Endotracheal tube cuff leak

Reviewed and revised 8 September 2014


  • endotracheal cuff leaks vary from trivial problems to life-threatening emergencies
  • detectable air leaks affect up to 11% of ICU patients


Structural defects in the endotracheal tube due to trauma (e.g. teeth, surgical instruments, lasers and local anaesthetic sprays) or manufacturing defects

  • inflation valve (e.g. incompetent)
  • pilot balloon (e.g. punctured)
  • inflation line (e.g. punctured or defect in intramural part)
  • cuff (e.g. torn or misshapen)

Leaks around an intact endotracheal tube

  • Cuff under-inflation
  • cephalad malposition of the ETT (partial tracheal extubation)
    • can be due to initial malposition, coughing, tongue movements, inadequate sedation, improper ETT fixation, secretions, frequent suctioning, head extension, accidental ETT pulling, and moving the patient)
  • misplaced orogastric or nasogastric tubes (passing alongside the cuff into the trachea)
  • marked discrepancy between ETT and tracheal diameters
  • excessive peak airway pressure resulting in leakage around an intact cuffs


  • loss of airway
  • aspiration
  • failure of oxygenation and ventilation


Assess for presence of cuff leak and underlying cause

  • Respiratory instability
    • oxygenation (colour, SpO2, PaO2)
    • ventilation (chest movement, ETCO2, PaCO2)
  • cuff leak
    • gurgling, decreased tidal volumes
    • assess cuff pressure and pilot balloon inflation
  • ETT position
    • distance at teeth
    • direct laryngoscopy (also check gastric tube entering the trachea)
    • CXR

Assess for urgency and difficulty of endotracheal tube replacement

  • expected duration of mechanical ventilation
  • history of a difficult airway
  • size of leak and effect on oxygenation and ventilation
  • aspiration risk
  • tolerance to interruption of ventilation
  • expected response to laryngoscopy and intubation
  • cervical spine precautions, movement restrictions and positioning (e.g. prone versus supine)


ETT replacement is the definitive treatment, but this is often not necessary or may be hazardous

  • correction of the underlying cause
    • adequately inflate cuff (aim for no-audible leak point at applied airway pressures of 20 cm H2O)
    • ensure ETT adequately positioned (e.g. deflate cuff, advance the reinflate cuff)
    • ensure gastric tubes are appropriately positioned
    • trouble-shoot excess peak airway pressures
    • conservative measures described for structural problems include:
      • incompetent inflation valve: 3-way stopcock used as a secondary valve to stop the leak
      • leaking pilot balloon: cutting the pilot balloon from the cuff tubing and inserting a 22-gauge IV catheter into the tubing with a stopcock valve attached to the catheter’s end
      • leaking cuff: continuous air insufflation through the inflation tubing has been describe to maintain an adequate pressure in the perforated cuff
  • if these fail or a structural problem is identified then ETT replacement is required (unless the patient is ready for extubation)
    • standard intubation by laryngoscopy if previous easy intubation and larynx is visualised
    • ETT exchange over a bronchoscope, bougie or exchange catheter allowing oxygenation during exchange
    • ensure appropriate expertise (e.g. airway specialist, ENT surgeon) and equipment (e.g. difficult airway trolley) are available for difficult airways

References and Links

Journal articles

  • El-Orbany M, Salem MR. Endotracheal tube cuff leaks: causes, consequences, and management. Anesth Analg. 2013 Aug;117(2):428-34. doi: 10.1213/ANE.0b013e318292ee21. PMID: 23744958. [Free Full Text]

CCC 700 6

Critical Care


Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a 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 three amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC


  1. Hi Chris, thanks for a great overview as usual. LITFL has been a staple of my ICU training which I’ve thankfully nearly completed!
    Under ‘assessment’ you mentioned checking the ETT distance at the teeth, which I agree, is standard practice in ICU. In my reading however, I came across an article by Patel and Mort (Cuff Leaks in the ICU: Etiologies, Management and Complications) where a very large review of cuff leaks in their ICU (1,460 events over 13 years) revealed no correlation between the depth at the teeth, and the likelihood of partial or complete unrecognised extubation in patients with a cuff leak. It’s a great article, the data seems compelling and I think it confirms what we see a lot; that cuff herniation is seen often with the ETT at 24cm or deeper as a result of incremental additions of air to the cuff and slow cephalad movement.
    I think this should be emphasised to ICU staff and I intend to spread the word. I’d be interested in your thoughts.
    Oli Walsh

  2. Hi Oli
    I agree we should not be reassured if the distance at teeth is unchanged in a “cuff leak” / suspected ETT dislodgment scenario.
    However, it is still worth checking in case the distance at the teeth has changed significantly, as that raises your suspicion +- urgency to address the problem.
    Like many things in ICU we have to integrate lots of pieces of information and despite what any studies say re: correlations, if the ETT is 5cm at the teeth it is not in the trachea! 🤪

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