There is a relatively small risk of getting ETT cuff pressures less than 30cmH2O with the use of the LOR syringe method [23, 24], 12.4% from the current study. If using an adult trach, draw 10 mL air into syringe. Cookies policy. H. Jin, G. Y. Tae, K. K. Won, J. The PBP method, although commonly employed in operating rooms, has been repetitively shown to administer cuff pressures out of the optimal range (2030cmH2O) [2, 3, 25]. 21, no. The cookies store information anonymously and assign a randomly generated number to identify unique visitors. Endotracheal intubation is a medical procedure in which a tube is placed into the windpipe (trachea) through the mouth or nose. One such approach entails beginning at the patient and following the circuit to the machine. Part 1: anaesthesia, British Journal of Anaesthesia, vol. Accuracy 2cmH2O) was attached. 3, p. 172, 2011. Interestingly, the amount of air required to achieve a cuff pressure of 20 cmH2O was similar with each tube size (Table 3). Our first goal was thus to determine if cuff pressure was within the recommended range of 2030 cmH2O, when inflated using the palpation method. mental status changes, such as confusion . An anesthesia provider inserted the endotracheal tubes, and the intubator or the circulating registered nurse inflated the cuff. COPD, head injury, ARDS), Rapid sequence induction (RSI) intubation, Procedural variation using rapid anaesthetisation with cricoid pressure to prevent aspiration while airway is quickly secured, Used for patients at risk of aspiration e.g. This result suggests that clinicians are now making reasonable efforts to avoid grossly excessive cuff inflation. The loss of resistance syringe method was superior to pilot balloon palpation at administering pressures in the recommended range. Students were under the supervision of a senior anesthetic officer or an anesthesiologist. The cookie is updated every time data is sent to Google Analytics. But interestingly, the volume required to inflate the cuff to a particular pressure was much smaller when the cuff was inflated inside an artificial trachea; furthermore, the difference among tube sizes was minimal under those conditions. Anesth Analg. We intentionally avoided this approach since our purpose was to evaluate cuff pressures and associated volumes in three routine clinical settings. Although this was a single-blinded, single-centre study, results suggest that the LOR syringe method was superior to PBP at administering pressures in the optimal range. Categorical data are presented in tabular, graphical, and text forms and categorized into PBP and LOR groups. However, complications have been associated with insufficient cuff inflation. The pressure reading of the VBM was recorded by the research assistant. Young, and K. K. Duk, Usefulness of new technique using a disposable syringe for endotracheal tube cuff inflation, Korean Journal of Anesthesiology, vol. Am J Emerg Med . The cuff was considered empty when no more air could be removed on aspiration with a syringe. 2017;44 Pediatr Pathol Lab Med. Tube positioning within patient can be verified. We offer in-person, hands-on training at our Asheville, N.C., Spay/Neuter Training Cent Show more. 1990, 44: 149-156. There was no correlation between the measured cuff pressure and the age, sex, height, or weight of the patients. T. M. Cook, N. Woodall, and C. Frerk, Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. This was a randomized clinical trial. 6, pp. DIS contributed to study design, data analysis, and manuscript preparation. Sengupta, P., Sessler, D.I., Maglinger, P. et al. The cookie is used to identify individual clients behind a shared IP address and apply security settings on a per-client basis. With air providing the seal in the cuff the mean rise in cuff pressure was 23 cmH2O . 6, pp. This cookie is set by Google Analytics and is used to distinguish users and sessions. Use low cuff pressures and choosing correct size tube. Cuff pressure adjustment: in both arms, very high and very low pressures were adjusted as per the recommendation by the ethics committee. We tested the hypothesis that the tube cuff is inadequately inflated when manometers are not used. 22, no. 10, no. The author(s) declare that they have no competing interests. 617631, 2011. In this cohort, aspiration had the second highest incidence of primary airway-related serious events [6]. Cuff pressure should be measured with a manometer and, if necessary, corrected. APSF President Robert K. Stoelting, MD: A Tribute to 19 Years of Steadfast Leadership, Immediate Past Presidents Report Highlights Accomplishments of 2016, Save the Date! The AAFP recommends inflating the cuff using air in 0.5-mL increments from a 3-mL syringe until no leak can be heard when the rebreathing bag is squeezed and the pressure in . The cookie is used to calculate visitor, session, campaign data and keep track of site usage for the site's analytics report. This method has been achieved with a modified epidural pulsator syringe [13, 18], a 20ml disposable syringe, and more recently, a loss of resistance (LOR) syringe [21, 23, 24]. Manage cookies/Do not sell my data we use in the preference centre. 