Cuff Leak Test
OVERVIEW
- The cuff leak test is used to predict risk of post-extubation stridor in intubated patients
- Use and interpretation of the test needs to take into account the overall context of the patient’s condition and the management implications
- does not exclude obstruction due to supraglottic structures being splinted apart while the ETT is in situ
PROCEDURE
- Suction endotracheal and oral secretions and set the ventilator in the assist control mode with the patient receiving volume-cycled ventilation
- With the cuff inflated, record displayed inspiratory and expiratory tidal volumes to see whether these are similar
- Deflate the cuff
- Directly record the expiratory tidal volume over the next six breathing cycles as the expiratory tidal volume will reach a plateau value after a few cycles
- Average the three lowest values
- The difference between the inspiratory tidal volume (measured before the cuff was deflated) and the averaged expiratory tidal volume (after cuff deflation) is the cuff leak volume
UTILITY
- suggested approach is to use 110 mL or 10% of tidal volume as the cut-off
- >110 mL difference in expiratory tidal volumes before and after cuff down has NPV 98% for post-extubation stridor in the original study by Miller and Cole (essentially rules it out)
- different cut-offs and performance characteristics in different studies (see Ochoa et al, 2009)
- tracheal extubation can still be successful in many patients with a positive test (low value)
- a low value for cuff leak can also be caused by encrusted secretions around the tube rather than by a narrowed upper airway
References and Links
CCC Airway Series
Emergencies: Can’t Intubate, Can’t Intubate, Can’t Oxygenate (CICO), Laryngospasm, Surgical Cricothyroidotomy
Conditions: Airway Obstruction, Airway in C-Spine Injury, Airway mgmt in major trauma, Airway in Maxillofacial Trauma, Airway in Neck Trauma, Angioedema, Coroner’s Clot, Intubation of the GI Bleeder, Intubation in GIH, Intubation, hypotension and shock, Peri-intubation life threats, Stridor, Post-Extubation Stridor, Tracheo-esophageal fistula, Trismus and Restricted Mouth Opening
Pre-Intubation: Airway Assessment, Apnoeic Oxygenation, Pre-oxygenation
Paediatric: Paediatric Airway, Paeds Anaesthetic Equipment, Upper airway obstruction in a child
Airway adjuncts: Intubating LMA, Laryngeal Mask Airway (LMA)
Intubation Aids: Bougie, Stylet, Airway Exchange Catheter
Intubation Pharmacology: Paralytics for intubation of the critically ill, Pre-treatment for RSI
Laryngoscopy: Bimanual laryngoscopy, Direct Laryngoscopy, Suction Assisted Laryngoscopy Airway Decontamination (SALAD), Three Axis Alignment vs Two Curve Theory, Video Laryngoscopy, Video Laryngoscopy vs. Direct
Intubation: Adverse effects of endotracheal intubation, Awake Intubation, Blind Digital Intubation, Cricoid Pressure, Delayed sequence intubation (DSI), Nasal intubation, Pre-hospital RSI, Rapid Sequence Intubation (RSI), RSI and PALM
Post-intubation: ETT Cuff Leak, Hypoxia, Post-intubation Care, Unplanned Extubation
Tracheostomy: Anatomy, Assessment of swallow, Bleeding trache, Complications, Insertion, Insertion timing, Literature summary, Perc. Trache, Perc. vs surgical trache, Respiratory distress in a trache patient, Trache Adv. and Disadv., Trache summary
Misc: Airway literature summaries, Bronchoscopic Anatomy, Cuff Leak Test, Difficult airway algorithms, Phases of Swallowing
CCC Ventilation Series
Modes: Adaptive Support Ventilation (ASV), Airway Pressure Release Ventilation (APRV), High Frequency Oscillation Ventilation (HFOV), High Frequency Ventilation (HFV), Modes of ventilation, Non-Invasive Ventilation (NIV), Spontaneous breathing and mechanical ventilation
Conditions: Acute Respiratory Distress Syndrome (ARDS), ARDS Definitions, ARDS Literature Summaries, Asthma, Bronchopleural Fistula, Burns, Oxygenation and Ventilation, COPD, Haemoptysis, Improving Oxygenation in ARDS, NIV and Asthma, NIV and the Critically Ill, Ventilator Induced Lung Injury (VILI), Volutrauma
Strategies: ARDSnet Ventilation, Open lung approach, Oxygen Saturation Targets, Protective Lung Ventilation, Recruitment manoeuvres in ARDS, Sedation pauses, Selective Lung Ventilation
Adjuncts: Adjunctive Respiratory Therapies, ECMO Overview, Heliox, Neuromuscular blockade in ARDS, Prone positioning and Mechanical Ventilation
Situations: Cuff leak, Difficulty weaning, High Airway Pressures, Post-Intubation Care, Post-intubation hypoxia
Troubleshooting: Autotriggering of the ventilator, High airway and alveolar pressures / pressure alarm, Ventilator Dyssynchrony
Investigation / Indices: A-a gradient, Capnography and waveforms, Electrical Impedance Tomography, Indices that predict difficult weaning, PaO2/FiO2 Ratio (PF), Transpulmonary pressure (TPP)
Extubation: Cuff Leak Test, Extubation Assessment in ED, Extubation Assessment in ICU, NIV for weaning, Post-Extubation Stridor, Spontaneous breathing trial, Unplanned extubation, Weaning from mechanical ventilation
Core Knowledge: Basics of Mechanical Ventilation, Driving Pressure, Dynamic pressure-volume loops, flow versus time graph, flow volume loops, Indications and complications, Intrinsic PEEP (autoPEEP), Oxygen Haemoglobin Dissociation Curve, Positive End Expiratory Pressure (PEEP), Pulmonary Mechanics, Pressure Vs Time Graph, Pressure vs Volume Loop, Setting up a ventilator, Ventilator waveform analysis, Volume vs time graph
Equipment: Capnography and CO2 Detector, Heat and Moisture Exchanger (HME), Ideal helicopter ventilator, Wet Circuit
MISC: Sedation in ICU, Ventilation literature summaries
Journal articles and textbooks
- De Backer D. The cuff-leak test: what are we measuring? Crit Care. 2005 Feb;9(1):31-3. Epub 2004 Dec 17. PubMed PMID: 15693980; PubMed Central PMCID: PMC1065116.
- Miller RL, Cole RP. Association between reduced cuff leak volume and postextubation stridor. Chest. 1996 Oct;110(4):1035-40. PubMed PMID: 8874265.
- Ochoa ME, Marín Mdel C, Frutos-Vivar F, Gordo F, Latour-Pérez J, Calvo E, Esteban A. Cuff-leak test for the diagnosis of upper airway obstruction in adults: a systematic review and meta-analysis. Intensive Care Med. 2009 Jul;35(7):1171-9. doi: 10.1007/s00134-009-1501-9. Epub 2009 Apr 28. Review. PubMed PMID: 19399474.
- Prinianakis G, Alexopoulou C, Mamidakis E, Kondili E, Georgopoulos D. Determinants of the cuff-leak test: a physiological study. Crit Care. 2005 Feb;9(1):R24-31. Epub 2004 Nov 29. PubMed PMID: 15693963; PubMed Central PMCID: PMC1065107.
- Wittekamp BH, van Mook WN, Tjan DH, Zwaveling JH, Bergmans DC. Clinical review: post-extubation laryngeal edema and extubation failure in critically ill adult patients. Crit Care. 2009;13(6):233. Epub 2009 Dec 1. Review. PubMed PMID: 20017891; PubMed Central PMCID: PMC2811912.
Critical Care
Compendium
