The Brandt Tube System Attenuates the Cuff Deflationary Phenomenon After Anesthesia with Nitrous Oxide

Fujio Karasawa, MD, PhD, Akira Takita, MD, Tomohisa Mori, Yasushi Kawatani, MD, and Takashi Oshima, MD
MD,

Isao Takamatsu,

MD,

Department of Anesthesiology, National Defense Medical College, Tokorozawa, Japan

The Brandt tube system can limit excessive cuff pressure during nitrous oxide (N2O) anesthesia, but there is a lack of data assessing whether the Brandt tube system avoids cuff deflation after cessation of N2O administration. In this study, we recorded air-filled cuff pressures of the Mallinckrodt Brandt or Hi-Contour (control) tracheal tubes (Mallinckrodt, Athlone, Ireland) during 67% N2O anesthesia and the cuffs were aspirated if the cuff pressure exceeded 22 mm Hg; 180 min later, O2 was substituted for N2O. The cuff pressure of both groups significantly decreased after N2O anesthesia but the time required for the cuff pressure to return to the initial pressure was longer in the

Brandt group than in the control group (76.5 35.2 min and 36.5 18.1 min, respectively; P 0.03). The incidence of air leaks was more frequent in the control group than in the Brandt group (P 0.015); changes in intracuff N2O were small in the Brandt group (6.6 1.2% to 3.4 0.9%) compared with those in the control group (46.2 3.8% to 18.6 5.6%). Therefore, the Brandt tube system attenuates the cuff deflationary phenomenon after N2O anesthesia, whereas repeated cuff deflation during N2O anesthesia causes cuff deflation after cessation of N2O, resulting in a possible risk of air leaks. (Anesth Analg 2003;96:606 10)

itrous oxide (N2O) easily permeates polyvinyl chloride, which is used to make the cuff, and induces an increase in intracuff pressure during anesthesia (1,2). On the other hand, we reported a deflationary phenomenon of the cuff after cessation of N2O anesthesia (3). Cuff deflation may occur through N2O rediffusion from the cuff after cessation of N2O administration, resulting in an increased risk of air leaks, even though stable cuff pressure can be achieved during anesthesia with N2O. In case of gastric content regurgitation, aspiration might also occur. Among numerous techniques and devices to prevent excessive cuff pressure (4 11), the Brandt tube system (Mallinckrodt, Athlone, Ireland), which has a large pilot balloon, is a unique device. The Brandt tube system effectively limits the increase in cuff pressure during N2O anesthesia (12) and is thought to facilitate N2O efflux into the air (12,13). However, there is a lack of data assessing whether the Brandt tube system effectively limits changes in cuff pressure
ITs present address is Department of Anesthesia, National Central Hospital in West Saitama, Wakasa 16711, 3591151, Japan. Accepted for publication May 13, 2002. Address correspondence to Dr. F. Karasawa, Department of Anesthesiology, National Defense Medical College, 32 Namiki, Tokorozawa, Saitama 3598513, Japan. Address e-mail to karasawa@me.ndmc.ac.jp. DOI: 10.1213/01.ANE.0000023207.59823.E3

after N2O anesthesia. Therefore, a control study was designed to compare the Brandt tube system with a standard type tube.

Methods
Thirty-six patients (ASA physical status I or II) undergoing elective surgery were included in the study. After obtaining institutional approval and patients informed consent, patients were randomly allocated to two groups (n 18 for each): the trachea was intubated with the Hi-Contour tracheal tube (Mallinckrodt, control group) or the Hi-Contour Brandt tracheal tube (Brandt group) (Fig. 1). Tube size was 7.5 mm inner diameter for females and 8.0 mm inner diameter for males. The Hi-Contour tracheal tube was used for the control group because it is a standard tracheal tube and has the same type and volume of cuff as the Hi-Contour Brandt tube system. After breathing 100% oxygen, anesthesia was induced with propofol (23 mg/kg). Vecuronium (0.1 mg/kg) was then administered to relax the muscles. The trachea was intubated with tracheal tubes by skilled anesthesiologists. Lubricant was not used. Immediately after intubation, the cuff was aspirated as much as possible and then inflated with the smallest volume of air that would not leak when the intraairway pressure was 18 cm H2O. The volume used to
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Figure 1. A standard type (Mallinckrodt Hi-Contour [top]) and Hi-Contour Brandt tracheal tube (bottom). The latter has a larger pilot balloon than the former but both cuffs are the same in type and volume.

