Best evidence statement (BESt) Tracheal cuff pressure management


Guideline Developer(s)

Cincinnati Children's Hospital Medical Center

Date Released

2013 Apr 1

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools

Audit Criteria/Indicators

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
  • Improved effectiveness of measurement of cuff pressures
  • Decreased risk of tracheal wall damage, decompensation due to inadequate ventilation, and/or aspiration
Potential Harms

If cuff is over distended tracheal damage can occur and if cuff is underinflated inadequate ventilation can occur and/or aspiration.

Rating Scheme for the Strength of the Recommendations

Table of Recommendation Strength

Strength Definition
It is strongly recommended that…

It is strongly recommended that… not…
When the dimensions for judging the strength of the evidence are applied, there is high support that benefits clearly outweigh risks and burdens. (or visa-versa for negative recommendations)
It is recommended that…

It is recommended that… not…
When the dimensions for judging the strength of the evidence are applied, there is moderate support that benefits are closely balanced with risks and burdens.
There is insufficient evidence and a lack of consensus to make a recommendation…

Note: See the original guideline document for the dimensions used for judging the strength of the recommendation.

Qualifying Statements

Qualifying Statements

This Best Evidence Statement addresses only key points of care for the target population; it is not intended to be a comprehensive practice guideline. These recommendations result from review of literature and practices current at the time of their formulation. This Best Evidence Statement does not preclude using care modalities proven efficacious in studies published subsequent to the current revision of this document. This document is not intended to impose standards of care preventing selective variances from the recommendations to meet the specific and unique requirements of individual patients. Adherence to this Statement is voluntary. The clinician in light of the individual circumstances presented by the patient must make the ultimate judgment regarding the priority of any specific procedure.

Methodology

Methods Used to Collect/Select the Evidence

Searches of Electronic Databases

Description of Methods Used to Collect/Select the Evidence

Search Strategy

  • Databases: Medline, CINAHL, Google Scholar
  • Search Terms: Cuff pressures, endotracheal tubes, tracheostomy tubes, minimal leak technique, minimal occlusive volume
  • Limits, Filters, Search Dates: Neonatal, Pediatric; 2001-2009
  • Date Search Done: April 2012-August 2012
Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Table of Evidence Levels

Quality Level Definition
1a† or 1b† Systematic review, meta-analysis, or meta-synthesis of multiple studies
2a or 2b Best study design for domain
3a or 3b Fair study design for domain
4a or 4b Weak study design for domain
5a or 5b General review, expert opinion, case report, consensus report, or guideline
5 Local Consensus

†a = good quality study; b = lesser quality study

Methods Used to Analyze the Evidence

Systematic Review

Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

Not stated

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

Peer Review

Description of Method of Guideline Validation

This Best Evidence Statement has been reviewed against quality criteria by 2 independent reviewers from the Cincinnati Children's Hospital Medical Center (CCHMC) Evidence Collaboration.

Identifying Information and Availability

Bibliographic Source(s)

Cincinnati Children's Hospital Medical Center. Best evidence statement (BESt). Tracheal cuff pressure management. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2013 Apr 1. 4 p. [10 references]

Adaptation

Not applicable: The guideline was not adapted from another source.

Source(s) of Funding

Cincinnati Children's Hospital Medical Center

Guideline Committee

Not stated

Composition of Group That Authored the Guideline

Team Leader/Author: Jessica Sexton, BHS, RRT-NPS, Transitional Care Center & Neonatal Intensive Care Unit

Team Members/Co-Authors: Tonie Perez, BHS, RRT-NPS, Neonatal Intensive Care Unit; Amy Wolf, BS, RRT-NPS, Transport

Support/Consultant: Cyndi White, MSc, RRT-NPS, FAARC, Research Respiratory Therapist

Financial Disclosures/Conflicts of Interest

Conflict of interest declaration forms are filed with the Cincinnati Children's Hospital Medical Center Evidence-based Decision Making (CCHMC EBDM) group. No financial or intellectual conflicts of interest were found.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available from the Cincinnati Children's Hospital Medical Center Web site.

