in the Pediatric Emergency Department Edward Ferenczy, MD Rady - - PowerPoint PPT Presentation

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in the Pediatric Emergency Department Edward Ferenczy, MD Rady - - PowerPoint PPT Presentation

Apr 01, 2023 219 likes •409 views

Endotracheal Tube Cuff Pressure in the Pediatric Emergency Department Edward Ferenczy, MD Rady Childrens Hospital Department of Critical Care Michael Stoner MD, Sandra Spencer MD, DJ Scherzer MD, Samantha Gee MD, Joseph Tobias MD

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Endotracheal Tube Cuff Pressure in the Pediatric Emergency Department

Edward Ferenczy, MD Rady Children’s Hospital Department of Critical Care

Michael Stoner MD, Sandra Spencer MD, DJ Scherzer MD, Samantha Gee MD, Joseph Tobias MD Nationwide Children’s Hospital

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ETT Cuff pressure in the ED

Overview

  • Question: How many children who are

emergently intubated are exposed to a high pressure in their ETT cuff?

  • Study: Prospective Cohort study
  • Answer: a little over half
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SLIDE 3

ETT Cuff pressure in the ED

What is known?

  • Cuff pressure can’t be accurately estimated
  • High ETT cuff pressure is associated with

adverse effects

  • Cuffed ETT use is common in children
  • Cuffed ETT use is recommended in children
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SLIDE 4

ETT Cuff pressure in the ED

The question:

  • How many children are exposed to a high ETT

cuff pressure after emergency intubation?

  • Do any factors correlate with a high ETT cuff

pressure?

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SLIDE 5

ETT Cuff Pressure in the ED

Setting:

  • Emergency Department of an urban, tertiary

care pediatric hospital

  • Level 1 Trauma center
  • >100,000 Annual visits
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SLIDE 6

ETT Cuff Pressure in the ED

Study Design:

  • Prospective cohort
  • IRB-approved, informed consent was waived
  • 12 months of data collection
  • Data collection performed by certified RT’s
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ETT Cuff Pressure in the ED

Cohort:

  • 104 patients enrolled
  • 42 girls and 62 boys
  • 10 days to 20 years old
  • 2.3kg to 102kg
  • 87 intubations in the study institution

emergency department, 7 in the field and 10 at outlying hospitals

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SLIDE 8

Primary Outcome: Cuff Pressure

≥30cmH2O: 56% N=58 ≤29cmH2O: 44% N=46

Cuff Pressure in 104 Endotracheally Intubated Children

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Primary Outcome: Cuff Pressure

5 10 15 20 25 30 35 40 45

13 32 44 15

Number of Children

<20cmH2O 20-29cmH2O 30-60cmH2O >60cmH2O

Number of children vs. Cuff pressure groups

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Secondary Outcomes

What was investigated:

  • Person performing intubation
  • Person performing cuff inflation
  • Endotracheal tube size
  • Patient age
  • Patient gender
  • Patient weight
  • Diagnostic category (medical or trauma)
  • Month & time of day
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SLIDE 11

Secondary Outcomes

What we found to be statistically significant:

  • Person performing intubation
  • Person performing cuff inflation
  • Endotracheal tube size
  • Patient age
  • Patient gender
  • Patient weight
  • Diagnostic category (medical or trauma)
  • Month & time of day
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Secondary Outcome: Cuff Inflator

OR 3.12, CI 1.1-8.6, p=0.028

10 20 30 40 50 60

Respiratory Therapist All Others 33cmH2O 51cmH2O Average Cuff Pressure (cmH2O )

Average pressure vs Cuff Inflator

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SLIDE 13

Secondary Outcome: Patient Age

OR 2.0, CI 1.3-3.2, p=0.002

10 20 30 40 50 60

< 1 month 1 month - 1 year > 1 year 24cmH2O 37cmH2O 45cmH2O Average cuff pressure (cmH2O)

Average cuff pressure vs age group

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Secondary Outcome: Patient Weight

OR 0.9, CI 0.8-0.97, p=0.007

10 20 30 40 50 60

<10kg 10kg-20kg >20kg 27cmH2O 42cmH2O 54cmH2O Average Cuff Pressure (cmH2O)

Average Cuff Pressure vs Weight

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ETT Cuff Pressure in the ED

What was learned:

  • Emergently intubated children are likely to be

exposed to high ETT cuff pressure

  • Regular use of a manometer in the ED may

help limit exposure to excessive ETT cuff pressure

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ETT Cuff Pressure in the ED

References:

  • J Bryant, et al, Can the intracuff pressure be estimated by palpation
  • f the pilot balloon? ICU Director, (2013) 4: 170-172
  • Miller MA, et al, A polyurethane cuffed endotracheal tube is

associated with decreased rates of ventilator-associated

  • pneumonia. Journal of Critical Care (2011) 26, 280-286
  • RD Seegobin, et al, Endotracheal cuff pressure and tracheal mucosal

blood flow: endoscopic study of effects of four large volume cuffs, British Medical Journal, (1984) 288: 965-968

  • Kleinman ME, et al Part 14: Pediatric advanced life support: 2010

American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation (122) 2010

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ETT Cuff Pressure in the ED

Special thanks to: Michael Stoner MD, Sandra Spencer MD & DJ Scherzer MD, Section of Emergency Medicine

Nationwide Children’s Hospital

Samantha Gee MD, Pediatric Critical Care,

Nationwide Children’s Hospital

Joseph Tobias MD, Anesthesiology and Pain

medicine (Chair), Pediatric Critical Care, Nationwide Children’s Hospital