513518, 2009. This point was observed by the research assistant and witnessed by the anesthesia care provider. Dont Forget the Routine Endotracheal Tube Cuff Check! The cookie is a session cookies and is deleted when all the browser windows are closed. This study set out to determine the efficacy of the loss of resistance syringe method at estimating endotracheal cuff pressures. 1977, 21: 81-94. 2003, 38: 59-61. It would thus be helpful for clinicians to know how much air must be injected into the cuff to produce the minimum adequate pressure. Compared with the cuff manometer, it would be cheaper to acquire and maintain a loss of resistance syringe especially in low-resource settings. However, these are prohibitively expensive to acquire and maintain in many operating theaters, and as such, many anesthesia providers resort to subjective methods like pilot balloon palpation (PBP) which is ineffective [1, 2, 1620]. In certain instances, however, it can be used to. Accuracy 2cmH. J. R. Bouvier, Measuring tracheal tube cuff pressurestool and technique, Heart and Lung, vol. An intention-to-treat analysis method was used, and the main outcome of interest was the proportion of cuff pressures in the range 2030cmH2O in each group. "Aire" indicates cuff to be filled with air. This is a standard practice at these hospitals. The integrity of the entire breathing circuit and correct positioning of the ETT between the vocal cords with direct laryngoscopy were confirmed. adequately inflate cuff . 288, no. Measured cuff volumes were also similar with each tube size. recommended selecting a cuff pressure of 25 cmH2O as a safe minimum cuff pressure to prevent aspiration and leaks past the cuff [17]; Bernhard et al. Cuff pressure should be maintained between 15-30 cm H 2 O (up to 22 mm Hg) . P. Sengupta, D. I. Sessler, P. Maglinger et al., Endotracheal tube cuff pressure in three hospitals, and the volume required to produce an appropriate cuff pressure, BMC Anesthesiology, vol. Intensive Care Med. The cookie is created when the JavaScript library executes and there are no existing __utma cookies. SuperWes explains how to know the difference.Thx to Caleb@BDM Films for the FX Anasthesiol Intensivmed Notfallmed Schmerzther. 2013 Aug;117(2):428-34. doi: 10.1213/ANE.0b013e318292ee21. Copyright 2013-2023 Oxford Medical Education Ltd. Myasthenia Gravis (MG) Neurological Examination, Questions about DVT (Deep Vein Thrombosis), Endotracheal tube (ETT) insertion (intubation), Supraglottic airway (e.g. We recommend that ET cuff pressure be set and monitored with a manometer. Used by Google DoubleClick and stores information about how the user uses the website and any other advertisement before visiting the website. At the study hospital, there are more females undergoing elective surgery under general anesthesia compared with males. If pressure remains > 30 cm H2O, Evaluate . Standard cuff pressure is 25mmH20 measured with a manometer. Cite this article. PM, SW, and AV recruited patients and performed many of the measurements. However, there was considerable patient-to-patient variability in the required air volume. 8184, 2015. An endotracheal tube : provides a passage for gases to flow between a patients lungs and an anaesthesia breathing system . Previous studies suggest that this approach is unreliable [21, 22]. allows one to provide positive pressure ventilation. 2023 BioMed Central Ltd unless otherwise stated. Bernhard WN, Yost L, Joynes D, Cothalis S, Turndorf H: Intracuff pressures in endotracheal and tracheostomy tubes. Summary Aeromedical transport of mechanically ventilated critically ill patients is now a frequent occurrence. To achieve the optimal ETT cuff pressure of 2030cmH2O [3, 8, 1214], ETT cuffs should be inflated with a cuff manometer [15, 16]. In the early years of training, all trainees provide anesthesia under direct supervision. 