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Table of Contents
Year : 2017  |  Volume : 6  |  Issue : 4  |  Page : 34-37

Effect of various patient positions on endotracheal tube cuff pressure after adult cardiac surgery

1 Rajaie Cardiovascular Medical and Research Center, University of Medical Sciences, Tehran, Iran
2 Echocardiography Research Center, Rajaie Cardiovascular Medical and Research Center, University of Medical Sciences, Tehran, Iran
3 Department of Anesthesia, Faculty of Medicine, University of Medical Sciences, Tehran, Iran

Date of Web Publication22-Jan-2018

Correspondence Address:
Dr. Azin Alizadehasl
Echocardiography Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Valiye-Asr Street, Adjacent to Mellat Park, Tehran
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/rcm.rcm_13_17

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Background: To avoid microaspiration or tracheal injury, the target endotracheal tube cuff pressure must be maintained 20–30 cmH2O. Changing in patients' positions may effect on endotracheal tube cuff pressure. The aim of this study was to investigate the effect of various patients' positions on endotracheal tube cuff pressure after adult cardiac surgery. Methods: This prospective, interventional study was conducted on 25 adult patients with orotracheal intubation for the cardiac surgery. Patients' endotracheal tube cuff pressure was assessed after surgery in a neutral starting position during an end-expiratory hold, and cuff pressure was regulated at 25 cmH2O. Then, ten changes in head position were performed: anteflexion, hyperextension, left and right lateral flexion, left and right rotation, semi-recumbent position (head elevation in 45°), recumbent position (head elevation in 10°), horizontal supine position, and finally, Trendelenburg position (10°). The observed cuff pressures were compared with the basic cuff pressure at the starting position. Results: Of total 250 measurements (25 participants in 10 positions), 109 (43/6%) were greater than the upper target limit of 30 cmH2O. In contrast, no measurements were less than the lower target limit of 20 cmH2O. 141 (56/4%) measurements were between the target limit of 20–30 cmH2O. All ten changes of patients' head position lead to statistically significant increase in endotracheal tube cuff pressure (P < 0.05). Conclusion: Simple changes in intubated patients' position could significantly increase in endotracheal tube cuff pressure that may potentially damage tracheal mucosa.

Keywords: Endotracheal intubation, patient positioning, cardiac surgery, Intensive Care Unit

How to cite this article:
Ziyaeifard M, Ferasatkish R, Alizadehasl A, Faritous Z, Alavi SM, Pouraliakbar H, Zare M, Dehdashtian E. Effect of various patient positions on endotracheal tube cuff pressure after adult cardiac surgery. Res Cardiovasc Med 2017;6:34-7

How to cite this URL:
Ziyaeifard M, Ferasatkish R, Alizadehasl A, Faritous Z, Alavi SM, Pouraliakbar H, Zare M, Dehdashtian E. Effect of various patient positions on endotracheal tube cuff pressure after adult cardiac surgery. Res Cardiovasc Med [serial online] 2017 [cited 2023 Mar 27];6:34-7. Available from: https://www.rcvmonline.com/text.asp?2017/6/4/34/223776

  Introduction Top

Intensive Care Unit (ICU) patients may have not the capacity to spontaneous breathing and require mechanical ventilation. During tracheal intubation period, it is important to keep endotracheal tube cuff pressure within the suggested range of 20–30 cmH2O to avoid further complications.[1] Cuff pressure lower than 20 cmH2O can lead to air leak or aspiration of secretions and ventilator-associated pneumonia. Microaspiration has been observed in 82%–88% of these patients.[2],[3] On the other hand, tracheal mucosal inflammation, erosion or ischemia and hemorrhage and rupture, and finally, tracheal stenosis or necrosis are the complications of cuff pressure greater than 30 cmH2O.[4] Nseir et al. showed that only 18% of ICU patients had normal cuff pressure and 82% had under- or overpressure in tracheal tube cuff.[5]

Endotracheal tube cuff pressure is increased by positive pressure ventilation, nitrous oxide, altitude, bronchoconstriction, laryngeal spasms, and edema.

