ENDOTRACHEAL TUBE

Tracheal intubation is the gold standard for airway management. ETT insertion provides maximal
protection against the aspiration of gastric contents, and allows for PPV with higher airway pressures
than with a face mask or an SGA. The modern, standard ETT is a disposable, single-use, cuffed,
plastic tube that is designed to be inserted through the nose or mouth and sit with its distal end in
the mid-trachea, providing a patent airway to allow for ventilation of the lungs. A variety of different
types of ETTs are available for use in specialized situations. Several features are commonplace
among the different styles, however, including a universal 15-mm adapter that allows the
attachment of the proximal end to different ventilating circuits and devices; a high-volume, low-
pressure cuff; a beveled tip to facilitate passage through the vocal cords; and an additional distal
opening in the side wall of the ETT known as a Murphy eye, which serves to provide an additional
portal for ventilation should the distal end of the lumen become obstructed by either soft tissue or
secretions.

Cuffed ETTs are routinely used for tracheal intubation in most patients; cuffless ETTs are used in
neonates and infants. The high-volume, low-pressure cuff is inflated with air to provide a seal against
the tracheal wall to protect the lungs from pulmonary aspiration and to ensure that the tidal volume
delivered ventilates the lungs rather than escapes into the upper airway.22 A pilot balloon with a
oneway valve allows for the inflation of the cuff and an assessment of the cuff pressure. The cuff
should be inflated to the minimum volume at which no air leak is present with positive pressure
inspiration; the cuff pressure should be less than 25 cm H2O.193 Excessive cuff pressure may result
in tracheal mucosal injury, vocal cord dysfunction from recurrent laryngeal nerve palsy, and sore
throat. Monitoring the cuff pressure with a pressure gauge is recommended. When N2O is used as
part of the anesthetic, cuff pressure should be Periodically measured throughout the surgery; N2O
diffusion into the cuff can result in increases in cuff pressure to potentially dangerous levels.

ETT size is normally described in terms of its internal diameter (ID); the relationship of the ID to the
external diameter varies between different designs and manufacturers. Selection of the ETT size
depends on the reason for placement and patient-specific factors such as gender and airway
pathologic conditions. Smaller ETTs result in increased airway resistance and work of breathing, and
ETTs with a smaller ID may preclude therapeutic fiberoptic bronchoscopy. Larger ETTs are more
likely to be associated with laryngeal or tracheal mucosal trauma and have a higher incidence of sore
throat after general anesthesia. Generally, in patients intubated only for the purposes of a general
anesthetic, a smaller ETT may be used than on the patient who will remain intubated in the medium
to long term as a result of respiratory failure; typically a 7-mm ETT is used for women and a 7.5- or 8-
mm ETT is used for men.

CUFFED SYSTEM IN ETT (SJA)

A critical function of the endotracheal tube (ETT) cuff is to seal the airway thus preventing leaks and
aspiration of pharyngeal contents into the trachea during ventilation. An ETT with a cuff is generally
used for mechanically ventilated patients to prevent gas leakage and pulmonary aspiration. The ETT
cuff pressure must be in a range that ensures delivery of the prescribed mechanical ventilation tidal
volume, reduces the risk for aspiration of secretions that accumulate above the cuff without
compromising the tracheal perfusion. (SJA)

The pressure exerted on the tracheal wall is one of the primary determinants of tracheal injury.[8]
The intra-cuff pressure in intubated patients should be high enough to prevent macroscopic
aspiration and an air leak to ensure adequate ventilation. The cuff pressure should be adequate
enough not to impair the mucosal blood flow.[9] It has been shown that continuous lateral wall cuff
pressure above 30 cm H2O compromises blood flow, and cuff pressure above 50 cm H2O completely
obstruct the tracheal wall blood flow.[3] It has been shown that compromised blood flow for 15 min
resulted in superficial damage to the tracheal mucosa.[10] It is reported that high ETT cuff pressure
lasted more than 15 min resulted in obstructed mucosal blood flow, the columnar epithelium was
destroyed, and basement membrane was exposed.[8,9,10] (SJA)

Some authors consider the maximum pressure of the inflation of the cuff as 25 cmH2O (18.40
mmHg) so that the capillary perfusion can be adequate[5,23]. If pressures greater than 25-30 mmHg
are maintained for a certain time, damage can be caused. If a continuous pressure equal to or higher
than 67.5 cmH2O (50 mmHg) is applied against the trachea during 15 minutes, the epithelium,
tracheal membrane and cartilage can be destroyed. Thus, there must be a strict and frequent control
of this pressure by the constant and continued measurement through a manometer. (del negro)

Damage to the trachea during intubation is inevitable as a result of the contact between the ETT and
the trachea.[8] Digital balloon palpation corresponds poorly with the measured endotracheal cuff
pressure, and anesthetist experience corresponds poorly with measured cuff pressures.[8,10,11,12]
The instrumental measurement and adjustment of cuff pressure resulted in a significantly lower
incidence of postprocedural sore throat, hoarseness, and blood-stained expectorant.[12] The
pressure exerted on the tracheal wall depends on the compliance of the trachea and the pressure
measured at the pilot balloon of an ETT cuff. ETT cuff pressure can be considered as a good estimate
of the pressure exerted on the tracheal mucosa. (SJA)