5, pp. 10.1007/s001010050146. Our primary outcomes were 1) measured endotracheal tube cuff pressures as a function of tube size, provider, and hospital; and 2) the volume of air required to produce a cuff pressure of 20 cmH2O as a function of tube size. You also have the option to opt-out of these cookies. Neither measured cuff pressure nor measured cuff volume differed among the hospitals (Table 2). Compliance of the cuff system was evaluated by linear regression of measured cuff pressure vs. measured cuff volume. PBP group (active comparator): in this group, the anesthesia care provider was asked to reduce or increase the pressure in the ETT cuff by inflating with air or deflating the pilot balloon using a 10ml syringe (BD Discardit II) while simultaneously palpating the pilot balloon until a point he or she felt was appropriate for the patient. But opting out of some of these cookies may have an effect on your browsing experience. An initial intracuff pressure of 30 cmH2O decreased to 20 cmH2O at 7 to 9 hours after inflation. These were adopted from a review on postoperative airway problems [26] and were defined as follows: sore throat, continuous throat pain (which could be mild, moderate, or severe), dysphagia, uncoordinated swallowing or inability to swallow or eat, dysphonia, hoarseness or voice changes, and cough (identified by a discomforting, dry irritation in the upper airway leading to a cough). Decrease the cuff pressure to 30 cm H2O by withdrawing a small amount of air from the balloon with a 10 mL syringe. The mean volume of inflated air required to achieve an intracuff pressure of 25 cmH2O was 7.1 ml. 21, no. Cuff pressures less than 20 cmH2O have been shown to predispose to aspiration which is still a major cause of morbidity, mortality, length of stay, and cost of hospital care as revealed by the NAP4 UK study. muscle or joint pains. Springer Nature. C. Stein, G. Berkowitz, and E. Kramer, Assessment of safe endotracheal tube cuff pressures in emergency care - time for change? South African Medical Journal, vol. 1992, 74: 897-900. CONSORT 2010 checklist. The chi-square test was used for categorical data. In our case, had the endotracheal tube been checked prior to the start of the case, the defect could have been easily identified which would have obviated the need for tube exchange. Air sampling is an insensitive means of detecting Legionella pneumophila, and is of limited practical value in environmental sampling for this pathogen. demonstrate the presence of legionellae in aerosol droplets associated with suspected bacterial reservoirs. Endotracheal tube cuff pressure in three hospitals, and the volume required to produce an appropriate cuff pressure. Charles Kojjo, Agnes Wabule, and Nodreen Ayupo were responsible for patient recruitment and data collection and analysis. The cookie is used to store and identify a users' unique session ID for the purpose of managing user session on the website. If air was heard on the right side only, what would you do? Volume+2.7, r2 = 0.39 (Fig. The high incidence of postextubation airway complaints in this study is most likely a site-specific problem but one that other resource-limited settings might identify with. Mandoe H, Nikolajsen L, Lintrup U, Jepsen D, Molgaard J: Sore throat after endotracheal intubation. A systematic approach to evaluation of air leaks is recommended to ensure rapid evaluation and identification of underlying issues. Morphometric and demographic characteristics of the patients were similar at each participating hospital (Table 1). The authors declare that they have no conflicts of interest. We also appreciate the statistical analysis by Gilbert Haugh, M.S., and the editorial assistance of Nancy Alsip, Ph.D., (University of Louisville). Crit Care Med. 720725, 1985. H. B. Ghafoui, H. Saeeidi, M. Yasinzadeh, S. Famouri, and E. Modirian, Excessive endotracheal tube cuff pressure: is there any difference between emergency physicians and anesthesiologists? Signa Vitae, vol. High-volume low-pressure cuffed endotracheal tubes (ETT) are the standard of airway protection. These included an intravenous induction agent, an opioid, and a muscle relaxant. Most manometers are calibrated in? Anesth Analg. A wide-bore intravenous cannula (16- or 18-G) was placed for administration of drugs and fluids. Acta Otorhinolaryngol Belg. 2006;24(2):139143. It helps us understand the number of visitors, where the visitors are coming from, and the pages they navigate. To detect a 15% difference between PBP and LOR groups, it was calculated that at least 172 patients would be required to be 80% certain that the limits of a 95%, two-sided interval included the difference. Perhaps the LOR syringe method needs to be evaluated against the no air leak on auscultation method. This however was not statistically significant ( value 0.053) (Table 3). Dullenkopf A, Gerber A, Weiss M: Fluid leakage past tracheal tube cuffs: evaluation of the new Microcuff endotracheal tube. The magnitude of effect on the primary outcome was computed for 95% CI using the t-test for difference in group means. Tracheal cuff seal, peak centering and the incidence of postoperative sore throat]. This method provides a viable option to cuff inflation. J. Rello, R. Soora, P. Jubert, A. Artigas, M. Ru, and J. Valls, Pneumonia in