الفهرس 
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Abstract
Endotracheal tube cuff pressure management is a critical part of airway management in
intubated and mechanically ventilated patients. The tracheal capillary perfusion pressure in
humans ranges from 22 to 32 mmHg (30–43.5 cmH2O). The ideal ETT cuff pressure should
be high enough to seal the trachea without impeding the tracheal mucosal blood flow.
Previous studies have reported that the ETT cuff pressure should be maintained within 20–30
cm H2O. Other studies have reported changes in tube cuff pressure outside the normal range
after initial adjustment.
Some of the reasons that have been reported for these changes include receiving
sedative medications, coughing, and ventilator dys-synchrony, changing patient temperature,
changing head position, and changing the size of the tracheal tube. However, other factors
that may also affect cuff pressure need to be identified and studied. Among these factors,
nursing interventions are the most common factor in mechanically ventilated patients that
may affect the tube cuff pressure. With the increasing demand for global intensive care, and
the essential role of nurses in ICUs for monitoring, regulating, and maintaining cuff pressure,
it is necessary to assess cuff pressure changes due to various nursing interventions.
Aim of the study
This study was conducted to compare endotracheal tube cuff pressure measurements
before and after nursing interventions among mechanically ventilated patients.
Materials & Method
A descriptive comparative research design was utilized to accomplish this study. This
study was conducted in the general ICU of Damanhur Medical National Institute Hospital.
A convenience sample of 70 adult patients mechanically ventilated via an endotracheal
tube with high-volume low-pressure cuff and a diameter ranging from 7 – 8.5 mm of both sex
who admitted to the previously mention setting were included in the study. Patients with prior
laryngeal and tracheal operations; laryngeal edema/stenosis; tracheal bleeding or tracheal
fistula; patients with mental or cognitive disabilities; unstable spinal cord injuries;
hemodynamic and respiratory instabilities ; body temperature abnormalities; inadequate
integrity of the pilot balloon favoring a false positive result were excluded from the study.
To accomplish the aim of the current study; one tool was used for data collection
”Endotracheal tube cuff pressure measurement record”. It was developed by the researcher
after reviewing related literature (Sultan et al., 2011; Das& Kumar., 2015; Asfour, 2016;
Beccaria et al., 2017; Hassan & Baraka, 2021) to record ETT cuff pressure measurements
before and after the selected nursing interventions in mechanically ventilated patients. It
consisted of three parts; Part I: covered the patients’ socio-demographic and admission data
(This part includes socio-demographic data of age and gender. It also includes clinical data as
current diagnosis, past medical history, date of ICU admission, length of intubation, site of
intubation, size of ETT, type of ETT, date & time of patients’ intubation, and duration of
mechanical ventilation).
Part II: endotracheal cuff pressure at different timing before and after the selected
nursing interventions. Part III: variables affecting the ETT cuff pressure measurements
(hemodynamic parameters (Temperature (T), Heart rate (HR), Respiratory rate (RR), Systolic
blood pressure (SBP), Diastolic blood pressure (DBP), peripheral oxygen saturation (SPO2)),
ventilator parameters (mode of mechanical ventilation, positive end expiratory pressure
(PEEP) level, peak inspiratory pressure (PIP) level), and ETT fixation point at different
timing before and after the selected nursing interventions.
The study design was accomplished as follows:
Approval of the ethics committee of the faculty of nursing was obtained. An official
approval to conduct this study was obtained after providing explanation of the aim of the
study. An informed consent was obtained from the patients’ legal guardians. The study tool
was tested for content validity by 5 experts in the field of the study. The necessary
modifications were done accordingly. Reliability of the tool was tested using Crombach’s
Alpha test. The reliability coefficient was 0.952 which is accepted. A pilot study was carried
out on 10% of the study sample in order to test the clarity and applicability of the research
tool.
Data were collected over a period of six consecutive months (from January 2021 to June
2021). Orally intubated – mechanically ventilated critically ill patients at the intended ICU were
enrolled in the study according to the previously mentioned inclusion criteria. The patient’s sociodemographic
and baseline clinical data were recorded in part I of the study tool.
The patient’s ETT cuff pressure measurements at different timing before and after the
selected nursing interventions were obtained and recorded using part II of the study tool. The
patient’s hemodynamic parameters, ventilator parameters, and ETT fixation point were recorded
in part III of the study tool.
