Tracheal cuff management as part of a lung-protective strategy.

Complications associated with mechanical ventilation have been extensively described in the literature in the last 3 decades.1 From ventilator-induced lung injury to ventilator-induced diaphragmatic dysfunction more recently defined, numerous side effects directly or indirectly related to mechanical ventilation have been identified. As a consequence, so-called lung-protective ventilation could be theoretically not limited to optimal ventilator settings but rather include prevention of complications occurring from intubation to extubation. Along this line, great attention has been paid to tracheal cuff management in recent literature.2,3 Excessive cuff pressure may cause severe ischemic damage to the tracheal mucosa, potentially leading to granuloma, stenosis, or necrosis, whereas insufficient pressure and sealing may favor aspiration and promote ventilator-associated pneumonia.4,5 Maintaining tracheal cuff pressure in an optimal range is therefore recommended and should be considered as an important part of a global protective ventilator strategy. In a large prospective randomized study enrolling 450 subjects mechanically ventilated for elective cardiopulmonary artery bypass grafting, Bolzan et al6 compared 2 strategies of tracheal cuff pressure management aiming to prevent complications associated with excessive cuff pressure. The strategy previously described and tested by the authors is based on the analysis of the volume-time curve to detect leaks occurring around the tracheal tube when the cuff is not sufficiently inflated.7 The authors used a specific device designed for respiratory mechanics assessment (Ventcare 9505 VSF, Takaoka, São Paulo, Brazil). Compared with a clinical approach based on manual stepwise cuff inflation guided by leak sound abolition, their original volume-time curve technique significantly reduced the incidence and severity of a number of postextubation symptoms prospectively defined, including sore throat, cough episodes, and thoracic pain, at 1 and 24 h after extubation. The extremely short duration of ventilation in this series did not justify an assessment of infectious complications. Because the volume-time curve technique aimed, by design, to maintain the minimal pressure to avoid leaks, we expected lower cuff pressure with this approach, as shown previously by the authors. Cuff pressure measured in the group managed with the volume-time curve was indeed significantly lower compared with that in the control group, but surprisingly, it remains in a relatively high range ( 31 vs 38 cm H2O) compared with previously reported measures and current recommendations. This may be due to a tendency to overinflate the cuff to completely avoid leaks. Considering that cuff pressure should not exceed 30 cm H2O and rather be maintained at 25– 27 cm H2O to preserve tracheal blood perfusion and avoid ischemia, this result could be viewed as a limit of the