intubated patients: role of respiratory airway care, American Journal of Respiratory and Critical Care Medicine, vol. This cookie is installed by Google Analytics. Underinflation increases the risk of air leakage and aspiration of gastric and oral pharyngeal secretions [4, 5]. Our results thus fail to support the theory that increased training improves cuff management. [21] found that the volume of air required to inflate the endotracheal tube cuff varies as a function of tube size and type. California Privacy Statement, Catastrophic consequences of endotracheal tube cuff over-inflation such as rupture of the trachea [46], tracheo-carotid artery erosion [7], and tracheal innominate artery fistulas are rare now that low-pressure, high-volume cuffs are used routinely. Measured cuff inflation pressures were virtually identical at the three study sites: one academic center and two private hospitals. After induction of anesthesia, a 71-year-old female patient undergoing a parotidectomy was nasally intubated with a TaperGuard 6.5 Nasal RAE tube using a C-MAC KARL STORZ GmbH & Co. KG Mittelstrae 8, 78532 Tuttlingen, Germany, video-laryngoscope. The individual anesthesia care providers participated more than once during the study period of seven months. Laura F. Cavallone, MD, Associate Professor, Department of Anesthesiology, Washington University in St. Louis, MO. This cookie is set by Youtube. When considering this primary outcome, the LOR syringe method had a significantly higher proportion compared to the PBP method. Every patient was wheeled into the operating theater and transferred to the operating table. Low pressure high volume cuff. 1981, 10: 686-690. Endotracheal intubation is done to: Keep the airway open in order to give oxygen, medicine, or anesthesia. Cuff pressure reading of the VBM manometer was recorded by the research assistant. We use this to improve our products, services and user experience. There are data regarding the use of the LOR syringe method for administering ETT cuff pressures [21, 23, 24], but studies on a perioperative population are scanty. S. Stewart, J. Zhonghua Yi Xue Za Zhi (Taipei). We did not collect data on the readjustment by the providers after intubation during this hour. CRNAs (n = 72), anesthesia residents (n = 15), and anesthesia faculty (n = 6) performed the intubations. It is used to either assist with breathing during surgery or support breathing in people with lung disease, heart failure, chest trauma, or an airway obstruction. However, the performance of the air filled tracheal tube cuff at altitude has not been studied in vivo. R. D. Seegobin and G. L. van Hasselt, Endotracheal cuff pressure and tracheal mucosal blood flow: endoscopic study of effects of four large volume cuffs, British Medical Journal, vol. 408413, 2000. This adds to the growing evidence to support the use of the LOR syringe for ETT cuff pressure estimation. However, a full hour was plenty of time for the provider to have checked and adjusted cuff pressure to a suitable level. It should however be noted that some of these studies have been carried out in different environments (emergency rooms) and on different kinds of patients (emergency patients) by providers of varying experience [2]. Inflate the cuff of the endotracheal tube with sufficient air to seal the area between the trachea and the tube. 30. If more than 5 ml of air is necessary to inflate the cuff, this is an . . Statement on the Standard Practice for Infection Prevention and Control Instruments for Tracheal Intubation. A caveat, though, is that tube sizes were chosen by clinicians in our study and presumably matched patient size; results may well have differed if tube size had been randomly assigned. Does that cuff on the trach tube get inflated with air or water? Patients who were intubated with sizes other than these were excluded from the study. 1993, 104: 639-640. Article Outcomes were compared by tube size, provider, and hospital with either an ANOVA (if the values were normally distributed) or the Kruskal-Wallis statistic (if the values were skewed). W. N. Bernhard, L. Yost, D. Joynes, S. Cothalis, and H. Turndorf, Intracuff pressures in endotracheal and tracheostomy tubes. Routine checks of the ETT integrity and functionality before insertion used to be the standard of care, but the practice is becoming less common, although it is still recommended in current ASA guidelines.1. However, there was considerable variability in the amount of air required. 111115, 1996. 