Endotracheal tube cuff pressure: An overlooked risk

The endotracheal tube (ETT) cuff's principal function is to implement proper tracheal sealing at a pressure high enough to prevent both gas leak and fluid aspiration, and low enough to maintain tracheal perfusion. Clinicians are often concerned primarily with the volume of air required to inflate an ETT cuff. However, the most important factor is how much pressure will be exerted on the tracheal mucosa when the cuff is properly distended. Cuff over-inflation complications range from sore throat to tracheal ischemia with tracheal rupture and fistula formation. The ideal ETT cuff pressure has not been defined with a high degree of certainty however most anesthesiologists generally recommend a target pressure of 20 to 30 cmH₂O. Although trachea-gas sealing can be achieved at ETT cuff pressure of 20 cmH2O, microaspiration can occur at a cuff pressure of 60 cmH₂O. Since the introduction of cuffed ETT in the mid- 20th century, several modifications in the cuff's shape and material have been done to address these challenges. It has been proven that the pressure within the inflated cuff is a dynamic process. As such, various clinical factors will significantly impact the pressure reading. Thus, continuous regulation of ETT cuff pressure should be routine practice. Our review included 158 articles that addressed the background into the development of cuffed ETT, function and anatomy of the ETT cuff system, cuff pressure and sealing characteristics, ETT cuff pressure regulation, microaspiration, and factors affecting ETT cuff pressure.