fill the cuff and the initial sealing pressure were recorded. The pilot balloon of the tracheal tube was connected to a pressure transducer through a threeway stopcock. Using a monitor (AS3; Datex, Helsinki, Finland), the mean intracuff pressure was measured every 5 or 10 min. If the mean intracuff pressure exceeded 22 mm Hg, gas in the cuff was aspirated to reduce the pressure to the initial value, and the aspirated volume from the cuff was recorded. Anesthesia was maintained with N2O (4 L/min) and O2 (2 L/min), supplemented with isoflurane or sevoflurane using a recirculating breathing system. The lungs were ventilated mechanically and the end-tidal CO2 was maintained within a physiologically normal range. The concentration of the inspired gas mixture was monitored by using a multigas monitor (Capnomac Ultima, Datex). The extent of paralysis was constant throughout the study periods. A humidifier was used, but the use of a nasogastric tube was avoided. The neuromuscular blockade was reversed with neostigmine and atropine after the completion of surgery. At 180 min from the start of anesthesia, patients in each group were randomly allocated to the following three subgroups (n 6 for each): O2 was substituted for N2O (subgroup Disc); anesthesia was not changed (subgroup Cont); the study was completed at 180 min (subgroup C180). The study was finished at 270 min from the start of anesthesia in the control group and at 360 min in the Brandt group. When air leaks were noticed by auscultation, the study was completed. At the end of the study, the cuff was aspirated as much as possible. Approximately 15 min after aspiration, the volume of the aspirated gases was measured at room temperature with a calibrated syringe both after the gases were compressed and after they were decompressed in the syringe, and the mean value was used

to avoid a possible error caused by friction between the barrel and a piston of the syringe. The N2O concentration was assayed by using a multigas monitor (Type 1302; Bruel & Kjaer, Naerum, Denmark). Using the least-squares method, a straight line was computed from the time versus the logarithm of percent pressure after cessation of N2O administration. The time required for the cuff pressure to return to the initial pressure was estimated. The time required for the cuff pressure to decrease by half (t1/2) was also estimated. A power analysis suggested that a sample size of six patients per group should be adequate to provide a power of 80% ( 0.05) for an 83% difference in air leaks (based on data of our preliminary study). Data were presented as the number of patients or mean sd. Two-way analysis of variance for repeated measurements was used to assess changes over time within, as well as between groups and one-way analysis of variance was performed to compare raw data between the groups. Post hoc analysis to allow for multiple comparisons was performed using a Bonferroni/Dunn correction. A t-test was used to make single comparisons of cuff pressure, volume, and N2O concentration. Proportional data were evaluated by using the Fishers exact probability test. A P value 0.05 was considered to be statistically significant.

Results
The patients were comparable between groups as well as among subgroups in age, sex, weight, and height (Table 1). In the control group, the cuff pressure of each subgroup significantly increased (P 0.01 for each group; Fig. 2); cuff pressure exceeded 22 mm Hg in all cases, the average number of deflations was 4, and the average total deflation volume was 2.0 mL within 180 min. There was no significant difference in cuff pressure among the subgroups within 180 min (P 0.495). Although the cuff pressures in subgroup Cont did not change significantly between 180 and 245 min, those in subgroup Disc significantly decreased after cessation of N2O administration. The air-filled cuff pressure of the Brandt system increased time-dependently for 180 min (P 0.05 for subgroups Disc and Cont; Fig. 3). Although the cuff pressures in subgroup Cont did not significantly change between 180 min and 360 min, those in subgroup Disc significantly decreased after cessation of N2O administration. There was no patient in the Brandt group whose cuff pressure exceeded 22 mm Hg or had air leaks (Table 2).

