Download Effectiveness of Interventions to Increase Provider Monitoring of

Effectiveness of Interventions to Increase
Provider Monitoring of Endotracheal Tube and
Laryngeal Mask Airway Cuff Pressures
CDR Randy E. Ashman, MSN, DNP, CRNA, NC, USN
Susan J. Appel, PhD, APRN-BC, CCRN, FAHA
CDR Arnel J. Barba, MS, DNP, CRNA, NC, USN
Previous research demonstrates that monitoring and
adjusting pressures in endotracheal (ET) tubes 30
cm H2O or less and laryngeal mask airways (LMAs)
60 cm H2O or less decrease rates of postoperative
pharyngolaryngeal complications. In this evidencebased practice project we examined whether a multistep intervention (departmental education plus reference cards in operating rooms plus addition of cuff
pressure documentation variable in electronic anesthesia record) would increase the frequency of providers monitoring intracuff pressures and decrease
the rate of high intracuff pressures. Before and after
the intervention, we recorded intracuff pressures of
51 ET tubes and 51 LMAs in surgical patients, as well
as providers’ self-reported incidence of monitoring
T
he endotracheal (ET) tube and laryngeal mask
airway (LMA) are widely used airway devices
in the practice of anesthesia. The most common
adverse event reported by patients postoperatively after use of an ET tube or LMA is a sore
throat and hoarseness.1,2 Other adverse pharyngolaryngeal
complications that have been reported with ET tube use
include lingual nerve damage, ulceration, bleeding, and
tracheal stenosis, necrosis, or rupture.3-7 For the LMA,
these complications include sore neck, dysphagia, venous
neck congestion, arytenoid cartilage dislocation, lingual
nerve damage, and jaw tenderness.2,8-17 These complications have been reported to be associated with higher cuff
pressures, especially when they exceed recommended
pressures.1,2 For example, Liu et al1 found a sore throat
incidence of 44% in patients whose mean ET tube cuff
pressure exceeded 43 ± 23.3 mm Hg. Wong et al8 reported
an incidence of sore throat in 56.5% of pediatric patients
whose LMA cuff pressures exceeded 100 cm H2O. Pressures of ET tubes should be maintained between 20 and
30 cm H2O (27-40 mm Hg),4,18 and LMA devices below 60
cm H2O (44 mm Hg).2 Several investigations have demonstrated that use of a manometer to maintain ET tube1 and
LMA2 cuff pressures at the recommended ranges reduces
the incidence of pharyngolaryngeal complications.
Liu et al1 conducted a multicenter randomized con-
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and adjusting intracuff pressures.
Our multistep intervention increased provider monitoring of intracuff pressures in ET tubes (77% pre- vs
94% postintervention, P = .025) and LMAs (37% pre- vs
94% postintervention, P < .001). Mean ET tube and
LMA cuff pressures were significantly lower postintervention: ET tube: pre = 34 ± 16 cm H2O vs post = 29
± 12 cm H2O (P = .045), LMA: pre = 73 ± 30 cm H2O vs
post = 49 ± 15 cm H2O (P < .001). Our multistep intervention improved compliance with intracuff pressure
recommendations.
Keywords: Anesthesia provider, cuff pressure monitoring with manometer, endotracheal tube, laryngeal
mask airway, pharyngolaryngeal complications.
trolled trial in 509 adult patients undergoing general
anesthesia (no nitrous oxide [N2O] administered) who
were randomly assigned to either a manometer group or
control group. Anesthesia providers inflated the ET tube
cuffs of all patients using the palpation method, after
which patients in the manometer group had their cuff
pressures adjusted between 15 and 25 mm Hg, whereas
the control group did not. Mean ET tube cuff pressures
in the manometer group was 43 ± 23.3 mm Hg before
adjustment (the highest was 210 mm Hg) and 20 ± 3.1
mm Hg after adjustment. Investigators found that using a
manometer to adjust ET tube cuff pressures reduced the
incidence of sore throat (34% vs 44%, P = .033), hoarseness (3% vs 11%, P = .001), and blood-streaked expectoration (4% vs 11%, P = .002) compared with the control
group, in which ET tube cuff pressures were not adjusted
or measured. Similar findings have been reported when a
manometer was used to reduce LMA cuff pressures. Seet
et al2 randomly assigned 203 adult patients undergoing
surgery with general anesthesia via an LMA (no N2O
administered) to a manometer group with cuff pressures
adjusted between 40 and 44 mm Hg (< 60 cm H2O) or a
routine care group. Their primary outcome was the difference in “composite pharyngolaryngeal adverse events”
(sore throat, dysphagia, and dysphonia) that occurred at
1, 2, or 24 hours postoperatively. After placement of the
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LMA, the mean initial cuff pressure in the manometer
group was 112 ± 59 mm Hg compared with 114 ± 57 mm
Hg in the routine care group. The use of a manometer significantly decreased the incidence of pharyngolaryngeal
complications (13.4% vs 45.6%, P < .001). At 2 and 24
hours the incidence of sore throat was significantly lower
in the manometer group vs routine care (2.1% vs 8.7%,
P = .038, and 3.1% vs 13.6%, P = .008, respectively).
