adult population for my unit. I have even began an informal audit of all self-extubations, especially those which lead to severe adverse events. Cuff monitoring has a significant application, in my opinion, in most of these self-extubations. The monitoring of the cuff, aside from the MOV that is used in our unit, goes as far as the chest x-ray. It is my understanding that the position of the cuff, 2 cm's above the carina, secures the cuff away from the glottis and in a stable position. In my random assessment of chest xrays focussing on the intubated patients in my unit, I have found, surprisingly, that a significant amount of them have issues with the cuffs encroaching the glottal region. It is assumed that this glottal stimuli not only creates a very uncomfortable and agitated patient, it also adversely affects the patients' vital signs, stimulates oral secretions, and could be a factor in aspirations leading to VAP. I feel that if a cuff shadow (not the tip of the ETT) is not visualized by xray to be in the proper position of the trachea, then there may be a risk for the ETT to migrate up into the glottal region with overinflation of the cuff. I have even seen self-extubations where the cuff was the size of a small golf ball because of addressing a "cuff leak" and overinflating the cuff. The trachea gets wider superiorly, which requires more volume of the cuff to establish MOV, and as the cuff gets bigger, it pulls the ETT out even farther. Another interesting situation relating to the position of the cuff and it's occlusion pressures; I observed a patient who suddenly had a severely occluded endotracheal tube and the patient had to be reintubated, eventually. As the ETT was extracted, the cuff appeared to be intact, but the chest xray of the occluded airway had shown that the endotracheal tube cuff was inflated over the end of the tube. This patient was requiring high peak airway pressures to establish adequate volumes, so my assumption was that the pressure of the cuff had to be well over the airway pressures to establish MOV, and the tip of the ETT migrated up just enough to allow the cuff to expand over the tip. In short, I would like to add that it is important to establish a proper endotracheal tube cuff postition when establishing occlusion pressures. I feel these two factors together, are important aspects of cuff management in the intensive care units. Daren Herrick RN BSN RRT |
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