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Table 1. Demographic Comparison Control Age (yr) Subgroup Subgroup Subgroup Sex (M/F) Subgroup Subgroup Subgroup Weight (kg) Subgroup Subgroup Subgroup Height (cm) Subgroup Subgroup Subgroup Disc Cont C180 Disc Cont C180 Disc Cont C180 Disc Cont C180 56.0 17.5 57.3 9.4 61.5 10.1 2/4 3/3 2/4 56.8 10.3 56.2 7.1 57.3 8.3 154.0 7.5 165.5 9.6 156.7 6.3 Brandt 65.0 7.8 58.0 13.6 64.7 10.3 4/2 3/3 4/2 56.8 11.5 51.5 10.3 60.5 5.2 157.7 10.0 158.3 12.4 159.2 8.1

Data are expressed as mean sd or number of patients (n 6 for each). All values are comparable between groups and among subgroups.

Figure 3. Changes in cuff pressure in the Brandt group. In subgroup Disc (circles), 67% nitrous oxide (N2O) was replaced with O2 180 min after the start of anesthesia; in subgroup Cont (closed diamonds), the administration of N2O was continued for 360 min (n 6 for each). There was no patient whose cuff pressure exceeded 22 mm Hg in either subgroup. *P 0.05 versus values at 180 min in subgroup Disc (by paired t-test). P 0.05 versus subgroup Cont (by unpaired t-test).

Figure 2. Changes in cuff pressure in the control group. In subgroup Disc (squares), 67% nitrous oxide (N2O) was replaced with O2 180 min after the start of anesthesia; in subgroup Cont (closed triangles), the administration of N2O was continued for 270 min. When cuff pressure exceeded 22 mm Hg, gases in the cuff were aspirated to decrease cuff pressure to the initial value. n 6 for each except for data at 240 and 245 min in subgroup Disc of the control, in which n 4 because data from two patients were discarded owing to air leaks. *P 0.05 versus values at 180 min in subgroup Disc (by paired t-test). P 0.05 versus subgroup Cont (by unpaired t-test).

After cessation of N2O administration, the cuff pressure in subgroup Disc of the control group decreased more quickly than in subgroup Disc of the Brandt group (Fig. 4) and air leaks were noticed in five of six patients in the control group, which was significantly larger compared with the Brandt group (Table 2). The time required for the cuff pressure to return to the initial pressure was 76.5 35.2 min in the Brandt group, which was significantly longer than in the control group (36.5 18.1 min, P 0.03). t1/2 was 45.2

Figure 4. Changes in cuff pressures in subgroups Disc of the Brandt (open triangles) and control (open circles) groups after cessation of 67% nitrous oxide administration. n 6 for each except for data at 240 and 245 min in subgroup Disc of the control, in which n 4 because data from two patients were discarded owing to air leaks. There were five patients who had air leaks in subgroup Disc of the control group, which was significantly larger than in subgroup Disc of the Brandt group (no patient, P 0.05). There was no significant difference in cuff pressure at 180 min between the subgroups, but thereafter there was a significant difference between the subgroups. P 0.05 versus subgroup Disc of the control group (by unpaired t-test).

18.6 min in the control group but was not determined in the Brandt group because cuff pressure did not decrease to half of the initial pressure in any patients.

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Table 2. Intracuff Volume, N2O Concentration, and Number of Patients with Air Leaks Control Volume (mL) Inflated Subgroup Disc Subgroup Cont Aspirated Subgroup Disc Subgroup Cont Changes Subgroup Disc Subgroup Cont N2O concentration (%) Subgroup Disc Subgroup Cont Air leaks Subgroup Disc Subgroup Cont Brandt

4.5 1.2 4.8 1.6 4.0 1.6 5.0 1.1 0.4 1.1 0.2 1.0 18.9 5.6 46.2 3.8 5 0

34.4 1.3 34.6 1.4 34.5 1.8 36.4 2.1 0.1 1.3* 1.8 1.0 3.4 0.9 6.6 1.2 0 0

Data are expressed as mean sd or number of patients (n 6 for each). * or P 0.05 or 0.001, respectively, versus subgroup Cont of the corresponding group; P 0.05 versus the control group.

