adjusting tracheal tube cuff pressure
We thank Dr Kunstyr for his reflections on our Commentary1 regarding the study of his group about the effects of adjusting tracheal tube cuff pressure during deep hypothermic circulatory arrest.2
To clarify the discussion and the interpretation of statements, it is essential to make the difference between what is considered to be a good clinical practice and what is actually a routine clinical practice. In this specific case, data from the literature clearly indicate that regular control and adjustments of cuff pressures prevent aspiration pneumonia.3 With these available data, good clinical practice would therefore imply that this strategy should be part of the routine anaesthetic management. We agree with Dr Kunstyr that this is probably not the case in a number of centres. However, it is not because a protective management is not applied during routine management that this routine strategy becomes the reference of good clinical practice. It is specifically this point that we wanted to underscore in our Commentary. In clinical studies, we need to make sure that patients in the control group get a treatment according to good clinical practice and not simply the ‘routine’ treatment, certainly when this implies that no protective actions are undertaken.
Dr Kunstyr and colleagues need to be commended for their observations because they admirably underscore that what we consider to be well tolerated routine clinical practice actually represents suboptimal treatment. Indeed, probably no-one would have expected that not controlling and adjusting cuff pressures during deep hypothermic arrest is associated with a 67% incidence of tracheal leakage. The question that of course remains is what are the clinical implications of these findings? Unfortunately, the study of Rubes et al.2 does not allow us to link this high incidence of tracheal leakage to an increased incidence of postoperative pulmonary complications.3 The authors might consider retrospectively checking these data – if available – in more detail.
Acknowledgements relating to this article
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Conflicts of interest: none.
1. De Hert S, De Baerdemaeker L. Randomised controlled trials. Are we looking at treatment effects of absence of good clinical practice in control groups? Eur J Anaesthesiol
2. Rubes D, Klein AA, Lips M, et al. The effect of adjusting tracheal cuff pressure during deep hypothermic arrest – a randomised trial. Eur J Anaesthesiol
© 2015 European Society of Anaesthesiology
3. Lucangelo U, Zin WA, Antonaglia V, et al. Effect of positive expiratory pressure and type of tracheal cuff on the incidence of aspiration in mechanically ventilated patients in an intensive care unit. Crit Care Med