Measuring endotracheal tube intracuff pressure: no room for complacency


Tracheal intubation constitutes a routine part in the care of critically ill and anaesthetised patients. Prolonged use of endotracheal with inflated cuff is one of the major multifactorial causes of complications. Both under-inflation and over-inflation of cuff are associated with complications. Despite known problems, regular measurement of cuff pressure is not routine, and it is performed on an ad hoc basis.


An endotracheal tube (ETT) is commonly used to protect a patient’s airway from aspiration of gastric contents and to facilitate positive pressure ventilation during anaesthesia, in the Post Anaesthesia Care Unit (PACU) and in the Intensive Care Unit (ICU) [1, 2]. The development, evolution and modification of the ETT continues to help with minimizing aspiration, isolating the lung, allowing the provision of a clear surgical field during general anaesthesia, monitoring laryngeal nerve damage during surgery, preventing airway fires during laser surgery and for the administering of medications [3]. Most modern ETTs are made of polyvinyl chloride and have a high-volume low-pressure cuffed design that conforms to the shape of the trachea. The cuff near the distal end of the ETT is inflated usually with air to create an airtight seal [4].

Micro-aspiration of secretions into the lower respiratory tract contaminated by bacteria is the main pathogenic mechanism for ventilator associated pneumonia (VAP). VAP has been shown to be prevented by subglottic secretion of drainage confirmed by meta-analyses of randomized controlled trials [5]. The level of evidence is moderate and recommendations have been made for these devices to be used in patients with an anticipated requirement for mechanical ventilation longer than 48 h [6]. Another potentially promising ETT design is to leverage on the advantageous effect of silver-coating in reducing biofilm formation and lowering respiratory tract colonization. A randomized controlled trial found that VAP rates were reduced in the group receiving silver-coated tube compared to the control (4.8% versus 7.5%, p = 0.03) [7]. Newer endotracheal tubes have combined several interventions together to reduce aspiration of secretions with the aim of eliminating VAP. These include the incorporation of low-volume low-pressure cuffs, subglottic secretion drainage ports, tracheal seal monitors, securing flanges, and coated tube lumen. Despite these new modifications showing positive initial reports [8], VAP remains a major concern in the ICU where the ETT resides in the trachea for longer duration. Prolonged intubation is associated with increased morbidity and mortality from the leakage of contaminated oral and gastric secretions beyond the inflated ETT cuff into the lungs. The presence of an ETT might accelerate this complication because it is also known to reduce the natural defences of the upper airway [9]. Preventing aspiration of secretions that sit above the cuff from reaching into the lungs by maintaining an adequate cuff pressure against the tracheal wall is one of the important mitigation factors [3]. ETT cuffs are designed to prevent aspiration and allow application of positive pressure ventilation, provided adequate cuff pressure is maintained [10]. The pressure of the ETT cuff is transmitted onto the wall of the trachea and should exceed the sum of hydrostatic pressure generated by a column of contents above the cuff and negative pressure generated during inspiration [11]. Despite known complications related to ETT intracuff pressure, there is a paucity of national or international guidelines on the optimal intracuff pressure, frequency of pressure measurement and methods of measurement [12,13,14,15,16].

Several noxious reactions and problems have been attributed to cuffed ETTs such as sore throat, coughing, hypertension, tachycardia, dysrhythmia and elevation of intracranial and intraocular pressures. These reactions are usually well tolerated in healthy patients, although they may impact anaesthesia (requiring higher doses of anaesthetic drugs) at induction, maintenance and emergence. These reactions can be problematic in patients with ischaemic heart disease, pre-existing hypertension, increased intracranial pressure, and ocular trauma.

This editorial explores the importance of measuring intracuff pressure, optimal pressure, issues related to under-inflation and over-inflation, frequency of measurement, methods and utility of pressure measurement; as well as the prevention of VAP and other associated complications through good clinical practice. Future direction in developing the ideal ETT is also discussed.

Importance of measuring ETT intracuff pressure

The cuff of an ETT is routinely inflated with air and rarely other substances (e.g. nitrous oxide, alkalinized lidocaine, saline etc.). A rapid decrease in cuff pressure may occur after administration of nitrous oxide which could increase the risk of VAP [17]. On the other hand, nitrous oxide may not always provide a low-pressure effect in high-volume low-pressure ETT; and could cause rupture of the trachea due to diffusion of nitrous oxide from reduced tracheal perfusion pressure and ischaemic damage upon over-inflation [18]. Soares et al. [19] filled the ETT cuff with alkalinised lidocaine and noted reduced haemodynamic response to tracheal extubation. The pressure of the cuff against the tracheal wall depends on the compliance of the trachea, cuff pressure and other factors (cuff material, inflated cuff volume, type of substance used to inflate the cuff). It is important to ensure that an appropriate amount of pressure is exerted on the tracheal wall by the cuff of the ETT. A suitable pressure is desirable in order to form an effective seal that reduces and prevents pulmonary aspiration and at the same time minimizing pressure injury to the tracheal wall [20,21,22,23]. Pressure measured at the pilot balloon of an ETT is considered a good estimate of the cuff pressure exerted onto the tracheal mucosa. There is a linear relationship between the measured intracuff pressure and the volume of air inflated into the cuff [24, 25]. The pressure inside the ETT cuff is known to be affected by several factors; including lateral wall pressure, duration of ETT placement [4], patient position [26], head position [27], cuff position [28], cuff volume, temperature [29], use of nitrous oxide [30] and other lesser known factors. Deliberate or inadvertent movement of the ETT may also affect cuff pressure by creating folds in the cuff letting pooled secretions pass downwards. Whatever may be the reasons for the compromised seal between the cuff and trachea, micro-aspirations contaminated with gastric contents or colonized oral secretions with bacteria can occur [31], resulting in VAP.

