Journal of Clinical Monitoring and Computing

, Volume 33, Issue 2, pp 301–305 | Cite as

Assessing the correct inflation of the endotracheal tube cuff: a larger pilot balloon increases the sensitivity of the ‘finger-pressure’ technique, but it remains poorly reliable in clinical practice

  • Antonio PisanoEmail author
  • Luigi Verniero
  • Nicola Galdieri
  • Antonio Corcione
Original Research


The pilot balloon palpation (or ‘finger-pressure’) method is still widely used to assess the endotracheal tube cuff inflation, despite consistent evidence of its poor sensitivity in recognizing cuff overinflation. It was recently speculated that this may be related to the lower wall tension (due to the smaller radius) of the pilot balloon as compared with the cuff, according to Laplace’s law. To verify this hypothesis and, secondarily, to assess whether the use of a ‘large’ pilot balloon (identical to the cuff) increases the reliability of this technique, 62 anesthetists (41 experienced anesthesiologists and 21 residents) were asked to estimate the pressure of a cuff inflated to 88 mmHg into a simulated trachea by feeling both a usual and a modified ‘large’ pilot balloon. A similar test was repeated at 40 mmHg. After palpation of the usual pilot balloon, only 35% of participants (49% of experienced anesthesiologists and 10% of residents) recognized considerable overinflation (88 mmHg), as compared with 87% of participants (95% of experienced anesthesiologists and 71% of residents) after palpation of the ‘large’ pilot balloon. Moreover, 89% of participants (85% of experienced anesthesiologists and 95% of residents) believed that pressure was higher in the ‘large’ balloon than in the normal one. However, only 32% of participants (51% of experienced anesthesiologists and none of residents) recognized slight overinflation (40 mmHg) after feeling the ‘large’ balloon. The pilot balloon size affects the sensitivity of the ‘finger-pressure’ technique, but it remains poorly reliable with a larger pilot balloon.


Tracheal tube cuff Airway management Pressure gauge Tracheal injury Ventilator-associated pneumonia 



This work was supported only by institutional funds of the Department of Critical Care, AORN ‘Dei Colli’, Naples, Italy.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Liu J, Zhang X, Gong W, Li S, Wang F, Fu S, Zhang M, Hang Y. Correlations between controlled endotracheal tube cuff pressure and postprocedural complications: a multicenter study. Anesth Analg. 2010;111(5):1133–7.CrossRefGoogle Scholar
  2. 2.
    Efrati S, Bolotin G, Levi L, Zaaroor M, Guralnik L, Weksler N, et al Levinger U, Soroksky A, Denman WT, Gurman GM. Optimization of endotracheal tube cuff pressure by monitoring CO2 levels in the subglottic space in mechanically ventilated patients: a randomized controlled trial. Anesth Analg. 2017;125(4):1309–15.CrossRefGoogle Scholar
  3. 3.
    Hockey CA, van Zundert AA, Paratz JD. Does objective measurement of tracheal tube cuff pressures minimise adverse effects and maintain accurate cuff pressures? A systematic review and meta-analysis. Anaesth Intensive Care. 2016;44(5):560–70.Google Scholar
  4. 4.
    Giusti GD, Rogari C, Gili A, Nisi F. Cuff pressure monitoring by manual palpation in intubated patients: how accurate is it? A manikin simulation study. Aust Crit Care. 2017;30(4):234–8.CrossRefGoogle Scholar
  5. 5.
    Michlig SA. Anaesthetic staff cannot identify extremely high tracheal tube cuff pressures by palpation of the pilot balloon. Br J Anaesth. 2013;111(2):300–1.CrossRefGoogle Scholar
  6. 6.
    Sole ML, Penoyer DA, Su X, Jimenez E, Kalita SJ, Poalillo E, Byers JF, Bennett M, Ludy JE. Assessment of endotracheal cuff pressure by continuous monitoring: a pilot study. Am J Crit Care. 2009;18:133–43.CrossRefGoogle Scholar
  7. 7.
    Svenson JE, Lindsay MB, O’Connor JE. Endotracheal intracuff pressures in the ED and prehospital setting: is there a problem? Am J Emerg Med. 2007;25:53–6.CrossRefGoogle Scholar
  8. 8.
    Janossy KM, Pullen J, Young D, Bell G. The effect of pilot balloon design on estimation of safe tracheal tube cuff pressure. Anaesthesia. 2010;65(8):785–91.CrossRefGoogle Scholar
  9. 9.
    Hoffman RJ, Rarwani V, Hahn IH. Experienced emergency medicine physicians cannot safely inflate or estimate endotracheal tube cuff pressure using standard techniques. Am J Emerg Med. 2006;24:139–42.CrossRefGoogle Scholar
  10. 10.
    Pisano A. Pitfalls from physics: why we can’t “feel” the tube cuff pressure with our fingers. Anesth Analg. 2017;124(4):1368.CrossRefGoogle Scholar
  11. 11.
    Pisano A. Bubbles, tracheal tube cuffs, and reservoir bags: surface tension and Laplace’s law. In: Physics for anesthesiologists. Cham: Springer; 2017. pp. 33–43.CrossRefGoogle Scholar
  12. 12.
    Pisano A. Toothpaste, sea deeps, and invasive pressure monitoring: Stevin’s law and Pascal’s principle. In: Physics for anesthesiologists. Cham: Springer; 2017. pp. 65–73.CrossRefGoogle Scholar
  13. 13.
    Özcan ATD, Döğer C, But A, Kutlu I, Aksoy ŞM. Comparison of endotracheal tube cuff pressure values before and after training seminar. J Clin Monit Comput. 2018;32(3):527–31.CrossRefGoogle Scholar
  14. 14.
    Efrati S, Deutsch I, Gurman GM. Endotracheal tube cuff-small important part of a big issue. J Clin Monit Comput. 2012;26(1):53–60.CrossRefGoogle Scholar
  15. 15.
    Kamata M, Kako H, Ramesh AS, Krishna SG, Tobias JD. An in vitro and in vivo validation of a novel color-coded syringe device for measuring the intracuff pressure in cuffed endotracheal tubes. Int J Clin Exp Med. 2015;8(7):11356–9.Google Scholar
  16. 16.
    Ramesh AS, Krishna SG, Denman WT, Tobias JD. An in vitro and in vivo validation of a novel monitor for intracuff pressure in cuffed endotracheal tubes. Paediatr Anaesth. 2014;24:1005–8.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media B.V., part of Springer Nature 2018

Authors and Affiliations

  1. 1.Cardiac Anesthesia and Intensive Care UnitAORN ‘Dei Colli’, Monaldi HospitalNaplesItaly
  2. 2.Department of Critical CareAORN ‘Dei Colli’NaplesItaly

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