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

litfl.com

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.

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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