What should be the optimal intracuff pressure?

Despite a perceived need to measure and monitor intracuff pressure, there is a lack of uniformity regarding the optimal pressure targets and requisite documentation. Most clinicians utilise cuff pressures of 20 to 30 cmH2O [32]. It is recommended that intracuff pressure should preferably be measured directly [22, 28]. Factors affecting the cuff pressure such as the size of the ETT, cuff type, initial cuff pressure, cuff pressure measuring devices and patient profiles should be considered [33].

Problems associated with under-inflation of intracuff pressure

A cuff pressure of < 20 cmH2O was found to be an independent risk factor for developing complications [22, 24]. If the cuff has insufficient inflation pressure, it increases the risk of micro-aspirations and the passage gastric contents and contaminated secretions of the oral cavity into the trachea; this potentially causing aspiration pneumonitis and pneumonia, bronchitis as well as accidental extubation and self-extubation [22, 34,35,36,37]. A previous study has shown that if the pressure inside the cuff is kept < 20 cmH2O, the risk of the occurrence of VAP is increased by four times compared to higher cuff pressure [36].

Problem associated with over-inflation of intracuff pressure

Over-inflation of ETT cuff is considered as the injection of a volume of air more than that needed to create an adequate seal between the cuff and the tracheal wall [4]. Kao et al. [38] reported hyperinflation of ETT cuff resulting in the herniation of the cuff balloon in front of the tube’s end, potentially blocking gas exchange during the creation of tracheal stoma. Wright and Baruch [39] observed a situation where there was a leak due to the herniation of large-volume and low-pressure cuffed ETT when more and more air was injected into the cuff. In this situation, the cuff herniated upwards through the glottis. Over-inflation of the ETT occurs more commonly than appreciated. In a study involving the helicopter service, ETT cuffs were inflated to pressures that are, on average, more than double the recommended maximum [40]. A cuff pressure of > 30 cmH2O may compromise local tissue blood flow and cause damage to the tracheal mucosal wall and surrounding anatomical structures [4, 41]. Blood flow in the antero-lateral part of the trachea has been reported to be compromised at pressures exceeding 30 cmH20 and obstructed at pressures exceeding 50 cmH20 [42]. High pressure affects micro-circulation and integrity of the tracheal mucosa, resulting in complications ranging from sore throat, hoarseness, tracheal stenosis, ulceration, necrosis, tracheal rupture and tracheo-esophageal fistula injury [43,44,45,46,47,48,49,50,51,52].

High-volume low-pressure ETT cuffs claim to have less deleterious effect on the tracheal mucosa compared with high-pressure low-volume cuffs. However, even low-pressure cuffs may easily be overinflated to yield pressures that exceed capillary perfusion pressure [41]. It is recommended that the commonly used traditional ETT cuffs are of high-volume low-pressure types and these should not be fully inflated during their use. The longitudinal folds in cuff wall are not under tension and the pressure exerted on the tracheal wall by the cuff is equal to the intracuff pressure [53]. It is known that intracuff pressure of 30 cmH2O of high-volume low-pressure cuff exerts approximately 30 cmH2O of pressure on the tracheal wall and that should suffice [54]. Unfortunately, high-volume low-pressure cuffs have been shown to still allow pulmonary aspiration at an intracuff pressure of 30 cmH2O along the longitudinal folds which may develop in the cuff wall [46].

How often should intracuff pressure be measured?

There appears to be a wide variation in clinical practices around the world regarding how often to measure the ETT cuff pressure, both in the intensive care unit as well as during anaesthesia. Sole et al. [9] recommended cuff pressure measurement of at least three times a day, once per shift in the intensive care unit, given the significant variability of the value of the cuff pressure during the day. Nseir et al. [24] recommended measuring cuff pressure every 8 h and noted that the cuff pressure was maintained within 20–30 cmH2O range in only 18% of patients, lower than 20 cmH2O at least once for 54% of patients and over 30 cmH2O at least once for 73% of patients. Danielis et al. [55] conducted an observational study involving 72 patients in ICU. They found that during the first four hours there were 4 cases of underinflated cuff and 5 cases of over-inflated, from the 5th–8th h 7 cases of intracuff pressures < 20 cmH2O, and 3 cases > 30 cmH2O. During the last four hours, 22 cases had underinflated cuff and 4 cases had overinflated cuff. The authors recommended that there was a need for continuous monitoring of ETT intracuff pressure in promptly identifying deviations from the pressure ranges and allowing their rapid correction. Motoyama et al. [56] observed that intracuff pressure decreased to < 20 cmH2O in 45% of measurement occasions taken from critically ill patients 2 h after adjusting it to 24 cmH2O. The authors recommended to measure intracuff pressure every 8–24 h because the air inside the cuff may escape from the endotracheal cuff surface or through the pilot balloon valve [56, 57]. Considering the wide variations in clinical practices, it is important to check intracuff pressure whenever feasible, possibly three-times daily to maintain the pressure within the target range. However, one has to be cognizant that repeated connecting and reconnecting cuff inflator to a pilot balloon decreases the intracuff pressure by 6.6 ± 1.9 cmH2O due to gas escaping from the cuff, resulting in the loss of adequate intracuff pressure [58].