Intracuff N2O concentrations at 180 min (subgroups C180) were 43.2 4.3% and 6.2 0.6% in the control and Brandt groups, respectively; the N2O concentration in each group did not change significantly during the subsequent time of anesthesia with N2O (subgroup Cont) but decreased significantly after cessation of N2O (subgroup Disc; Table 2).

Discussion
In the present study, we assessed the stability of intracuff pressure of the Brandt tracheal tube after cessation of N2O administration. Although the cuff pressure decreased after cessation of N2O, the decrease occurred slowly. However, the cuff pressure in the control group (the Hi-Contour tracheal tube) decreased quickly after cessation of N2O, and the time required for cuff pressure to decrease to the initial value was shorter in the control group than in the Brandt group. Furthermore, the time required for cuff pressure of a standard tracheal tube (control) to decrease by half (t1/2) was 45.2 18.6 minutes, which is similar to that for other standard tracheal tube cuffs (6). In the Brandt group, however, t1/2 could not be assessed because the cuff pressure did not decrease to half. Therefore, deflation of the cuff of the Brandt group is considered to occur over a much longer period of time than that of other tracheal tubes including the N2O gas-barrier type cuff (Portex Soft-Seal Cuff; Sims Portex, Kent, UK), which has a longer t1/2 than standard tracheal tubes (3). In general, the tracheal cuff pressure should be maintained below the mean mucosal capillary perfusion pressure of 22 mm Hg to avoid ischemic mucosal

damage (14). Otherwise, sore throat is common (35 60%) in surgical patients after anesthesia with tracheal intubation (2,9,1521). Despite a satisfactory sealing pressure during anesthesia using expensive devices or other useful methods (2,4 11), however, N2O diffuses out of the cuff after anesthesia (3). Therefore, intracuff pressure decreases in the operating room after anesthesia or during transport to the intensive care unit in patients with intubated ventilation, resulting in a high risk of air leaks and aspiration of gastric contents. The cuff pressure of the Brandt tracheal tube did decrease after cessation of N2O, returning to the initial value in 76.5 35.2 min. There was, however, no patient whose cuff pressure decreased by half and no air leak was observed during 180 min after cessation of N2O administration. Furthermore, the cuff pressure of the Brandt group did not exceed 22 mm Hg during 6 hours of N2O anesthesia. The Brandt system is, therefore, reliable both during and after N2O anesthesia. In this study, we measured N2O in the cuff/ balloon to investigate the underlying mechanism of the Brandt system. There are few reports in which the gas concentration in the cuff/balloon of the Brandt tube system has been assessed. Compared with the N2O concentrations in the control group (46.2 3.8%), those in the Brandt group (6.6 1.2%) were very small despite long-duration N2O anesthesia, indicating that the rediffusion mechanism contributes to a smaller increase in cuff pressure. However, the small decrease in N2O concentrations in the cuff/balloon of the Brandt group might be why the cuff deflation level was so small after cessation of N2O. Furthermore, cuff pressure in the Brandt group did not decrease to half of the initial pressure in any patients because aspirating cuffs were not necessary to avoid excessive pressure in the Brandt group. The Brandt system, therefore, preserves stable cuff pressure because of a small change in the N2O concentration in the cuff/balloon both during and after N2O anesthesia. In conclusion, we have demonstrated that the Brandt tube system can effectively limit the deflationary phenomenon of the cuff after N2O anesthesia, whereas repeated deflation of standard tube cuffs during N2O anesthesia may cause cuff deflation after cessation of N2O, resulting in an increased risk of air leaks. We therefore recommend the use of the Brandt tube system in cases of prolonged emergence from anesthesia or during transportation of intubated patients after N2O anesthesia.

References
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