Will the Taper Shaped Cuff Replace the Conventional High Volume-Low Pressured Cuff on Endotracheal Tube?

Sung Jin Hong

doi:10.4266/kjccm.2014.29.1.1

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Editorial Will the Taper Shaped Cuff Replace the Conventional High Volume-Low Pressured Cuff on Endotracheal Tube?: Sung Jin Hong, M.D. Ph.D.; The Korean Journal of Critical Care Medicine 2014;29(1):1-2.
DOI: https://doi.org/10.4266/kjccm.2014.29.1.1
Published online: February 28, 2014

Department of Anesthesia and Pain Medicine, Yeouido St. Mary’s Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea

Correspondence to: Sung Jin Hong, Department of Anesthesia and Pain Medicine, Yeouido St. Mary’s Hospital, The Catholic University of Korea College of Medicine, 10 63-ro, Yeongdeungpo-gu, Seoul 150-713, Korea, Tel: +82-2-3379-1322, Fax: +82-2-783-0368, E-mail: hongs@catholic.ac.kr

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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An effective tracheal seal plays an essential role in precluding aspiration and boosting efficiency with mechanical ventilation when endotracheal tube is inflated. High cuff pressure can cause damage to the tracheal wall and lead to serious complications such as tracheal stenosis. Endotracheal tube (ET) cuff pressures greater than 30 cmH₂O may impede capillary blood flow in the tracheal wall, and ET cuff pressures greater than 50 cmH₂O is considered high enough to completely block capillary blood flow.[1] Low volume high pressure cuff was used in early ETs but replaced by high volume low pressure (HVLP) cuff because the former causes mucosal injury along the lateral tracheal wall. HVLP cuffs appeared ideal because they are capable of producing a seal with low pressure.

However, HVLP’s large cuff diameter has emerged as a key issue as it is 1.5 to 2 times larger than the adult trachea. Longitudinal or oblique folds are developed upon inflation within the larger sized HVLP cuffs. The seal then becomes incomplete and allows secretions and air to leak as a result. Pulmonary aspiration of microorganism mass found in the oral cavity is considered one of leading causes of ventilator-associated pneumonia. In addition, over inflation of HVLP cuff can markedly increase cuff pressure, particularly around the folds and result in injury to the tracheal mucosa.[2] Low volume cuff tubes has recently drawn attention again while many researchers explored benefits of modified low volume low pressure (LVLP) cuff tubes.

A taper-shaped cuff is designed to fit into the trachea at its narrow end and provides smaller cuff volume. This tapered cuff design is more effective in minimizing longitudinal folds when inflated, improving tracheal seal and preventing leakage of secretions and air even under high airway pressures, compared with conventional HVLP cuffs.[2,3] The transition from HVLP cuffs to taper-shaped cuffs is currently underway in endotracheal tubes. That is, the trend is moving back to low volume cuff tracheal tubes, which exert low pressure, in favor of better outcomes. Then we can have a question: Are tapered cuffs safe from pressure injury that is the most critical complication of low volume high pressure cuffs?

While transmission of intracuff pressure to the tracheal wall depends on the cuff material, taper-shaped cuffs can transmit all the intracuff pressure to the tracheal wall.[4] In endoracheal position, the intracuff pressure of LVLP cuffs can be significantly increased by a slight change in inflating volume. In addition, the tapered cuff design provides smaller area of contact with the tracheal wall, compared to cylindrical shaped HVLP cuffs,[2] meaning that the extent of transmitted pressure is higher on the tracheal wall. It is therefore important to examine pressure changes with volume in tracheal tube cuff inflated. Special attention to pressure changes is also crucial in the tracheal tube cuff exposed to nitrous oxide for anesthesia because cuff pressure can significantly increase with increasing volume.[5]

In case the taper-shaped cuff is not inflated adequately and develops an asymmetrical shape, can it cause the tube to move to an oblique position within the trachea? Is there no risk of obstruction of respiration gas flow as a result? Given that the shape of the trachea can vary among patients, there is a possibility that taper-shaped cuffs can be asymmetrically inflated.

Ventilator-associated pneumonia prevention is described as the most important advantage of taper-shaped cuffed tubes. However, clinical outcomes show that their contribution to preventing ventilator-associated pneumonia is similar to that of HVLP tubes.[6] Further studies are needed to verify clinical effects of taper-shaped cuffed tube placement combined with oral hygiene measures on ventilator-associated pneumonia prevention. It should be also noted that a successful tracheal sealing also may prompt cuff pressure and tracheal wall pressure to increase in proportion to airway pressure. The intracuff pressure should be monitored when airway pressure remains high.

Previous studies suggested effective tracheal sealing, efficient ventilation and prevention of aspiration as benefits of taper-shaped cuffs by explaining that tapered shaped cuffs provides lower intracuff pressure without longitudinal folds, compared to HLVP cuffs.[4] Most studies were conducted with model lungs and the studies involved human lungs are very rare. Further clinical experiences are therefore required to define certain clinical features as advantages of taper-shaped cuffed tubes.

References

1). Seegobin RD, van Hasselt GL. Endotracheal cuff pressure and tracheal mucosal blood flow: endoscopic study of effects of four large volume cuffs. Br Med J (Clin Res Ed) 1984;288:965-8.Article PubMed PMC
2). Li Bassi G, Ranzani OT, Marti JD, Giunta V, Luque N, Isetta V, et al. An in vitro study to assess determinant features associated with fluid sealing in the design of endotracheal tube cuffs and exerted tracheal pressures. Crit Care Med 2013;41:518-26.Article PubMed
3). Zanella A, Scaravilli V, Isgro S, Milan M, Cressoni M, Patroniti N, et al. Fluid leakage across tracheal tube cuff, effect of different cuff material, shape, and positive expiratory pressure: a bench-top study. Intensive Care Med 2011;37:343-7.Article PubMed
4). Doyle A, Santhirapala R, Crowe M, Blunt M, Young P. The pressure exerted on the tracheal wall by two endotracheal tube cuffs: A prospective observational bench-top, clinical and radiological study. BMC Anesthesiology 2010;10:21. Article PubMed PMC PDF
5). Tsuboi S, Miyashita T, Yamaguchi Y, Yamamoto Y, Sakamaki K, Goto T. The TaperGuard™ endotracheal tube intracuff pressure increase is less than that of the Hi-Lo™ tube during nitrous oxide exposure: a model trachea study. Anesth Analg 2013;116:609-12.Article PubMed
6). Bowton DL, Hite RD, Martin RS, Sherertz R. The impact of hospital-wide use of a tapered-cuff endotracheal tube on the incidence of ventilator-associated pneumonia. Respir Care 2013;58:1582-7.Article PubMed

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