The first reading of the patients ETT cuff pressure; patients’ ETT cuff pressure was
measured by the researcher using a cuff pressure manometer (Pressure Gauge Universal
Germany). The pressure observed was recorded and classified according to ETT cuff pressure
scoring system using part II of the study tool.
Adjusting the patient’s ETT to a normal range by the researcher; all selected
patients were initially placed semi-fowler position with the head of the bed HOB 30-45 and
the head in neutral position. The researcher used the minimal leak technique (MLT) guided
with ETT cuff pressure manometer to maintain ETT cuff pressure within the normal range
and to identify baseline values for all the studied patients which were adjusted to the value of
20 to 30cmH2o according to the individual differences.
Before the nursing interventions; four nursing interventions were included in this
study as follows; complete bed bath, endotracheal tube suction (utilizing open method with
vacuum pressure 120 mmHg), oral hygiene, change of positioning of patient in bed (right
lateral and left lateral positions with the head of the bed 30˚). Immediately before each of the
selected nursing interventions the ETT cuff pressure was measured by the researcher using
cuff pressure manometer. The patient’s hemodynamic parameters were obtained and
Ventilator parameters were also obtained. Furthermore the ETT fixation point was assessed.
During the nursing interventions; while the nurse was performing the selected
interventions, the role of the researcher was to observe the nurse’s clinical performance of the
selected interventions.
After the nursing interventions; Patient’s ETT cuff pressure, hemodynamic
parameters and ventilator data were rechecked by the researcher and recorded at three times
as the following: immediately after, 15 and 30 minutes after each of the selected nursing
interventions. The ETT fixation point was reassessed once after. The patient’s ETT cuff
pressure was adjusted to a normal range whenever necessary. The data were collected
consecutively during the morning shift.
Results of the study
Most of the studied patients in this study were males; aged between 51 and 60 years old
and neurological disorders were the main diagnosis among them. Concerning the past medical
history, more than half of the studied patients had a history of diabetes and other endocrine &
gastrointestinal disorders. Regarding the duration of intubation, high numbers of studied
patients were intubated for 4 days and more. The mean sizes of the ETT were between 7 to 8
mm for all the studied patients. Moreover, it was found that 60% of the studied patients were on
SIMV mode, while 40% of them were on assist control ventilation mode ACV mode. The mean
of PEEP was about 5 cm H2o and the mean of the PIP was about 23.49 ± 3.86 cm H2o.
According to first endotracheal cuff pressure measurements, it was noted that the high
percentage (65.7%) of studied patients recorded a cuff pressure above 30 cmH2o.
As regards the comparison of the tracheal cuff pressures as regards different times of
different nursing interventions, results of the current study showed that there was a significant
decrease in the mean values of endotracheal cuff pressure starting before till 30 minutes after
the complete bed bath, oral hygiene, and right and left lateral positioning procedures.
Conversely in the endotracheal suctioning, the mean value of ETT cuff pressure before
showed an increase immediately after, followed by a decrease after 15 minutes, then an
increase after 30 minutes.
As regards the comparison of tracheal cuff pressure measurement at different timing
among different nursing interventions, it was noted that there is no statistically significant
difference in the mean values of the endotracheal cuff pressure between the five procedures
before and immediately after nursing interventions as (p=0.447 and 0.16 respectively). While
after 15 and 30 minutes there were highly significant differences in the mean values of
endotracheal cuff pressure between the five procedures with p=0.0001 for both times.
Conclusion
The current study aimed to compare endotracheal cuff pressure measurements before
and after nursing interventions among mechanically ventilated patients. Based on the current
study findings, it can be concluded that:
The cuff pressure measurements were significantly changed at different timing after
performing the selected nursing interventions.
The lowest ETT cuff pressure value was found to be at 30 minutes after changing
patients position to the left lateral position with HOB 30˚
There was a statistically significant relationship between the patients’ demographic and
clinical characteristics and cuff pressure changes after performing selected nursing
interventions.
Recommendations
Conduct in-service educational programs and workshops to raise CCNs awareness
regarding the importance of tracheal cuff pressure monitoring.
Study the barriers facing the ICU nurses to maintain endotracheal cuff pressure.
Developing a protocol for the endotracheal cuff pressure management for the intubated
and mechanically ventilated patients.
Measurement and regular monitoring of the ETT cuff pressure after the nursing
interventions carried out for patients using objective means.
Use of a continuous cuff pressure regulator to decrease the nurses’ workload and cuff
leak.
Replication of the study on a large sample for generalization of the findings.