The intracuff pressure does not remain constant during surgery and varies due to several factors
such as the patient’s body temperature, airway pressure, endotracheal intubation time, and
anesthesia with nitrous oxide [4–8]. Moreover, the head-down position and pneumoperitoneum
caused by carbon dioxide insufflation can lead to increased airway and intracuff pressures [9,10]. A
manual cuff pressure manometer can be used to set the initial intracuff pressure and adjusted
relative to subsequent changes in the intracuff pressure. However, this method risks a pressure drop
at each measurement, potentially resulting in cuff underinflation [11]. Therefore, continuous cuff
pressure regulation is preferable to intermittently measuring intracuff pressure using a manual
manometer [12]. (SJM)

In head and neck surgery, the patient’s head and neck are positioned to facilitate the operation by
exposing the surgical field. Moreover, intraoperative head and neck position changes are required in
cases of surgery of several areas. The head and neck position can alter orotracheal tube intracuff
pressure [13–15] since the airway’s length and dimension changes with neck flexion, extension, and
rotation. This can cause tube displacement and cuff compression or release [16–18]. Thus, it is
necessary to adjust the intracuff pressure after tracheal intubation and repositioning.

TECHNIQUE OF MEASURING INTRACUFF PRESSURE (pengukuran…)

1) Manual palpation of pilot balloon

The pilot balloon of ETT is checked by palpation for approximate pressure, but this technique has
been found to be inadequate. This method determines approximate pressure inside the cuf [9] and
known to produce over-infation of the cuf in 30–98% of the cases [59], depending on the type of ETT
used and the population studied [14, 60, 61]. The rapid, qualitative evaluation of the pilot balloon via
manual palpation can serve as a surrogate estimation of intracuff pressure, but this method is
subject to inherent inaccuracies and does not provide any quantitative data. Saraçoğlu et al. [62]
demonstrated that there was no signifcant correlation between the experience of the anaesthesia
provider and the appropriateness of the ETT intracuf pressure when subjects were instructed to
manually infate the cuf to what they deemed as an appropriate amount. Harm et al. [63] showed
that not only do anaesthesia providers frequently misjudge pressures but persons responsible for
prehospital intubations do as well.

2) Minimum leak technique

It is the determination of volume of air to inject into the cuff based on how much is required to
detect a small end-inspiratory leak by auscultating the front of the chest [46]. The cuff is inflated
either until just a minimal leak occurs at peak inspiration or with slightly more volume to fully
occlude the airway and prevent a leak during positive pressure ventilation. Similar to the palpation
technique, this method is also prone to errors but might have better acceptability amongst
practicing clinicians [46, 64]. Bulamba et al. [65] recommended using a loss of resistance syringe as a
viable option to simple palpation method. A 7 ml plastic, luer slip, loss of resistance syringe
containing air into the pilot balloon and the loss of resistance syringe plunger could passively draw
back until it ceased.

3) Minimum occlusive volume

This is the volume of air required to inject into the cuff to eliminate audible end-inspiratory leak with
positive pressure ventilation but does not guarantee a safe maximum pressure. Minimum leak
technique and minimum occlusive volume appear to have similar principles [46, 64].

4) Predetermined volume technique

This involves injection of pre-determined volume of air to inflate the cuff, but this varies depending
on manufacturers. The injection of air with a syringe of a predetermined volume into the cuff is the
most widely used in clinical practice. This is simple, fast and cost-effective; however, the relationship
between the volume injected, pressure attained in cuff and lateral pressure exerted on the tracheal
wall are not linear. Blanch [66] opined that significant differences in intracuff pressure readings
occur when different methods of inflation are used.
5) Analogue/digital manometer

This is most accurate method and the pressure can be measured by connecting the pilot balloon to a
simple calibrated analogue or digital manometer [10, 14, 22, 66, 67].

6) Direct intracuff pressure monitoring

A pressure transducer or a similar automated system is attached directly to the pilot balloon which
provides a quantitative pressure reading of the cuff. The manometer provides greater accuracy as a
detection tool [68]. Pressure measuring systems are either an integral part of the ETT or can be
attached separately. This is subject to cost implications and logistical considerations. Flores-Fraco
[69] described a novel simple technique for measuring cuff pressure that can be performed with
readily available materials by using a 1 mL syringe interposed between a blood pressure manometer
and the pilot balloon of the endotracheal tube.

HEAD-NECK POSITION AND INTRACUFF PRESSURE

Head and neck positioning affects the nasotracheal tube intracuff pressure. The mechanism of this
change in intracuff pressure by head and neck positioning has been suggested as tube migration and
deformation of the shapes of adjacent anatomic structures [15,22]. The airway length changes as the
head or neck posture changes and the tube is pulled outward or inward along the trachea [19].

Kim et al. observed orotracheal tube tip withdrawal from the carina with head rotation [13]. They
found the intracuff pressure of the endotracheal tube increased more with head rotation toward the
same side of tube fixation than with head rotation to the opposite side. Jordi Ritz et al. showed that
neck flexion moved the tube toward the carina and neck extension moved the tube away from the
carina [18]. In addition, Kako et al. explained the cuff pressure changes as follows Neck flexion
displaces the trachea posteriorly, causing cuff compression by the esophagus and cervical spine,
while neck extension moves the trachea anteriorly, causing cuff pressure release [17]. Therefore, we
suggest that nasotracheal tube movements along the airway and the change in the force exerted on
the cuff by surrounding structures are the reasons for intracuff pressure changes in different head
and neck positions.

However, there is no guarantee that the intracuff pressure will fall within the safe range in all
patients when their postures changes. Thus, it is necessary to adjust the intracuff pressure after
tracheal intubation and repositioning.