Techniques of measuring intracuff pressure

There are various in-house as well as commercially available methods for inflating the cuff of ETTs described as follows:

Manual palpation of pilot balloon

The pilot balloon of ETT is checked by palpation for approximate pressure, but this technique has been found to be inadequate. This method determines approximate pressure inside the cuff [9] and known to produce over-inflation of the cuff in 30–98% of the cases [59], depending on the type of ETT used and the population studied [14, 60, 61]. The rapid, qualitative evaluation of the pilot balloon via manual palpation can serve as a surrogate estimation of intracuff pressure, but this method is subject to inherent inaccuracies and does not provide any quantitative data. Saraçoğlu et al. [62] demonstrated that there was no significant correlation between the experience of the anaesthesia provider and the appropriateness of the ETT intracuff pressure when subjects were instructed to manually inflate the cuff to what they deemed as an appropriate amount. Harm et al. [63] showed that not only do anaesthesia providers frequently misjudge pressures but persons responsible for prehospital intubations do as well.

Minimum leak technique

It is the determination of volume of air to inject into the cuff based on how much is required to detect a small end-inspiratory leak by auscultating the front of the chest [46]. The cuff is inflated either until just a minimal leak occurs at peak inspiration or with slightly more volume to fully occlude the airway and prevent a leak during positive pressure ventilation. Similar to the palpation technique, this method is also prone to errors but might have better acceptability amongst practicing clinicians [46, 64]. Bulamba et al. [65] recommended using a loss of resistance syringe as a viable option to simple palpation method. A 7 ml plastic, luer slip, loss of resistance syringe containing air into the pilot balloon and the loss of resistance syringe plunger could passively draw back until it ceased.

Minimum occlusive volume

This is the volume of air required to inject into the cuff to eliminate audible end-inspiratory leak with positive pressure ventilation but does not guarantee a safe maximum pressure. Minimum leak technique and minimum occlusive volume appear to have similar principles [46, 64].

Predetermined volume technique

This involves injection of pre-determined volume of air to inflate the cuff, but this varies depending on manufacturers. The injection of air with a syringe of a predetermined volume into the cuff is the most widely used in clinical practice. This is simple, fast and cost-effective; however, the relationship between the volume injected, pressure attained in cuff and lateral pressure exerted on the tracheal wall are not linear.

Blanch [66] opined that significant differences in intracuff pressure readings occur when different methods of inflation are used.

Analogue/digital manometer

This is most accurate method and the pressure can be measured by connecting the pilot balloon to a simple calibrated analogue or digital manometer [10, 14, 22, 66, 67].

Direct intracuff pressure monitoring

A pressure transducer or a similar automated system is attached directly to the pilot balloon which provides a quantitative pressure reading of the cuff. The manometer provides greater accuracy as a detection tool [68]. Pressure measuring systems are either an integral part of the ETT or can be attached separately. This is subject to cost implications and logistical considerations. Flores-Fraco [69] described a novel simple technique for measuring cuff pressure that can be performed with readily available materials by using a 1 mL syringe interposed between a blood pressure manometer and the pilot balloon of the endotracheal tube.

Automatic control devices

Systems that automatically control tracheal cuff inflation and pressure are expected to maintain a consistent pressure, but their impact on preventing VAP is mixed. Valencia et al. [57] in a randomized study involving 142 subjects comparing cuff inflation by either an automated device or manual pressure measurement every 8 h found a higher rate of measurement to be within the recommended range of 20–30 cmH2O in the automated group (79.3% vs 48.3%). Fewer measurements were < 20 cmH2O in the automated group (0.7% vs 45.3%). Surprisingly, there was also a higher rate of measurement > 30 cmH2O (20.0% vs 6.4%). In another randomized study by Nseir et al. [24] involving 122 subjects compared an automated system versus 3 times daily manual measurements. The automated system was associated with a greater ability to keep pressure within the range of 20–30 cmH2O (98% vs 74%), fewer measurements were < 20 cmH2O (0.1% vs 19%) or > 30 cmH2O (0.7% vs 5%) and there was a lower rate of ventilator associated pneumoniae (9.8 vs 26.2%). Kim and Lee [70] used a conventional invasive blood pressure monitor transducer to continuously display the ETT cuff pressure on the anaesthetic monitoring system. Michikoshi et al. [71] described a new automated cuff pressure controller which was developed based on the concept of a durable device that does not require a power source, and can continuously maintain uniform cuff pressure, while also being able to rapidly adjust sudden pressure changes. The device comprised an air bag, pressing plate, pressure control system, air pump, jog dial, safety valve, and pressure gauge. If intracuff pressure suddenly changes, the pressing plate immediately stabilizes the pressure; and through the flow of air from the cuff into the air bag, the pressure on the respiratory tract mucosa is mitigated.