Print copies: For information regarding the full-text guideline, print copies, or evidence-based practice support services contact the Cincinnati Children's Hospital Medical Center Health James M. Anderson Center for Health Systems Excellence at EBDMInfo@cchmc.org.

Availability of Companion Documents

The following are available:

Print copies: For information regarding the full-text guideline, print copies, or evidence-based practice support services contact the Cincinnati Children's Hospital Medical Center Health James M. Anderson Center for Health Systems Excellence at EBDMInfo@cchmc.org.

In addition, suggested process or outcome measures are available in the original guideline document.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on May 23, 2013.

Copyright Statement

This NGC summary is based on the original full-text guideline, which is subject to the following copyright restrictions:

Copies of this Cincinnati Children's Hospital Medical Center (CCHMC) Best Evidence Statement (BESt) are available online and may be distributed by any organization for the global purpose of improving child health outcomes. Examples of approved uses of the BESt include the following:

  • Copies may be provided to anyone involved in the organization's process for developing and implementing evidence based care
  • Hyperlinks to the CCHMC website may be placed on the organization's website
  • The BESt may be adopted or adapted for use within the organization, provided that CCHMC receives appropriate attribution on all written or electronic documents
  • Copies may be provided to patients and the clinicians who manage their care

Notification of CCHMC at EBDMInfo@cchmc.org for any BESt adopted, adapted, implemented or hyperlinked by the organization is appreciated.

Scope

Disease/Condition(s)

Diseases and conditions requiring cuffed endotracheal tubes or cuffed tracheostomy tubes

Guideline Category

Management

Clinical Specialty

Anesthesiology
Internal Medicine
Pediatrics
Pulmonary Medicine

Intended Users

Advanced Practice Nurses
Nurses
Physician Assistants
Physicians

Guideline Objective(s)

To evaluate, in pediatric patients with cuffed endotracheal or tracheostomy tubes, if minimal leak technique (MLT)/minimal occlusive volume (MOV) technique compared to using a cuff manometer is a more effective way to measure cuff pressures

Target Population

Neonatal and pediatric patients with a cuffed endotracheal tube or cuffed tracheostomy tube

Interventions and Practices Considered
  1. Tracheal cuff pressure measurement (cuff manometer)
  2. Minimal leak technique (MLT)/minimal occlusive volume (MOV) technique
Major Outcomes Considered

Effectiveness of measuring cuff pressures

Recommendations

Major Recommendations

The strength of the recommendation (strongly recommended, recommended, or no recommendation) and the quality of the evidence (1a‒5b) are defined at the end of the "Major Recommendations" field.

It is recommended that cuff pressure be measured in the neonatal and pediatric population.

Note 1: There are no studies that compare any one of these measurement approaches to another in neonates and pediatrics therefore one approach over another cannot be recommended. Research among the neonatal and pediatric populations would prove beneficial.

Note 2: At Cincinnati Children's Hospital Medical Center (CCHMC), current policy is to utilize minimal occlusive volume (MOV) and measure pressures with a cuff manometer, at least once per shift.

Definitions:

Table of Evidence Levels

Quality Level Definition
1a† or 1b† Systematic review, meta-analysis, or meta-synthesis of multiple studies
2a or 2b Best study design for domain
3a or 3b Fair study design for domain
4a or 4b Weak study design for domain
5a or 5b General review, expert opinion, case report, consensus report, or guideline
5 Local Consensus

†a = good quality study; b = lesser quality study

Table of Recommendation Strength

Strength Definition
It is strongly recommended that…

It is strongly recommended that… not…
When the dimensions for judging the strength of the evidence are applied, there is high support that benefits clearly outweigh risks and burdens. (or visa-versa for negative recommendations)
It is recommended that…

It is recommended that… not…
When the dimensions for judging the strength of the evidence are applied, there is moderate support that benefits are closely balanced with risks and burdens.
There is insufficient evidence and a lack of consensus to make a recommendation…

Note: See the original guideline document for the dimensions used for judging the strength of the recommendation.

Clinical Algorithm(s)

None provided

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need

Getting Better

IOM Domain

Effectiveness
Patient-centeredness

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