title: Endotracheal tubes and fluid aspiration: an in vitro evaluation of new cuff technologies.
abstract: Aspiration of subglottic secretions past the endotracheal tube (ETT) cuff is a prerequisite for developing ventilator-associated pneumonia (VAP). Subglottic secretion drainage (SSD) ETTs reduce aspiration of subglottic secretions and have demonstrated lower VAP rates. We compared the performance of seven SSD ETTs against a non-SSD ETT in preventing aspiration below inflated cuffs.
  
  
  
  ETTs were positioned vertically in 2 cm diameter cylinders. Four ml of a standard microbial suspension was added above inflated cuffs. After 1 h, aspiration was measured and ETTs demonstrating no leakage were subjected to rotational movement and evaluation over 24 h. Collected aspirated fluid was used to inoculate agar media and incubated aerobically at 37 °C for 24 h. The aspiration rate, volume and number of microorganisms that leaked past the cuff was measured. Experiments were repeated (×10) for each type of ETT, with new ETTs used for each repeat. Best performing ETTs were then tested in five different cylinder diameters (1.6, 1.8, 2.0, 2.2 and 2.4 cm). Experiments were repeated as above using sterile water. Volume and time taken for aspiration past the cuff was measured. Experiments were repeated (×10) for each type of ETT. Results were analysed using non-parametric tests for repeated measures.
  
  
  
  The PneuX ETT prevented aspiration past the cuff in all experiments. All other ETTs allowed aspiration, with considerable variability in performance. The PneuX ETT was statistically superior in reducing aspiration compared to the SealGuard (p < 0.009), KimVent (p < 0.002), TaperGuard (p < 0.004), Lanz (p < 0.001), ISIS (p < 0.001), SACETT (p < 0.001) and Soft Seal (p < 0.001) ETTs. Of the 4 ETTs tested in differing cylinder sizes, the PneuX significantly reduced aspiration across the range of diameters compared to the SealGuard (p < 0.0001), TaperGuard (p < 0.0001) and KimVent (p < 0.0001) ETTs.
  
  
  
  ETTs showed substantial variation in fluid aspiration, relating to cuff material and design. Variability in performance was likely due to the random manner in which involutional folds form in the inflated ETT cuff. The PneuX ETT was the only ETT able to consistently prevent aspiration past the cuff in all experiments.
authors.affiliation: Oral and Biomedical Sciences, School of Dentistry, Cardiff University, Heath Park, Cardiff, Wales, CF14 4XY, UK. maryannemariyaselvam@gmail.com.
authors.forename: Maryanne Z
authors.initials: MZ
authors.lastname: Mariyaselvam
authors.affiliation: Oral and Biomedical Sciences, School of Dentistry, Cardiff University, Heath Park, Cardiff, Wales, CF14 4XY, UK.
authors.forename: Lucy L
authors.initials: LL
authors.lastname: Marsh
authors.affiliation: Oral and Biomedical Sciences, School of Dentistry, Cardiff University, Heath Park, Cardiff, Wales, CF14 4XY, UK.
authors.forename: Sarah
authors.initials: S
authors.lastname: Bamford
authors.affiliation: School of Biosciences, Cardiff University, Cardiff, Wales, UK.
authors.forename: Ann
authors.initials: A
authors.lastname: Smith
authors.affiliation: Adult Critical Care, University Hospital of Wales, Cardiff, Wales, UK.
authors.forename: Matt P
authors.initials: MP
authors.lastname: Wise
authors.affiliation: Oral and Biomedical Sciences, School of Dentistry, Cardiff University, Heath Park, Cardiff, Wales, CF14 4XY, UK.
authors.forename: David W
authors.initials: DW
authors.lastname: Williams
mesh_terms: D004867:Equipment Design; D006801:Humans; D066298:In Vitro Techniques; D007442:Intubation, Intratracheal / Q000295:instrumentation*; D008954:Models, Biological; D019152:Paracentesis / Q000295:instrumentation*; D011015:Pneumonia, Aspiration / Q000517:prevention & control
keywords: Endotracheal tube; Endotracheal tube cuff; Nosocomial pneumonia; Pulmonary aspiration; Ventilator-associated pneumonia