Pressure-sensing syringe for ETT cuffs

Slocum et al. [72] reported an in vitro prototype disposable pressure-sensing syringe for measuring ETT cuff pressure which simultaneously inflates to a predetermined safe value and measures the pressure generated within the cuff. Commercial availability remains a problem.

Mobile terminal application program

A recent innovative idea using a mobile device to remind and measure ETT intracuff pressure with a simple manometer was published earlier in this journal (JCMC-D-19-00225R2) by Wang et al. [73] which merits a detailed discussion. The mobile terminal scanned the two-dimensional code of patient's wrist band. ETT cuff pressure was measured using a simple manometer. The mobile terminal scanned the two-dimensional code on the manometer and entered the cuff pressure on the interface before and after measurement. The device was programmed in such a way that when the cuff pressure was not measured over 8 h, the mobile terminal would pop up a message to remind the nurse to measure the pressure. The mobile terminal programme also has the function of feedback of intracuff pressure measurement. The head nurse could glance over the cuff pressure measurement of each patient on the computer, including the frequency of cuff pressure measurement and the pressure value before and after each measurement. Essentially, the mobile terminal application programme is a novel mobile phone application and reminder system for 8-hourly cuff pressure measurement using an analogue manometer with the functionality of documenting cuff pressures in viewable electronic medical records. In this before-and-after observational study cum quality improvement project, the authors found a statistically significant increase in compliance of cuff pressure for the mobile terminal application program group within the recommended range (78.4% versus 56.9%, p < 0.05), defined by the investigators as between 25 and 30 cmH2O. The study was powered based on a 10% increase in cuff pressure maintenance in the recommended range. Despite collecting clinical data over a 1-year period in a 40-bed Intensive Care Unit, the patient-centric or clinically important outcome of VAP yielded no difference between the groups (13.7% in the baseline group versus 11.9% in the intervention group, p = 0.543); this indicating that the pathogenesis of VAP is multifaceted and other factors aside from cuff pressures would contribute to this adverse outcome.

Air bubble technique

In this issue of the journal (JCMC -D-20-00062R1) Bloria [74] suggested an alternative method to identify ETT cuff hyperinflation. The author tested the method using a 1 L normal saline intravenous infusion bag exposed to atmospheric pressure. The infusion bag was connected to the ETT pilot balloon with a 3-ways connector. The column of normal saline exerted a hydrostatic pressure of approximately 25–27 cmH2O. Excess air, if any, in the ETT cuff escaped and appeared as air bubbles rising through the saline bag.

We should be aware that all quality improvement projects are susceptible to the Hawthorne effect or observer effect; where the behaviour of the users may be modified favourably due to the awareness of the introduction of new initiative and the fact that one is being observed for performance [75]. This may therefore undermine the relationships between the intervention, outcome variables (such as intracuff pressure measurements) and the integrity of the results [75]. In the long-term, the increased burden of reminders for consistent cuff pressure measurement, maintenance and documentation may result in task and alarm fatigue, thereby making project sustainability a concern. To obtain buy-in, ground staff involved in this process should be educated and convinced of the patient safety benefits of this intervention.

Anaesthetists and intensivists do not consistently and regularly measure intracuff pressure of ETTs in the operating theatre; and even in the Intensive Care Units. Reasons may include: (a) they are not convinced it makes a significant impact on the aspiration risk; (b) manometers or other measuring devices are not readily available (intermittent techniques are clumsy and continuous techniques may be difficult to implement); (c) most manometers used intermittently results in a cuff leak during attachment and detachment of the manometer to the pilot cuff, thus accurate measurement may be difficult; and (d) trainees do not perform these procedures because of supervisor role-modelling. We would make an appeal to the manufacturers of ETTs to incorporate accurate and easy-to-use in-line intracuff pressure manometers that provides continuous readings at the correct level. This functionality already exists for some supraglottic airway devices [76]. Intermittent measurement of intracuff pressure only provides a limited recording of intracuff pressure of ETTs that does not guarantee continuous safety during head and neck manipulations of the patient, which can result in immediate changes in the ETT intracuff pressure outside of the recommended range.


Patients are increasingly ventilated during anaesthesia and in the Intensive Care Units for longer duration. Adequate pressure in the ETT cuff is of paramount importance, as both over-inflation as well as under-inflation are associated with clinically significant complications. There is a paucity of conclusive data regarding the optimal frequency of measurement and range of intracuff pressure; however published literature suggests that the cuff pressure should be measured 3-times daily in Intensive Care Unit patients. It is desirable during anaesthesia to use a continuous in-built intracuff pressure measurement technique. More research is required to be geared towards designing an ideal intracuff pressure measuring device or to incorporate in-line intracuff pressure manometers in the endotracheal tube. Equipment manufacturers might be able to find such solutions and develop a product which will have an important role to play in preventing ETT intracuff pressure related complications and safe airway management.


  1. 1.

    Aziz MF. Advancing patient safety in airway management. Anesthesiology. 2018;128:434–6.

    PubMed  Article  Google Scholar 

  2. 2.