Whereas sedation, neuromuscular blockade, and diminished core temperature can result in a decrease in cuff pressure.[4] Sole et al. reported that tracheal tube cuff pressure could be changed over time and also in different situations such as patient movement, bed position, head extension, and patient effort to speaking.[6]

Recent studies reported an alteration in endotracheal tube cuff pressure as a consequence of changing body position of the patients who are admitted to ICU.[7],[8],[9] Lizy et al. assessed the effect of 16 different head and body positions on tracheal tube cuff pressure and concluded that each change in patients' head or body position could lead to in possibly harmful cuff pressures.[8]

However, there is still little information about endotracheal tube cuff pressure related to change of body position in cardiac surgery ICU patients.

Mucosal edema and diminished perfusion of organs including respiratory system are frequent in patients undergoing cardiopulmonary bypass (CPB), and subsequently, they may be more susceptible to cuff pressure changes related to different body positions.[10] Considering different hemodynamic and fluid challenges and inflammatory responses in cardiac surgery using CPB, we decided to conduct this study to evaluate the effect of different head and body positions of these patients on the endotracheal tube cuff pressure after surgery in ICU.

  Methods Top

After approval of research proposal in institutional review board, this experimental study was conducted at a referral cardiovascular medical and research center between July 2015 and September 2015. An informed written consent was obtained from all of the patients. We assessed endotracheal tube cuff pressure in different positions in mechanically ventilated patients who were hospitalized in cardiac surgery ICU.

The studied patients consisted of 25 adult patients who required mechanical ventilation by endotracheal intubation for 24 h or more. All of the cases were intubated with a high volume, low-pressure TROGE-cuffed endotracheal tubes (Troge Medical GMBH. D-20148 Hamburg. Germany) with the selected size of 7–7.5-mm internal diameter (ID) for women and 8–8.5-mm ID for men.

Patients were eligible for the study if they have met the inclusion criteria: aged 18–75 years old, underwent coronary artery bypass surgery (CABG), valvular surgery or both (using CPB), orally intubated, under positive pressure mechanical ventilation, and stable hemodynamics.

Patients with unstable hemodynamics (using high doses of norepinephrine, sternum left open, excess drainage, intra-aortic balloon pump, and systolic blood pressure <90 mmHg), difficult intubation, limitation of neck movement (history of neck surgery, neck arthrosis), body temperature lower than 35°C or higher than 37.5°C, and obesity (body mass index [BMI] >35) were excluded.

Sampling was performed in the first 2 h after admitting the patients from operating room to ICU. A fixed calibrated endotracheal tube cuff pressure manometer Riester (VBM Medizintechnik GmbH. Einsteinstrasse 1. 72172 Sulz a. N. Germany) was used for measuring the endotracheal tube cuff pressure. Normal range of endotracheal tube cuff pressure is determined to be 20–30 cmH2O. Demographic data including age, sex, height, weight, BMI, endotracheal tube size, underlying diseases, body temperature and end-expiratory positive pressure and clinical data consisting intubation date, duration of intubation, type of cardiac surgery (coronary bypass and valvular surgery or both), and patients' endotracheal tube cuff pressure in different positions were recorded.

At the beginning of the study, each patient was in a supine neutral position with 30° head up. The pressure of the endotracheal tube cuff was set on 25 cmH2O at the end-expiratory period. Each patient was placed in 10 different positions, so totally 250 positions and related cuff pressures were obtained in all patients. The applied head and body positions include: anteflexion, hyperextension, right lateral flexion, left lateral flexion, left rotation of the head, right rotation of the head, semi-recumbent position with 45° head up, recumbent position with 10° head up, supine position, and 10° Trendelenburg position. The endotracheal tube cuff pressure was measured after that patient was in a new position for 120 s. After each change in position and measurement of the cuff pressure, the body was returned to the starting position (supine position with 30° head up) and the endotracheal tube cuff pressure was reset on 25 cmH2O, and then, the patient was turned into a new position. Changing of the positions was randomly sorted in each patient.

The data adaptation on normal distribution was tested by Kolmogorov–Smirnov (K-S) test and all data were normally distributed, so parametric statistical tests were used. One-sample t-test and general linear model were performed for analyzing data using SPSS statistical package for Windows, Version 16.0 (SPSS Inc., Chicago, IL, USA) was used. P ≤ 0.05 was considered statistically significant.

