Changes in intracuff pressure of a cuffed endotracheal tube during surgery for congenital heart disease using cardiopulmonary bypass.
BACKGROUND
With the development of newer polyurethane cuffed endotracheal tubes (cETTs), there has been a shift in clinical practice among pediatric anesthesiologists. Despite improvements in design, excessive inflation of the cuff can still compromise tracheal mucosal perfusion. Several perioperative factors can affect the intracuff pressure (CP), and there is no consensus on safe CP in pediatric patients undergoing repair of congenital cardiac disease (CHD) utilizing cardiopulmonary bypass (CPB). In the current study, the CP was continuously monitored in pediatric patients undergoing surgery for CHD.


METHODS
After IRB approval, this observational study was conducted on pediatric patients who underwent repair of CHD using CPB with a cETT in place. After anesthetic induction and endotracheal intubation, the cuff was inflated using the air leak technique while maintaining a continuous positive airway pressure of 20 cmH2 O. After inflation, the CP was continuously monitored throughout the procedure. In addition, temperature and mean arterial pressure (MAP) were also recorded.


RESULTS
The study included 33 patients who ranged in age from 1 month to 15.3 years. Their weight ranged from 4.0 to 83.6 kg. Six patients were excluded from the analysis due to the need to add or remove air from the cuff, leaving 27 patients for data analysis for cuff pressure over time. The baseline CP at the time of inflation was 16.1 ± 7.6 cmH2 O. With the use of CPB and initiation of hypothermia, when compared to the baseline, the CP decreased by -0.7 ± 5.8 cmH2 O at 35-37°C, -9.1 ± 8.4 cmH2 O at 31-33°C, -7.8 ± 6.2 cmH2 O at 27-29°C, and -11.1 ± 6.0 cmH2 O at <27°C. With rewarming, the CP increased back to the baseline level (-3.5 ± 7.0 cmH2 O).


CONCLUSIONS
There was a significant decrease in the CP during CPB and associated hypothermia. This may offer some protection for mucosal perfusion during CPB which is usually associated with lower than normal MAP. However, the decrease in the CP may compromise the tracheal seal which may not offer the intended protection for the airway from aspiration.
Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.|Department of Anesthesiology and Pain Medicine, The Ohio State University, Columbus, OH, USA.
Hiromi
H
Kako
The Ohio State University School of Medicine, Columbus, OH, USA.
Omar
O
Alkhatib
Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.|Department of Anesthesiology and Pain Medicine, The Ohio State University, Columbus, OH, USA.
Senthil G
SG
Krishna
Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.|Department of Anesthesiology and Pain Medicine, The Ohio State University, Columbus, OH, USA.
Sarah
S
Khan
Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.|Department of Anesthesiology and Pain Medicine, The Ohio State University, Columbus, OH, USA.
Aymen
A
Naguib
Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.|Department of Anesthesiology and Pain Medicine, The Ohio State University, Columbus, OH, USA.|Department of Pediatrics, The Ohio State University, Columbus, OH, USA.
Joseph D
JD
Tobias
D000293:Adolescent; D002315:Cardiopulmonary Bypass; D002648:Child; D002675:Child, Preschool; D004867:Equipment Design; D005260:Female; D006330:Heart Defects, Congenital / Q000601:surgery*; D006801:Humans; D007223:Infant; D007442:Intubation, Intratracheal / Q000706:statistics & numerical data*; D008297:Male; D016343:Monitoring, Intraoperative / Q000706:statistics & numerical data*; D011312:Pressure; D011446:Prospective Studies
airway management; endotracheal; intraoperative monitoring; intubation; pediatrics