    Pandit JJ, Irwin MG. Airway management in critical illness: practice implications of new Difficult Airway Society guidelines. Anaesthesia. 2018;73:544–8.

    CAS  PubMed  Article  Google Scholar 

  3. 3.

    Haas CF, Eakin RM, Konkle MA, Blank R. Endotracheal tubes: old and new. Respir Care. 2014;59:933–52.

    PubMed  Article  Google Scholar 

  4. 4.

    Sultan P, Carvalho B, Rose BO, Cregg R. Endotracheal tube cuff pressure monitoring: a review of the evidence. J Perioper Pract. 2011;21:379–86.

    PubMed  Article  Google Scholar 

  5. 5.

    Caroff DA, Li L, Muscedere J, Klompas M. Subglottic secretion drainage and objective outcomes: a systematic review and meta-analysis. Crit Care Med. 2016;44:830–40.

    PubMed  Article  Google Scholar 

  6. 6.

    Rouzé A, Jaillette E, Poissy J, Préau S, Nseir S. Tracheal tube design and ventilator-associated pneumonia. Respir Care. 2017;62:1316–23.

    PubMed  Article  Google Scholar 

  7. 7.

    Kollef MH, Afessa B, Anzueto A, Veremakis C, Kerr KM, Margolis BD, et al. Silver-coated endotracheal tubes and incidence of ventilator-associated pneumonia: the NASCENT randomized trial. JAMA. 2008;300:805–13.

    CAS  PubMed  Article  Google Scholar 

  8. 8.

    Gopal S, Luckraz H, Giri R, Nevill A, Muhammed I, Reid M, et al. Significant reduction in ventilator-associated pneumonia with the Venner-PneuX System in high-risk patients undergoing cardiac surgery: the Low Ventilator-Associated-Pneumonia study. Eur J Cardiothorac Surg. 2015;47:e92–96.

    PubMed  Article  Google Scholar 

  9. 9.

    Sole ML, Su X, Talbert S, Penoyer DA, Kalita S, Jimenez E, et al. Evaluation of an intervention to maintain endotracheal tube cuff pressure within therapeutic range. Am J Crit Care. 2011;20:109–17 (quiz 118).

    PubMed  PubMed Central  Article  Google Scholar 

  10. 10.

    Sanaie S, Rahmani F, Chokhachian S, Mahmoodpoor A, Rahimi Panahi J, Mehdizadeh Esfanjani R, et al. Comparison of tracheal tube cuff pressure with two technique: fixed volume and minimal leak test techniques. J Cardiovasc Thorac Res. 2019;11:48–52.

    PubMed  PubMed Central  Article  Google Scholar 

  11. 11.

    Mehta S, Myat HM. The cross-sectional shape and circumference of the human trachea. Ann R Coll Surg Engl. 1984;66:356–8.

    CAS  PubMed  PubMed Central  Google Scholar 

  12. 12.

    Combes X, Schauvliege F, Peyrouset O, Motamed C, Kirov K, Dhonneur G, et al. Intracuff pressure and tracheal morbidity: influence of filling with saline during nitrous oxide anesthesia. Anesthesiology. 2001;95:1120–4.

    CAS  PubMed  Article  Google Scholar 

  13. 13.

    Doyle DJ. Digital display of endotracheal tube cuff pressures made simple. Anesthesiology. 1999;91:329.

    CAS  PubMed  Article  Google Scholar 

  14. 14.

    Galinski M, Tréoux V, Garrigue B, Lapostolle F, Borron SW, Adnet F. Intracuff pressures of endotracheal tubes in the management of airway emergencies: the need for pressure monitoring. Ann Emerg Med. 2006;47:545–7.

    PubMed  Article  Google Scholar 

  15. 15.

    Stewart SL, Secrest JA, Norwood BR, Zachary R. A comparison of endotracheal tube cuff pressures using estimation techniques and direct intracuff measurement. AANA J. 2003;71:443–7.

    PubMed  Google Scholar 

  16. 16.

    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.

    PubMed  Article  Google Scholar 

  17. 17.

    Fujiwara S, Noguchi A, Nakamura Y, Tsukamoto M, Hitosugi T, Yokoyama T. Diffusion of nitrous oxide through endotracheal tube cuffs. 2016. Accessed 31 Dec 2019.

  18. 18.

    Atalay C, Aykan Ş, Can A, Doğan N. Tracheal rupture due to diffusion of nitrous oxide to cuff of high-volume low-pressure intubation tube. Eurasian J Med. 2009;41:136–9.

    PubMed  PubMed Central  Google Scholar 

  19. 19.

    Soares SMF, Arantes VM, Módolo MP, Dos Santos VJB, Vane LA, Navarro E, Lima LH, et al. The effects of tracheal tube cuffs filled with air, saline or alkalinised lidocaine on haemodynamic changes and laryngotracheal morbidity in children: a randomised controlled trial. Anaesthesia. 2017;72:496–503.

    CAS  PubMed  Article  Google Scholar 

  20. 20.

    Metheny NA, Schallom L, Oliver DA, Clouse RE. Gastric residual volume and aspiration in critically ill patients receiving gastric feedings. Am J Crit Care. 2008;17:512–9 (quiz 520).