  Results Top

Twenty-five patients including 7 women and 18 men were assessed. The enrolled patients included 16 cases of CABG surgery, six cases of valvular surgery, and 3 cases with both CABG and valve surgery. Demographic data are shown in [Table 1].
Table 1: Demographic data of the studied patients

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Total 250 measurements were made (25 patients in 10 different positions). According to the collected data, 109 (43.6%) cuff pressures were above 30 cmH2O and 141 (56.4%) measurements were in the range of 20–30 cmH2O. Of note, none of the measurements were below 20 cmH2O. Endotracheal tube cuff pressure changed significantly with different neck positions in comparison with “supine position with neutral head position” [Table 2]. The mean endotracheal tube cuff pressure in anteflexion of the head was the highest in comparison with other positions.
Table 2: Endotracheal tube cuff pressure (mmHg) in different head and body positions

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In addition, all the studied body and neck positions compared 2 × 2 with each other separately using general leaner model. We found that tracheal tube cuff pressure was significantly different in all other positions with “Semi-recumbent position, 45°” and “Trendelenburg, 10°” position.

  Discussion Top

Microaspiration and ventilator-associated pneumonia, mucosal necrosis, tracheal stenosis or rupture related to low or high endotracheal tube cuff pressure are feared complications in the critical care setting.[2]

In the present study, we found that changes in patient body position can lead to significant alteration in endotracheal tube cuff pressure except in supine position. Lizy et al.[8] reported statistically significant changes in the endotracheal tube cuff pressure by applying different body positions. They also found that minimum cuff pressure was obtained at supine and 10° Trendelenburg positions. General linear model revealed the statistically significant difference between the endotracheal tubes cuff pressure in different body positions in our patients (P< 0.001) which is similar to Lizy's study results. Among 192 measurements (16 positions × 12 patients) in Lizy study, 78 (40.6%) endotracheal tubes cuff pressure were above 30 cmH2O.[8] In contrast, none of the measurements were below 20 cmH2O. Similarly, among 250 measurements (10 positions × 25 patients) in our study, 109 (43.6%) endotracheal tubes cuff pressures were higher than 30 cmH2O and none of the cuff pressures was below 20 cmH2O. One hundred forty-one (56.4%) measurements were in the indicated range of 20–30 cmH2O. The results showed that performing simple changes in body position of the patients under mechanical ventilation can result in significant alteration in endotracheal tube cuff pressure.

Another study by Kako et al. shows similar results with this study. Kako, in pediatric patients, found that cuff pressure increased in 545 measurements (68.1%) with changes in the position of the head and neck. He concluded notable alterations in the endotracheal cuff pressure with changes in neck and head position that leads to a substantial increase in the cuff pressure.[7]

Other studies which support the results of this study are: “Head rotation, flexion, and extension alter endotracheal tube position in adults and children” by Kim et al. and “Endotracheal tube cuff pressure alteration after changes in position in patients under mechanical ventilation” by Godoy et al.[2],[9]

In intubated patients, the endotracheal tube cuff pressure should be checked in regular intervals to avoid the complications resulting from improper cuff pressure. Of note, patients who have undergone major surgery, especially the prolonged ones such as brain or heart surgery do not have stable hemodynamics. These patients can be at an increased risk for tracheal stenosis as a result of prolonged mechanical ventilation. To avoid such damages, it is suggested that cuff pressure should be rechecked regularly.[11],[12] Kako suggests for long intubation cases when the head and neck turned from the neutral position, the cuff pressure must be measured after patient positioning to ensure that the cuff pressure is within normal range.[7] High cuff pressures can result in tracheal ischemia, histological damage of trachea, and at last tracheal stenosis. This can occur sometime after discharging the patients from ICU.[13],[14],[15],[16] Kim et al. reported that in patients undergoing lumbar spine surgery position changes from supine to prone with no head movement leads to increase in endotracheal tube cuff pressure.[17]

  Conclusion Top

It is concluded that despite adjusting endotracheal tube cuff pressure in the recommended range for the first time, it can be altered – mostly upward – as a result of changing the position of patients. Hence, to avoid related morbidity, it is important to recheck the cuff pressure after any change in patient position.


Regarding the aim of the study that evaluated the effect of patients' head positions on tracheal tube cuff pressure, we primarily consider “head positions” instead of “patients number” as samples for our study. Hence, by consulting with the biostatistician expert, he calculated 25 patients with 250 head positions for us. Finally, we fund that all 10 changes of patients' head position lead to a statistically significant increase in endotracheal tube cuff pressure (P< 0.05).


