Under Pressure: An Evidence-Based Practice Improvement Approach to Reducing Injuries Related to Endotracheal Tube Cuff Pressures

BACKGROUND: Approximately 15 million endotracheal tube (ETT) intubations are performed in operating rooms (ORs) nationwide every year. Based on available evidence, anesthesia providers should use a manometer to measure ETT cuff pressures and adjust them to 20-30 cm H2O. Higher ETT cuff pressures have been linked to endotracheal injury, which often manifests as postoperative sore throat (POST).

LOCAL PROBLEM: The project site is an academic medical center in the Southeast region of the U.S. The facility does not assess ETT cuff pressures in patients undergoing general anesthesia. This project aims to increase the number of ETT cuffs filled to 20-30 cm H2O, measured with a manometer and documented on the anesthesia record, to 25% within three months.

METHODS: The Evidence-Based Practice Improvement Model guided the implementation of a manometer in specific ORs. Compliance with ETT cuff pressure measurement served as the process measure, while the outcome measures encompassed ETT cuff pressures and the incidence of POST. Additionally, cost and time were evaluated as balancing measures.

INTERVENTIONS: Manometry was initiated in designated operating rooms to maintain ETT cuff pressures between 20-30 cm H2O and reduce POST. Compliance was evaluated continuously, and Plan-Do-Study-Act (PDSA) cycles were performed as needed.

RESULTS: Data analysis of 476 intubations revealed a mean compliance of 41.4% for ETT cuff pressures at 20-30 cm H2O utilizing manometry, exceeding the project aim of 25%. Post-implementation, median ETT cuff pressures decreased from 32 to 28 cm H2O, with a 46.7% pressure increase within the recommended range. Additionally, 85.7% of POST incidents occurred with ETT cuff pressures outside the target range.

CONCLUSIONS: The project supports using a manometer to increase the number of appropriately filled ETT cuffs. Using a manometer is cost-effective and results in no delay in anesthesia readiness. Further projects could encompass additional procedures, patient characteristics, and other factors.