    PubMed  PubMed Central  Article  Google Scholar 

  21. 21.

    Poetker DM, Ettema SL, Blumin JH, Toohill RJ, Merati AL. Association of airway abnormalities and risk factors in 37 subglottic stenosis patients. Otolaryngol Head Neck Surg. 2006;135:434–7.

    PubMed  Article  Google Scholar 

  22. 22.

    Sengupta P, Sessler DI, Maglinger P, Wells S, Vogt A, Durrani J, et al. Endotracheal tube cuff pressure in three hospitals, and the volume required to produce an appropriate cuff pressure. BMC Anesthesiol. 2004;4:8.

    PubMed  PubMed Central  Article  Google Scholar 

  23. 23.

    Zias N, Chroneou A, Tabba MK, Gonzalez AV, Gray AW, Lamb CR, et al. Post tracheostomy and post intubation tracheal stenosis: report of 31 cases and review of the literature. BMC Pulm Med. 2008;8:18.

    PubMed  PubMed Central  Article  Google Scholar 

  24. 24.

    Nseir S, Duguet A, Copin M-C, De Jonckheere J, Zhang M, Similowski T, et al. Continuous control of endotracheal cuff pressure and tracheal wall damage: a randomized controlled animal study. Crit Care. 2007;11:R109.

    PubMed  PubMed Central  Article  Google Scholar 

  25. 25.

    Hoffman RJ, Dahlen JR, Lipovic D, Stürmann KM. Linear correlation of endotracheal tube cuff pressure and volume. West J Emerg Med. 2009;10:137–9.

    PubMed  PubMed Central  Google Scholar 

  26. 26.

    de Godoy ACF, Vieira RJ, Capitani EMD. Endotracheal tube cuff pressure alteration after changes in position in patients under mechanical ventilation. J Bras Pneumol. 2008;34:294–7.

    PubMed  Article  Google Scholar 

  27. 27.

    Brimacombe J, Keller C, Giampalmo M, Sparr HJ, Berry A. Direct measurement of mucosal pressures exerted by cuff and non-cuff portions of tracheal tubes with different cuff volumes and head and neck positions. Br J Anaesth. 1999;82:708–11.

    CAS  PubMed  Article  Google Scholar 

  28. 28.

    Bernhard WN, Yost L, Joynes D, Cothalis S, Turndorf H. Intracuff pressures in endotracheal and tracheostomy tubes. Related cuff physical characteristics. Chest. 1985;87:720–5.

    CAS  PubMed  Article  Google Scholar 

  29. 29.

    Atlas GM. A mathematical model of differential tracheal tube cuff pressure: effects of diffusion and temperature. J Clin Monit Comput. 2005;19:415–25.

    PubMed  Article  Google Scholar 

  30. 30.

    Mitchell V, Adams T, Calder I. Choice of cuff inflation medium during nitrous oxide anaesthesia. Anaesthesia. 1999;54:32–6.

    CAS  PubMed  Article  Google Scholar 

  31. 31.

    Hamilton VA, Grap MJ. The role of the endotracheal tube cuff in microaspiration. Heart Lung. 2012; 41. Accessed 9 Aug 2019.

  32. 32.

    Talekar CR, Udy AA, Boots RJ, Lipman J, Cook D. Tracheal cuff pressure monitoring in the ICU: a literature review and survey of current practice in Queensland. Anaesth Intensive Care. 2014;42:761–70.

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  33. 33.

    Vyas D, Inweregbu K, Pittard A. Measurement of tracheal tube cuff pressure in critical care. Anaesthesia. 2002;57(3):275–7.

    CAS  PubMed  Article  Google Scholar 

  34. 34.

    Pneumatikos IA, Dragoumanis CK, Bouros DE. Ventilator-associated pneumonia or endotracheal tube-associated pneumonia? An approach to the pathogenesis and preventive strategies emphasizing the importance of endotracheal tube. Anesthesiology. 2009;110:673–80.

    PubMed  Article  Google Scholar 

  35. 35.

    Torres A, Gatell JM, Aznar E, El-Ebiary M, Puig de la Bellacasa J, González J, et al. Re-intubation increases the risk of nosocomial pneumonia in patients needing mechanical ventilation. Am J Respir Crit Care Med. 1995;152:137–41.

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  36. 36.

    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;30:234–8.

    PubMed  Article  Google Scholar 

  37. 37.

    Nseir S, Zerimech F, Fournier C, Lubret R, Ramon P, Durocher A, et al. Continuous control of tracheal cuff pressure and microaspiration of gastric contents in critically ill patients. Am J Respir Crit Care Med. 2011;184:1041–7.

    PubMed  Article  Google Scholar 

  38. 38.

    Kao M-C, Yu Y-S, Liu H-T, Tsai S-K, Lin S-M, Huang Y-C. Airway obstruction caused by endotracheal tube cuff herniation during creation of tracheal stoma. Acta Anaesthesiol Taiwan. 2005;43:59–62.

    PubMed  Google Scholar 

  39. 39.

    Wright D, Baruch M. Herniation of tracheal tube cuffs: a simple teaching model. Anaesthesia. 2001;56:277.

    CAS  PubMed  Article  Google Scholar 

  40. 40.