Similar findings were found for dysphagia, with lower
rates in the manometer group at 1, 2, and 24 hours (1%
vs 12.6%, P < .001; 0% vs 12.6%, P < .001; and 2.1% vs
8.7%, P = .038, respectively). A significant difference in
dysphonia was seen only at 1 hour postoperatively (5.2%
vs 15.5%, P = .017). The investigators concluded that
adjustment of the LMA cuff pressure to less than 44 mm
Hg or 60 cm H2O should be considered a best practice.
Other investigators have reported similar findings
that support the adjustment of LMA cuff pressures. Nott
et al,19 studying 839 patients, found that lowering LMA
cuff pressures to allow a slight leak at 10 to 12 cm H2O
reduced the incidence of sore throat from 15.7% to 7%
(P < .001) compared with a nonadjusted group whose
cuffs were inflated with standard volumes. Burgard et
al,20 studying 200 patients, found that limiting the LMA
cuff pressure to “minimal airtightness pressure” (< 60 cm
H2O) reduced the incidence of sore throat from 8% to 0%
compared with a non-adjusted group for which the mean
LMA cuff pressure was 192 ± 32 cm H2O.
Despite evidence supporting the adjustment of ET
tube and LMA cuff pressures to recommended ranges, the
monitoring of intracuff pressures in ET tubes and LMAs
with manometers is not widely practiced by anesthesia
providers.2 Even at our hospital, which has manometers
in every operating room for easy access by anesthesia
providers, there is varied use of the instrument. Many
providers will palpate pilot balloon pressure and use
their finger’s tactile sense as a subjective measure of intracuff pressure. Other methods include “minimal leak”
or injecting a predetermined volume of air. Many studies
have shown these methods to be inaccurate.4,18,21,22 In a
study of 40 anesthesia providers, Stewart et al22 found
that providers obtained an initial ET tube cuff pressure
above 40 cm H2O in 65% of patients using their preferred
method of estimation (palpation: 88%, minimal leak:
10%, or predetermined volume: 2%). Sengupta et al,18
studying 93 patients, found an initial ET tube cuff pressure higher than 30 cm H2O in 50.5% of cases. Hoffman
et al,21 in a study of 41 emergency medicine attending
physicians, found that providers obtained an initial ET
tube cuff pressure above 120 cm H2O in 90% of cases
using the palpation method. Trivedi et al,4 studying 75
patients, found that providers obtained an initial ET tube
cuff pressure above 30 cm H2O in 26.2% of cases.
Despite the evidence, these methods continue to
be used clinically to estimate the cuff pressures in ET
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tubes and LMAs. At our institution, we did not have
any evidence-based practice (EBP) guidelines to aid the
anesthesia provider in setting, monitoring, or documenting intracuff pressures. We also did not have a standardized way to consistently document intracuff pressures
in the anesthesia record, nor did we have a method for
providing quality assurance data on what pressures were
maintained throughout the intraoperative period. An
EBP quality improvement project was undertaken to
align clinical practice with current evidence that suggests
that regularly checking and adjusting ET tube and LMA
cuff pressures to within normal ranges decreases the incidence of pharyngolaryngeal complications.1,2 Evidence
also suggests that simple reminders (automated via the
electronic medical record or posted) improve compliance
with guidelines.23 Therefore, the purpose of this EBP
quality improvement project was to explore whether an
educational intervention, physical reference cards, and
a prominent cuff pressure documentation variable in
the electronic anesthesia record would increase the frequency of provider monitoring of intracuff pressures and
thereby decrease the occurrence of high intraoperative
ET tube and LMA cuff pressures.
Methods
The institutional review board (IRB) at Naval Medical
Center San Diego in San Diego, California, determined
this project was quality improvement and did not require
IRB review. The IRB at The University of Alabama,
Tuscaloosa, Alabama, approved this study after expedited review (IRB #15-OR-117-ME). Patient consents
were not required because monitoring intracuff pressures
is accepted practice, within the purview of anesthesia
providers, and the pressure manometers used were not
experimental. No personal identifying information about
the patients or providers was obtained. This EBP quality
improvement project used the Iowa Model of EvidenceBased Practice Theory and involved 3 phases.