We appreciate the ones who helped us in this study, especially Mr. Najafikhah in Rajaie Cardiovascular Medical and Research Center (Tehran, Iran) for his kind cooperation.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Henderson J. Airway management in the adult. Miller's Anesthesia. 7th ed. Philadelphia: Churchill Livingston Elsevier; 2010. p. 1573-4.  Back to cited text no. 1
Godoy AC, Vieira RJ, Capitani EM. Endotracheal tube cuff pressure alteration after changes in position in patients under mechanical ventilation. J Bras Pneumol 2008;34:294-7.  Back to cited text no. 2
Jaillette E, Martin-Loeches I, Artigas A, Nseir S. Optimal care and design of the tracheal cuff in the critically ill patient. Ann Intensive Care 2014;4:7.  Back to cited text no. 3
Saleh Moghaddam AR, Malekzade J, Mesbahi Z, Esmaeli H. Relationship between temperature and cuff pressure in mechanically ventilated patients with endotracheal tube. Horizon Med Sci 2013;19:105-9.  Back to cited text no. 4
Nseir S, Brisson H, Marquette CH, Chaud P, Di Pompeo C, Diarra M, et al. Variations in endotracheal cuff pressure in intubated critically ill patients: Prevalence and risk factors. Eur J Anaesthesiol 2009;26:229-34.  Back to cited text no. 5
Sole ML, Penoyer DA, Su X, Jimenez E, Kalita SJ, Poalillo E, et al. Assessment of endotracheal cuff pressure by continuous monitoring: A pilot study. Am J Crit Care 2009;18:133-43.  Back to cited text no. 6
Kako H, Krishna SG, Ramesh AS, Merz MN, Elmaraghy C, Grischkan J, et al. The relationship between head and neck position and endotracheal tube intracuff pressure in the pediatric population. Paediatr Anaesth 2014;24:316-21.  Back to cited text no. 7
Lizy C, Swinnen W, Labeau S, Poelaert J, Vogelaers D, Vandewoude K, et al. Cuff pressure of endotracheal tubes after changes in body position in critically ill patients treated with mechanical ventilation. Am J Crit Care 2014;23:e1-8.  Back to cited text no. 8
Kim JT, Kim HJ, Ahn W, Kim HS, Bahk JH, Lee SC, et al. Head rotation, flexion, and extension alter endotracheal tube position in adults and children. Can J Anaesth 2009;56:751-6.  Back to cited text no. 9
Hein OV, Birnbaum J, Wernecke K, England M, Konertz W, Spies C, et al. Prolonged Intensive Care Unit stay in cardiac surgery: Risk factors and long-term-survival. Ann Thorac Surg 2006;81:880-5.  Back to cited text no. 10
Jordan P, Van Rooyen D, Venter D. Endotracheal tube cuff pressure management in adult critical care units. South Afr J Crit Care 2012;28:13-6.  Back to cited text no. 11
Jaber S, Amraoui J, Lefrant JY, Arich C, Cohendy R, Landreau L, et al. Clinical practice and risk factors for immediate complications of endotracheal intubation in the Intensive Care Unit: A prospective, multiple-center study. Crit Care Med 2006;34:2355-61.  Back to cited text no. 12
Azarfarin R, Ashouri N, Totonchi Z, Bakhshandeh H, Yaghoubi A. Factors influencing prolonged ICU stay after open heart surgery. Res Cardiovasc Med 2014;3:e20159.  Back to cited text no. 13
Olsen GH, Krishna SG, Jatana KR, Elmaraghy CA, Ruda JM, Tobias JD, et al. Changes in intracuff pressure of cuffed endotracheal tubes while positioning for adenotonsillectomy in children. Paediatr Anaesth 2016;26:500-3.  Back to cited text no. 14
Ziyaeifard M, Totonchi Z. Real-time ultrasound guided the new standard technique for percutaneous dilatational tracheostomy (PDT). Anesth Pain Med 2015;5:e24653.  Back to cited text no. 15
Shin HW, Kim DH, Yoo HS, Lee DK, Yoo YD, Lim CH, et al. Changes in cuff pressure and position of cylindrical-cuff and tapered-cuff tracheal tubes during laparoscopic abdominal surgery. J Int Med Res 2015;43:544-54.  Back to cited text no. 16
Kim D, Jeon B, Son JS, Lee JR, Ko S, Lim H, et al. The changes of endotracheal tube cuff pressure by the position changes from supine to prone and the flexion and extension of head. Korean J Anesthesiol 2015;68:27-31.  Back to cited text no. 17


  [Table 1], [Table 2]

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