775778, 1992. The data were exported to and analyzed using STATA software version 12 (StataCorp Inc., Texas, USA). ETT exchange could pose significant risk to patients especially in the case of the patient with a difficult airway. CAS . The cookie is set by Google Analytics. M. L. Sole, X. Su, S. Talbert et al., Evaluation of an intervention to maintain endotracheal tube cuff pressure within therapeutic range, American Journal of Critical Care, vol. When this point was reached, the 10ml syringe was then detached from the pilot balloon, and a cuff manometer (VBM, Medicintechnik Germany. The exact volume of air will vary, but should be just enough to prevent air leaks around the tube. 20, no. We observed a linear relationship between the measured cuff pressure and the volume of air retrieved from the cuff. How much air is injected into the cuff is not a major concern for almost all anaesthetists and they usually depend on palpating the external cuff tense to judge is it too much, accurate or not enough? 66.3% (59/89) of patients in the loss of resistance group had cuff pressures in the recommended range compared with 22.5% (20/89) from the pilot balloon palpation method. This method is cheap and reproducible and is likely to estimate cuff pressures around the normal range. This cookies is set by Youtube and is used to track the views of embedded videos. ETT cuff pressures would be measured with a cuff manometer following estimation by either the PBP method or the LOR method. By using this website, you agree to our 87, no. 24, no. In addition, most patients were below 50 years (76.4%). Chest. Interestingly, there was also no significant or important difference as a function of provider measured cuff pressures were virtually identical whether filled by CRNAs, residents, or attending anesthesiologists. Lomholt et al. They were only informed about the second purpose of the study: determining the relationship between cuff volume and pressure. A newer method, the passive release technique, although with limitations, has been shown to estimate cuff pressures better [2124]. The difference in the incidence of sore throat and dysphonia was statistically significant, while that for cough and dysphagia was not. In contrast, newer ultra-thin cuff membranes made from polyurethane effectively prevent liquid flow around cuffs inflated only to 15 cm H2O [2]. This is an open access article distributed under the, PBP group (active comparator): in this group, the anesthesia care provider was asked to reduce or increase the pressure in the ETT cuff by inflating with air or deflating the pilot balloon using a 10ml syringe (BD Discardit II) while simultaneously palpating the pilot balloon until a point he or she felt was appropriate for the patient. This cookies is installed by Google Universal Analytics to throttle the request rate to limit the colllection of data on high traffic sites. It does not correspond to any user ID in the web application and does not store any personally identifiable information. Google Scholar. LOR group (experimental): in this group, the research assistant attached a 7ml plastic, luer slip loss of resistance syringe (BD Epilor, USA) containing air onto the pilot balloon. In addition, over 90% of anesthesia care at this hospital was provided by anesthetic officers and anesthesia residents during the study period. On the other hand, Nordin et al. 1993, 42: 232-237. The datasets analyzed during the current study are available from the corresponding author on reasonable request. The manual method used a pressure manometer to adjust pressure at cruising altitude and after landing. The tube will remain unstable until secured; therefore, it must be held firmly until then. The study would be discontinued if 5% of study subjects in one study group experienced an adverse event associated with the study interventions as determined by the DSMB, or if a value of <0.001 was obtained on an interim analysis performed halfway through patient accrual. ismanagement of endotracheal (ET) tube cuff pressure (CP), defined as a CP that falls outside the recommended range of 20 to 30 cm H 2 O, is a frequent occur-rence during general anesthetics, with study findings ranging from 55% to 80%.1-4 Endotra-cheal tube cuffs are typically filled with air to a safe and adequate pressure of 20 to 30 cm H 2 Our study set out to investigate the efficacy of the loss of resistance syringe in a surgical population under general anesthesia. The regression equation indicated that injected volumes between 2 and 4 ml usually produce cuff pressures between 20 and 30 cmH2O independent of tube size for the same type of tube. Conventional high-volume, low-pressure cuffs may not prevent micro-aspiration even at cuff pressures up to 60 cm H2O [2], although some studies suggest that only 25 cm H2O is sufficient [3]. Vet Anaesth Analg. B) Defective cuff with 10 ml air instilled into cuff. 1720, 2012. Tobin MJ, Grenvik A: Nosocomial lung infection and its diagnosis. A research assistant (different from the anesthesia care provider) read out the patients group, and one of the following procedures was followed. In general, the cuff inflates properly for adults, but physicians often over-inflate the cuff during . 