The first phase was a baseline evaluation of the intracuff pressures of 51 ET tubes and 51 LMAs in surgical
patients undergoing general anesthesia obtained as a
convenience sample over a 10-day period. After verifying
that the patient was 18 years or older, the investigator
asked anesthesia providers whether they had checked the
intracuff pressure of the ET tube or LMA after placement
and whether the pressure needed adjustment. Providers
were also asked about the use of N2O before the point
of data collection. The investigator then checked and
recorded the intracuff pressure of the ET tube or LMA.
This pressure was shared with the anesthesia provider
and adjusted as requested. Data on demographic and
clinical characteristics collected included N2O use, cuff
type (ET tube or LMA), cuff size, patient’s height and
weight, and provider type. Provider type included anesthesiologists and Certified Registered Nurse Anesthetists
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Figure 1. Prominent Cuff Pressure Documentation Variable in Electronic Anesthesia Record
(CRNAs) working alone or with student nurse anesthetists (SRNAs) and anesthesiologists working with anesthesia residents. Each patient’s BMI was calculated using
the standard formula of weight in kilograms divided by
the height in meters squared.
In phase 2, the investigator presented to the anesthesia
department a summary of 4 studies1,2,8,19 showing reduced
postoperative pharyngeal complications when ET tube and
LMA cuff pressures were controlled and 3 studies18,21,22
showing the inaccuracy of pilot balloon palpation. The
investigator also shared the results of the phase 1 survey,
including the mean, minimum, and maximum pressures
recorded for ET tubes and LMAs, and the frequency of
self-reported monitoring by providers. Recommended cuff
pressures for ET tubes and LMAs were also discussed. The
investigator created a prominent cuff pressure documentation variable in the electronic anesthesia record (Figure 1)
and placed a physical reference card of recommended cuff
pressures in all operating rooms (Figure 2). All departmental staff were emailed the educational presentation,
and those who missed the live presentation were given a
summary of the information in person by the investigator.
This included a couple of reservists who initially came to
training during phase 3 of the study.
After a 2-day period, the investigator conducted phase
3, evaluating the intracuff pressures of another 51 ET
tubes and 51 LMAs in surgical patients undergoing
general anesthesia, in the same manner as that for phase
1, over an 11-day period. The investigator then compared
the postintervention results with the initial baseline
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Figure 2. Physical Reference/Reminder Card Placed in
Operating Room
Abbreviations: ETT, endotracheal tube; LMA, laryngeal mask airway.
survey. Outcomes of interest were the percentage of providers monitoring ET tube or LMA intracuff pressures
and the mean differences in intracuff pressures before and
after the interventions. Before this project, a power analysis was performed with an α = 0.05 and a β = 0.80. We set
a conservative goal to both increase provider monitoring
of intracuff pressures and reduce the proportion of high
intracuff pressures by 25%. We then added 10% to each
group as a safety measure against insufficient power and
settled on a sample size of 51 for each pre- and postgroup
of ET tubes and LMAs, with a final sample size of 204.
Descriptive and inferential statistics were used to
analyze the results. Chi-square tests were used to examine
the relationship between time period (pre- or postintervention) and frequency of providers monitoring intracuff
pressures, whereas independent-samples t tests were
used to examine differences in mean pre- and postintervention intracuff pressures in each cuff type (ET tube
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ET tube
Characteristic
LMA
Pre
Post
P
Pre
Post
P
Height (in), mean ± SD
67 ± 4.6
66.5 ± 4.1
.556
68 ± 4.7
66.8 ± 3.9
.193
Weight (kg), mean ± SD
84.2 ± 18.9
76.4 ± 18.2
.035
77.3 ± 16.3
77.3 ± 15
<1
BMI (kg/m2), mean ± SD
29.2 ± 6.5
26.7 ± 5.3
.033
26 ± 5.1
26.8 ± 4.9
.405
4 (7.8)
5 (9.8)
.500
6 (11.8)
5 (9.8)
N2O used, No. (%)
Device size,
ETT or LMA, No. (%)
5.5
7.0 or 3
7.5 or 4
8.0 or 5
.437
0 (0)
26 (51)
18 (35.3)
7 (13.7)
1 (2)
20 (39.2)
24 (47)
6 (11.8)
.750
.826
--3 (5.9)
26 (51)
22 (43.1)
--3 (5.9)
29 (56.9)
19 (37.2)
Table. Demographic and Clinical Characteristics of Population in Preintervention and Postintervention Groups
(N = 204)a
Abbreviations: BMI, body mass index; ET, endotracheal; LMA, laryngeal mask airway; N2O, nitrous oxide.