    Tennyson J, Ford-Webb T, Weisberg S, LeBlanc D. Endotracheal tube cuff pressures in patients intubated prior to helicopter EMS transport. West J Emerg Med. 2016;17:721–5.

    PubMed  PubMed Central  Article  Google Scholar 

  41. 41.

    Seegobin RD, van Hasselt GL. Endotracheal cuff pressure and tracheal mucosal blood flow: endoscopic study of effects of four large volume cuffs. Br Med J (Clin Res Ed). 1984;288:965–8.

    CAS  Article  Google Scholar 

  42. 42.

    Seegobin RD, van Hasselt GL. Aspiration beyond endotracheal cuffs. Can Anaesth Soc J. 1986;33:273–9.

    CAS  PubMed  Article  Google Scholar 

  43. 43.

    Knowlson GT, Bassett HF. The pressures exerted on the trachea by endotracheal inflatable cuffs. Br J Anaesth. 1970;42:834–7.

    CAS  PubMed  Article  Google Scholar 

  44. 44.

    Stauffer JL, Olson DE, Petty TL. Complications and consequences of endotracheal intubation and tracheotomy. A prospective study of 150 critically ill adult patients. Am J Med. 1981;70:65–766.

    CAS  PubMed  Article  Google Scholar 

  45. 45.

    Greene KE, Peters JI. Pathophysiology of acute respiratory failure. Clin Chest Med. 1994;15:1–12.

    CAS  PubMed  Google Scholar 

  46. 46.

    Guyton DC, Barlow MR, Besselievre TR. Influence of airway pressure on minimum occlusive endotracheal tube cuff pressure. Crit Care Med. 1997;25:91–4.

    CAS  PubMed  Article  Google Scholar 

  47. 47.

    Craven DE, Steger KA. Epidemiology of nosocomial pneumonia. New perspectives on an old disease. Chest. 1995;108:1S–16S.

    CAS  PubMed  Article  Google Scholar 

  48. 48.

    Deslée G, Brichet A, Lebuffe G, Copin MC, Ramon P, Marquette CH. Obstructive fibrinous tracheal pseudomembrane. A potentially fatal complication of tracheal intubation. Am J Respir Crit Care Med. 2000;162:1169–71.

    PubMed  Article  Google Scholar 

  49. 49.

    Harris R, Joseph A. Acute tracheal rupture related to endotracheal intubation: case report. J Emerg Med. 2000;18:35–9.

    CAS  PubMed  Article  Google Scholar 

  50. 50.

    Fan C-M, Ko PC-I, Tsai K-C, Chiang W-C, Chang Y-C, Chen W-J, et al. Tracheal rupture complicating emergent endotracheal intubation. Am J Emerg Med. 2004;22:289–93.

    PubMed  Article  Google Scholar 

  51. 51.

    Hoffman RJ, Kato Y, Rivera LC, Sheth S, Prokofieva A, Parwani V. ETT cuff inflation and assessment. The experience and practice of Fire Department of New York paramedics. EMS Mag. 2009;38:64–6.

    PubMed  Google Scholar 

  52. 52.

    Nobre de Jesus G, Freitas F, Fernandes SM, Alvarez A. Post-intubation tracheal laceration. Intensive Care Med. 2019;45:521–2.

    PubMed  Article  Google Scholar 

  53. 53.

    Young PJ, Rollinson M, Downward G, Henderson S. Leakage of fluid past the tracheal tube cuff in a benchtop model. Br J Anaesth. 1997;78:557–62.

    CAS  PubMed  Article  Google Scholar 

  54. 54.

    Doyle A, Santhirapala R, Crowe M, Blunt M, Young P. The pressure exerted on the tracheal wall by two endotracheal tube cuffs: a prospective observational bench-top, clinical and radiological study. BMC Anesthesiol. 2010;10:21.

    PubMed  PubMed Central  Article  Google Scholar 

  55. 55.

    Danielis M, Benatti S, Celotti P, De Monte A, Trombini O. Continuous monitoring of endotracheal tube cuff pressure: best practice in intensive care unit. Assist Inferm Ric. 2015;34:15–20.

    PubMed  Google Scholar 

  56. 56.

    Motoyama A, Asai S, Konami H, Matsumoto Y, Misumi T, Imanaka H, et al. Changes in endotracheal tube cuff pressure in mechanically ventilated adult patients. J Intensive Care. 2014;2:7.

    PubMed  PubMed Central  Article  Google Scholar 

  57. 57.

    Valencia M, Ferrer M, Farre R, Navajas D, Badia JR, Nicolas JM, et al. Automatic control of tracheal tube cuff pressure in ventilated patients in semirecumbent position: a randomized trial. Crit Care Med. 2007;35:1543–9.

    PubMed  Article  Google Scholar 

  58. 58.

    Asai S, Motoyama A, Matsumoto Y, Konami H, Imanaka H, Nishimura M. Decrease in cuff pressure during the measurement procedure: an experimental study. J Intensive Care. 2014;2:34.

    PubMed  PubMed Central  Article  Google Scholar 

  59. 59.

    de Macedo Coelho R, de Paiva TTM, da Silva Telles Mathias LA. In vitro evaluation of the method effectiveness to limit inflation pressure cuffs of endotracheal tubes. Braz J Anesthesiol. 2016;66:120–5.