2, pp. CAS 3, p. 965A, 1997. The patient was then preoxygenated with 100% oxygen and general anesthesia induced with a combination of drugs selected by the anesthesia care provider. Acta Anaesthesiol Scand. Lomholt N: A device for measuring the lateral wall cuff pressure of endotracheal tubes. We conducted a single-blinded randomized control study to evaluate the LOR syringe method in accordance with the CONSORT guideline (CONSORT checklist provided as Supplementary Materials available here). The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2253/4/8/prepub. 111, no. 56, no. Analytics cookies help us understand how our visitors interact with the website. Cuff pressure in endotracheal (ET) tubes should be in the range of 2030 cm H2O. February 2017 4, pp. 1.36 cmH2O. The study was approved by the School of Medicine Research and Ethics Committee, Makerere University, and registered with http://www.clinicaltrials.gov (NCT02294422). Figure 1. if GCS <8, high aspiration risk or given muscle relaxation), Potential airway obstruction (airway burns, epiglottitis, neck haematoma), Inadequate ventilation/oxygenation (e.g. This was statistically significant. Endotracheal tube cuff pressure: a randomized control study comparing loss of resistance syringe to pilot balloon palpation. The patients were followed up and interviewed only once at 24 hours after intubation for presence of cough, sore throat, dysphagia, and/or dysphonia. A) Normal endotracheal tube with 10 ml of air instilled into cuff. laryngeal mask airway [LMA], i-Gel), How to insert a nasopharyngeal airway (NPA), Common hypertensive emergencyexam questions for medical finals, OSCEs and MRCP PACES, Guedel Airway Insertion Initial Assessment of a Trauma Patient, Haemoptysis case study with questions and answers, A fexible plastic tube with cuff on end which sits inside the trachea (fully secures airway the gold standard of airway management), Ventilation during anaesthetic for surgery (if muscle relaxant is required, long case, abdominal surgery, or head positing may be required), Patient cant protect their airway (e.g. CAS The intracuff pressure, volume of air needed to fill the cuff and seal the airway, number of tube changes required for a poor fit, number with intracuff pressure 20 cm H 2 O, and intracuff pressure 30 cm H 2 O are listed in Table 4. 208211, 1990. Nordin U, Lindholm CE, Wolgast M: Blood flow in the rabbit tracheal mucosa under normal conditions and under the influence of tracheal intubation. 87, no. Endotracheal tube cuff pressure in three hospitals, and the volume required to produce an appropriate cuff pressure, http://www.biomedcentral.com/1471-2253/4/8/prepub. On the other hand, overinflation may cause catastrophic complications. 28, no. Martinez-Taboada F. The effect of user experience and inflation technique on endotracheal tube cuff pressure using a feline airway simulator. Anesthesia services are provided by different levels of providers including physician anesthetists (anesthesiologists), residents, and nonphysician anesthetists (anesthetic officers and anesthetic officer students). 6422, pp. 345, pp. The cookie is used to determine new sessions/visits. This cookie is native to PHP applications. 1992, 49: 348-353. The rate of optimum endotracheal tube cuff pressure was 90.5% in the group guided by manometer and 31.8% in the conventional procedure group (p < 0.001 . Correspondence to After deflating the cuff, we reinflated it in 0.5-ml increments until pressure was 20 cmH2O. C. K. Cho, H. U. Kwon, M. J. Lee, S. S. Park, and W. J. Jeong, Application of perifix(R) LOR (loss of resistance) syringe for obtaining adequate intracuff pressures of endotracheal tubes, Journal of Korean Society of Emergency Medicine, vol. Listen for the presence of an air leak around the cuff during a positive pressure breath. 9, no. 795800, 2010. The primary outcome of the study was to determine the proportion of cuff pressures in the optimal range from either group. 31. Upon closer inspection of the ETT that had been removed from the airway, there appeared to be a defect in which the air injected into the pilot balloon did not reach the cuff (see Figures 1 and 2). 769775, 2012. 2, pp. PubMed 33. 1984, 24: 907-909. The relationship between measured cuff pressure and volume of air in the cuff. In case of a very low pressure reading (below 20cmH, https://pdfs.semanticscholar.org/c12e/50b557dd519bbf80bd9fc60fb9fa2474ce27.pdf. The air leak resolved with the new ETT in place and the cuff inflated. None of the authors have conflicts of interest relating to the publication of this paper.

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