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Thoughts From A Clinician

What's pressure have to do with it?

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Critical care transport medicine is designed to take ICU-level care to the patient. Ever emerging technology continues to allow the critical care transport provider to escalate the care and competence delivered to our patients.  One of the least-discussed measurements for the critically ill or injured and intubated patient is the endotracheal tube (ETT) cuff pressure.  Respiratory therapy and many intensive care units measure this pressure, but it is not always done during a critical care transport.  So, what does pressure have to do with it?  Could we find ourselves, as clinicians, causing severe harm to patients if we over or under inflate an endo-tracheal tube cuff?  Surprisingly, the research is relatively abundant on this subject and there are several studies that demonstrate clear guidance regarding this topic.

A review of the literature reveals that endotracheal tube cuff pressure is worth noting, assessing and monitoring.  This includes the critical care transport environment.  One such study, published in the Journal of Intensive Care by Motoyama (2014) showed that cuff pressure varied significantly when measured in two-hour intervals.  It is important to note that this study was completed in the ICU and not in a transport setting.  It can be reasonably deduced that the transport environment would cause more significant pressure variabilities over a presumably shorter period of time.  Given that most critical care transports are not two hours, it may seem insignificant.  However, some patients are intubated and on mechanical ventilation for long periods of time prior to transport by a critical care transport crew.  This is a relatively easy parameter to assess and monitor in order to ensure that we are providing the best patient care possible.

Regarding ETT cuff pressures, many providers would likely say that it helps to ensure there is no airway tissue damage (from an over inflated ETT cuff).  As you might suspect, there are several other reasons to measure ETT cuff pressures.  Let’s revisit the study mentioned previously to learn about another important reason to monitor ETT cuff pressures.  That study demonstrated a significant drop in cases of ventilator acquired pneumonia (VAP) when continuous cuff pressure monitoring was performed.  Keeping the pressure just high enough within the cuff prohibits pathogens from invading and causing any of a host of respiratory diseases.  Another study, published in 2011, from the American Journal of Critical Care showed that the therapeutic range for ETT cuff pressure is 20-30 cmH20.  The study also noted a drop in ETT cuff pressure over time, without any intervention.  Remember, this study was done in an ICU with many providers regularly assessing the patients.  In what way can we relate this back to the transport setting to make it applicable to our own place of practice?  Perhaps looking at the purchase of digital monometers to measure cuff pressure.  Talk to your superiors and medical director to find out what their thoughts are on cuff pressure measurement.  We know that measuring pressure within the ETT cuff can be just another tool in the tool bag for us as providers to document and provide continuity of care.  As always be safe out there and remember to think like a clinician.


  1. Motoyama et al. Journal of Intensive Care 2014; 2:7
  2. American Journal of Critical Care. 2011 March; 20(2): 109–118. doi:10.4037/ajcc2011661.

Peer Review #1:

Thank you for inflating (pun intended!) the importance of endotracheal tube cuff pressure in critical care transport.  Several important take-home points can be extracted from this essay.  First, there is a danger in cuff pressures that are too low as well as too high.  Inappropriately low pressures may result in a higher risk of aspiration as well as cuff leak and inadequate ventilation.  High pressures will result in tissue ischemia and the potential for long-term complications related to endotracheal intubation.  Second, these issues can occur within the time frames relevant to critical care transport.  Certainly, aspiration and inadequate ventilation can have immediate impact on our patients.  Even overinflation can produce ischemia within minutes, particularly in a hemodynamically compromised patient.  Finally, our goal should be to deliver a patient with as many issues addressed as possible.  We often transport from environments where higher acuity is uncommon and less familiar, so anticipating the opportunity to correct some of the oft-forgotten details should be included in our approach to care.
Dr. Dan Davis, MD

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