    Article  Google Scholar 

  60. 60.

    Bassi M, Zuercher M, Erne J-J, Ummenhofer W. Endotracheal tube intracuff pressure during helicopter transport. Ann Emerg Med. 2010;56(89–93):e1.

    Google Scholar 

  61. 61.

    Vottier G, Matrot B, Jones P, Dauger S. A cross-over study of continuous tracheal cuff pressure monitoring in critically-ill children. Intensive Care Med. 2016;42:132–3.

    PubMed  Article  Google Scholar 

  62. 62.

    Saraçoğlu A, Dal D, Pehlivan G, Göğüş FY. The professional experience of anaesthesiologists in proper inflation of laryngeal mask and endotracheal tube cuff. Turk J Anaesthesiol Reanim. 2014;42:234–8.

    PubMed  PubMed Central  Article  Google Scholar 

  63. 63.

    Harm F, Zuercher M, Bassi M, Ummenhofer W. Prospective observational study on tracheal tube cuff pressures in emergency patients—is neglecting the problem the problem? Scand J Trauma Resusc Emerg Med. 2013;21:83.

    PubMed  PubMed Central  Article  Google Scholar 

  64. 64.

    Guyton D, Banner MJ, Kirby RR. High-volume, low-pressure cuffs. Are they always low pressure? Chest. 1991;100:1076–81.

    CAS  PubMed  Article  Google Scholar 

  65. 65.

    Bulamba F, Kintu A, Ayupo N, Kojjo C, Ssemogerere L, Wabule A, et al. Achieving the recommended endotracheal tube cuff pressure: a randomized control study comparing loss of resistance syringe to pilot balloon palpation. Anesthesiol Res Pract. 2017;2017:2032748.

    PubMed  PubMed Central  Google Scholar 

  66. 66.

    Blanch PB. Laboratory evaluation of 4 brands of endotracheal tube cuff inflator. Respir Care. 2004;49:166–73.

    PubMed  Google Scholar 

  67. 67.

    Tobias JD, Schwartz L, Rice J, Jatana K, Kang DR. Cuffed endotracheal tubes in infants and children: should we routinely measure the cuff pressure? Int J Pediatr Otorhinolaryngol. 2012;76:61–3.

    PubMed  Article  Google Scholar 

  68. 68.

    Morris LG, Zoumalan RA, Roccaforte JD, Amin MR. Monitoring tracheal tube cuff pressures in the intensive care unit: a comparison of digital palpation and manometry. Ann Otol Rhinol Laryngol. 2007;116:639–42.

    PubMed  Article  Google Scholar 

  69. 69.

    Flores-Franco RA. Improvised technique for measuring tracheal tube cuff pressure. WJA. 2016;5:36.

    Article  Google Scholar 

  70. 70.

    Kim JB, Lee JM. A simple and widely available alternative method for endotracheal tube cuff pressure monitoring. Can J Anaesth. 2018;65:956–7.

    PubMed  Article  Google Scholar 

  71. 71.

    Michikoshi J, Matsumoto S, Miyawaki H, Niu H, Seo K, Yamamoto M, et al. Performance comparison of a new automated cuff pressure controller with currently available devices in both basic research and clinical settings. J Intensive Care. 2016;4:4.

    PubMed  PubMed Central  Article  Google Scholar 

  72. 72.

    Slocum AHJ, Slocum AHS, Spiegel JE. Design and in vitro testing of a pressure-sensing syringe for endotracheal tube cuffs. Anesth Analg. 2012;114:967.

    PubMed  Article  Google Scholar 

  73. 73.

    Wang et al. (JCMC-D-19-00225R2)

  74. 74.

    Bloria. (JCMC-D-20-00062R1)

  75. 75.

    McCambridge J, Witton J, Elbourne DR. Systematic review of the Hawthorne effect: new concepts are needed to study research participation effects. J Clin Epidemiol. 2014;67:267–77.

    PubMed  PubMed Central  Article  Google Scholar 

  76. 76.

    Wong DT, Tam AD, Mehta V, Raveendran R, Riad W, Chung FF. New supraglottic airway with built-in pressure indicator decreases postoperative pharyngolaryngeal symptoms: a randomized controlled trial. Can J Anaesth. 2013;60:1197–203.

    PubMed  Article  Google Scholar 

Download references


We do not have any financial or other interest in any product mentioned this manuscript.

Author information




CMK, ES, TVZ have made substantial contribution to the manuscript in drafting the article or revising it critically for important intellectual content, final approval of the version to be published and agree to be accountable for all aspects of the work.

Corresponding author

Correspondence to Chandra M. Kumar.

Ethics declarations

Conflict of interest

We declare that the authors listed in the manuscript do not have any potential conflicts of interest financial or otherwise.

Human and animal rights statement

No human or animals were included in the study.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Kumar, C.M., Seet, E. & Van Zundert, T.C.R.V. Measuring endotracheal tube intracuff pressure: no room for complacency. J Clin Monit Comput 35, 3–10 (2021).

Download citation


  • Endotracheal
  • Cuff pressure
  • Under-pressure
  • Over-pressure
  • Complication