Prevalence and determinants of inappropriate endotracheal cuff pressure in adult surgical patients undergoing general anesthesia: a prospective observational study

Abstract

Background: Endotracheal tube (ETT) cuff pressure should be maintained between 20 – 30 cmH₂O to prevent air leak, aspiration, and tracheal injury. Cuff inflation is frequently guided by clinical judgement rather than manometry. Data on inappropriate cuff pressure prevalence and determinants in Asian surgical populations are limited. Methods: We prospectively studied adult patients undergoing elective surgery with endotracheal intubation at a tertiary hospital. After intubation, anaesthesia providers inflated the ETT cuff per usual practice based on clinical judgement without manometry. The research team measured initial cuff pressure with a manometer and adjusted it to 20 – 30 cmH₂O, recording initial and final pressures and volumes. The primary outcome was prevalence of inappropriate initial cuff pressure (< 20 or > 30 cmH₂O). Secondary analyses were exploratory, using multinomial logistic regression to examine associated factors and models for cuff inflation volume and final pressure. Results: Of 270 patients, only 107 (39.6%) had initial cuff pressure within the recommended range; 77 (28.5%) were < 20 cmH₂O and 86 (31.9%) were > 30 cmH₂O. Patient characteristics (age, sex, body mass index) were not associated with cuff-pressure category. ETT brand showed significant associations with excessive pressure. Postoperative airway symptoms were infrequent and similar across groups. An exploratory multivariable model incorporating age, sex, ETT size, and brand demonstrated moderate explanatory performance for cuff inflation volume (coefficient of determination [R²] = 0.336). Conclusion: Empiric cuff inflation results in inappropriate ETT cuff pressure in nearly two-thirds of adult surgical patients, and common clinical variables do not reliably predict safe pressure. Routine manometric monitoring should be used to ensure adequate cuff inflation; reliance on fixed inflation volumes or simple volume-based formulas is not recommended. Trial registration: Not applicable.