aA Pearson correlation showed that there was no relationship between initial ET tube cuff pressure and weight (r = −.001, P = .993) or
BMI; r = .029, P = .771). This also held true for LMA initial cuff pressure and weight (r = .010, P = .918) or BMI (r = −.041, P = .686).
or LMA). A Pearson correlation coefficient was used to
examine the relationship between BMI and intracuff pressure. A P value of < .05 was considered significant. Data
were analyzed using SPSS version 23 software.24
Results
The intracuff pressures were measured in a total of 102
ET tubes and 102 LMAs (51 in each group before and
after the intervention). There were no significant differences in demographic or clinical characteristics, including provider type, between the pre- and postintervention
groups except patient weight and BMI in the ET tube
group (Table). Mean (± SD) patient weight for the ET
tube preintervention group was 84.2 ± 18.9 kg, whereas
the postintervention group mean was 76.4 ± 18.2 kg (P =
.035). Because of this difference, a Pearson correlation was
conducted to check for a relationship between initial ET
tube cuff pressure and patient weight or BMI. Our results
showed no relationship between initial ET tube cuff pressure and weight (r = −.001, P = .993), or BMI (r = .029, P =
.771). This also held true for initial LMA cuff pressure and
weight (r = .010, P = .918), or BMI (r = −.041, P = .686).
The interventions significantly increased the frequency
at which providers monitored ET tube and LMA intracuff pressures and decreased intracuff pressures in both
groups. Providers monitored the pressures of ET tubes in
39 (77%) of the preintervention cases vs 48 (94%) of the
postintervention cases (P = .025). The pressures of LMAs
were monitored by providers in 19 (37%) of the preintervention cases vs 48 (94%) of the postintervention cases
(P < .001; Figure 3). In the preintervention group, mean
ET tube cuff pressure was 34 ± 16 cm H2O (minimum =
12 cm H2O; maximum = 85 cm H2O) compared with 29
± 12 cm H2O (minimum = 17 cm H2O; maximum = 80
cm H2O) in the postintervention group (P = .045; Figure
4). Only 24 (47%) of the ET tubes had pressures of 30 cm
H2O or less in the preintervention group compared with
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37 (73%) of the ET tubes in the postintervention group (P
= .015). The preintervention mean LMA cuff pressure was
73 ± 30 cm H2O (minimum = 21 cm H2O; maximum >
120 cm H2O) compared with 49 ± 15 cm H2O (minimum
= 15 cm H2O; maximum > 120 cm H2O) in the postintervention group (P < .001; see Figure 4). In the preintervention group only 23 (45%) of the LMAs had pressures of
60 cm H2O or less compared with 47 (92%) of the LMAs
in the postintervention group (P < .001).
The use of N2O increased intracuff pressures in both
ET tubes and LMAs. Combining pre- and postintervention groups, the mean ET tube cuff pressure without N2O
use (n = 93) was 30 ± 13 cm H2O, whereas the mean ET
tube cuff pressure with N2O use (n = 9) was 49 ± 18 cm
H2O (P < .001). Combining pre- and postgroups, the
mean LMA cuff pressure without N2O use (n = 91) was
59 ± 25 cm H2O, and the mean LMA cuff pressure with
N2O use (n = 11) was 81 ± 33 cm H2O (P = .052).
Discussion
This study showed that an educational intervention,
physical reference cards, and a prominent cuff pressure
variable in the electronic anesthesia record for documenting cuff pressures were effective at increasing provider
monitoring and adjustment of intracuff pressures as well
as reducing the mean cuff pressures seen intraoperatively.
In the preintervention groups, we found a mean ET tube
cuff pressure of 34 ± 16 cm H2O and a mean LMA cuff
pressure of 73 ± 30 cm H2O. These measures were lower
than the pressures found in other studies, a difference
most likely due to a higher baseline frequency of providers monitoring intracuff pressures in ET tubes (77%) and
LMAs (37%) at our facility.1,2,20,25 We were surprised that
we effected only a small change in the range of intracuff
pressures after the intervention. There was a small decrease in the maximum ET tube pressure, but the LMA
maximum pressure after the intervention was still greater
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Figure 3. Percentage Monitoring by Device Type
Figure 4. Cuff Pressure and Device Type
Abbreviations: ETT, endotracheal tube; LMA, laryngeal mask airway.
