Resuscitation 88 (2015) e9
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Reply to Letter to the Editor Reply to Letter: Confirmation of the depth of the endotracheal tube: Where should the cuff be? Sir, We are grateful to Dr Li and colleagues for their interest in our article, “Tracheal rapid ultrasound saline test (T.R.U.S.T.) for confirming correct endotracheal tube depth in children.” They raise valid questions regarding how this technique can be used in clinical practice. The first question asks whether T.R.U.S.T. can be used to determine which part of the cuff is visualized at the sternal notch, and whether ultrasound can guide optimal placement of the cuff at this anatomical level. In our protocol, an endotracheal tube with a saline-inflated cuff was slowly withdrawn from an endobronchial position, and withdrawal was stopped at the first sonographic visualization of the cuff at the level of the sternal notch. Unfortunately, there was no way for us to know what component of the cuff was being visualized. It may be that the most proximal portion of the cuff was always seen first, meaning that the majority of the cuff was still hidden under the manubrium. Alternately, the majority of the saline may have accumulated at the mid-point of the cuff, meaning that half of the cuff was above the upper border of the sternal notch. We were encouraged by the fact that regardless of which part of the cuff we were seeing, the tip of the tube was never endobronchial when the cuff was seen at the sternal notch. The second question concerns the potential for tracheal mucosal injury, either by direct pressure or by friction during tube movement. During cuff inflation with the tube at the endobronchial position, we used a manometer to ensure that the cuff pressure
http://dx.doi.org/10.1016/j.resuscitation.2014.12.020 0300-9572/© 2014 Elsevier Ireland Ltd. All rights reserved.
remained below 35 cm H2 O, which represents the tracheal mucosal perfusion pressure. As the tube was withdrawn from the smaller diameter bronchus to the larger diameter trachea, cuff pressures were noted to decrease. As for frictional forces, in clinical practice inflated cuffs move up and down the trachea as the position of the head changes, as neck flexion and extension cause cuff movement. In our study, the tube and cuff were also lubricated prior to intubation to decrease frictional forces. For our patients, no adverse events were noted during recovery, and we have had no reports of later complications. Sincerely, Conflict of interest statement None. Mark O. Tessaro ∗ Evan P. Salant Lawrence E. Haines Alexander C. Arroyo Eitan Dickman Maimonides Medical Center, 4802 10th Avenue, Brooklyn, NY 11219, United States ∗ Corresponding
author. E-mail address: [email protected] (M.O. Tessaro) 20 December 2014
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Reply to Letter to the Editor Reply to Letter: Confirmation of the depth of the endotracheal tube: Where should the cuff be? Sir, We are grateful to Dr Li and colleagues for their interest in our article, “Tracheal rapid ultrasound saline test (T.R.U.S.T.) for confirming correct endotracheal tube depth in children.” They raise valid questions regarding how this technique can be used in clinical practice. The first question asks whether T.R.U.S.T. can be used to determine which part of the cuff is visualized at the sternal notch, and whether ultrasound can guide optimal placement of the cuff at this anatomical level. In our protocol, an endotracheal tube with a saline-inflated cuff was slowly withdrawn from an endobronchial position, and withdrawal was stopped at the first sonographic visualization of the cuff at the level of the sternal notch. Unfortunately, there was no way for us to know what component of the cuff was being visualized. It may be that the most proximal portion of the cuff was always seen first, meaning that the majority of the cuff was still hidden under the manubrium. Alternately, the majority of the saline may have accumulated at the mid-point of the cuff, meaning that half of the cuff was above the upper border of the sternal notch. We were encouraged by the fact that regardless of which part of the cuff we were seeing, the tip of the tube was never endobronchial when the cuff was seen at the sternal notch. The second question concerns the potential for tracheal mucosal injury, either by direct pressure or by friction during tube movement. During cuff inflation with the tube at the endobronchial position, we used a manometer to ensure that the cuff pressure
http://dx.doi.org/10.1016/j.resuscitation.2014.12.020 0300-9572/© 2014 Elsevier Ireland Ltd. All rights reserved.
remained below 35 cm H2 O, which represents the tracheal mucosal perfusion pressure. As the tube was withdrawn from the smaller diameter bronchus to the larger diameter trachea, cuff pressures were noted to decrease. As for frictional forces, in clinical practice inflated cuffs move up and down the trachea as the position of the head changes, as neck flexion and extension cause cuff movement. In our study, the tube and cuff were also lubricated prior to intubation to decrease frictional forces. For our patients, no adverse events were noted during recovery, and we have had no reports of later complications. Sincerely, Conflict of interest statement None. Mark O. Tessaro ∗ Evan P. Salant Lawrence E. Haines Alexander C. Arroyo Eitan Dickman Maimonides Medical Center, 4802 10th Avenue, Brooklyn, NY 11219, United States ∗ Corresponding
author. E-mail address: [email protected] (M.O. Tessaro) 20 December 2014