Abbreviations: ETT, endotracheal tube; LMA, laryngeal mask airway.
than 120 cm H2O. These higher pressures were because 3
(6%) of the providers did not check intracuff pressures in
ET tubes and LMAs after the intervention. In fact, nearly
all postintervention pressures that were above recommended limits were due to either providers not initially
checking the intracuff pressure or checking and adjusting
the pressure, but then not rechecking it later while using
N2O. Providers who use N2O should consider checking
and adjusting intracuff pressures more frequently.
Limitations of this project included a small sample
size, short timeframe, and observer bias. Baseline frequency of providers monitoring intracuff pressures at
our facility was likely higher than at other facilities
because of the availability of manometers. Manometers
are relatively cheap ($200-$500 each) and last for many
years with minimal maintenance. Monitoring intracuff
pressures is an easy task for providers to perform, but
they must be provided the equipment. Without this
equipment, providers are forced to use methods that have
been shown to be inaccurate and result in high intracuff
pressures (palpation, minimal leak, and predetermined
volume).4,18,21,22 Given the increasing evidence that
monitoring and reducing intracuff pressures can decrease
postoperative pharyngeal complications,1,2 the use of
manometers combined with provider education could
have tangible and intangible benefits to patients, providers, and facilities. For patients, this means decreasing
the rates of postoperative sore throat, sore neck, hoarseness, dysphagia, nerve damage, mucosal ulceration,
and bleeding, as well as tracheal stenosis, necrosis, or
rupture. These complications could lead to longer hospitalizations, the need for additional medications or higher
doses to manage symptoms, lost work to care for self or
family members, the need for further surgery to repair
damage to the trachea and/or pharynx, and long-term
sequelae with increased morbidity. These consequences
ultimately lead to decreased patient satisfaction. For
anesthesia providers and facilities, these complications
present an increased cost of care, decreased patient
safety, an increased exposure to medical-legal proceed-
ings, a declining patient base as dissatisfied patients seek
care elsewhere, and ultimately reduced funding. Viewed
in these terms, the advantage of a protocol that includes
providing manometers, educating anesthesia providers
on the importance of monitoring cuff pressures, providing prominent reference cards of recommended cuff
pressures, and including a documentation variable in
the electronic anesthesia record becomes clear. Other
facilities could observe a significant improvement in cuff
pressures by providing manometers and implementing a
protocol similar to the one used in this project.
The next steps in this project will be to develop an
automated report that can retrieve cuff pressure data
from the electronic anesthesia records and provide quarterly reports to providers on their rate of monitoring cuff
pressures. Future research could explore sustainment
techniques including the optimal frequency of these interventions, the effectiveness of regular feedback to providers on their monitoring performance, and the effect of
providing patient satisfaction or other outcomes data on
provider behavior and performance related to the monitoring of intracuff pressures.
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AUTHORS
CDR Randy E. Ashman, MSN, DNP, CRNA, NC, USN, is an active-duty
CRNA in the United States Navy. He currently serves as a nurse anesthetist at
the Naval Medical Center, San Diego, California. Email: [email protected].
Susan J. Appel, PhD, APRN-BC, CCRN, FAHA, is a professor in the
Capstone College of Nursing, The University of Alabama, Tuscaloosa,
Alabama. Email: [email protected].
CDR Arnel J. Barba, MS, DNP, CRNA, NC, USN, is an active-duty
CRNA in the United States Navy. Currently, he serves as an assistant
professor in the Daniel K. Inouye Graduate School of Nursing, Uniformed
Services University of the Health Sciences, Nurse Anesthesia Program,
United States Navy, San Diego, California. Email: [email protected].
DISCLOSURES
The authors declare they have no financial relationships with any commercial entity related to the content of this article. The authors did not
discuss off-label use within the article.
MILITARY DISCLAIMER
The views expressed here are the authors and do not necessarily reflect
the official policy of the Department of the Navy, Department of Defense,
or the U.S. Government.
ACKNOWLEDGMENTS
The authors gratefully acknowledge the support of the Anesthesia Department at the Naval Medical Center San Diego in San Diego, California, and
the Capstone College of Nursing at The University of Alabama, Tuscaloosa, Alabama, for their assistance in making this project possible.
Author’s Correction
In “Laryngeal Mask Airway and Valsalva Maneuver During Ophthalmic Surgery: A Case Report” in the
December 2016 AANA Journal (Vol. 84, No. 6, p. 423), under “Case Summary” the patient is described as
having “a left orbital socket defect requiring exoneration.” The word should be exenteration.
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