![]() ![]() Volume loss around cuff >24% tidal volume.Volume loss around cuff >110 ml (difference between inspired/exhaled volumes).The following are some commonly used criteria: There is no uniform definition of what constitutes a cuff leak. This isn't addressed in the guidelines, but still merits discussion. Therefore, you are free to proceed immediately to extubation if you wish to do so. What if the patient has a low risk of reintubation, but the cuff leak test is checked anyway and is absent? The same statistical considerations still apply. Thus, among patients with a low pre-test probability of reintubation, there is no utility in performing this diagnostic test. Such patients may be extubated regardless of test result. Among patients with a low pre-test probability of reintubation (0-5%), even if there is no cuff leak then the risk of reintubation is still acceptable. The ideal extubation failure rate is debatable, with most sources suggesting ~15% as reasonable(2). This affects the post-test probability of reintubation as follows (1): The absence of a cuff leak increases the likelihood of reintubation (positive likelihood ratio ~4) whereas the presence of a cuff leak reduces the likelihood of reintubation (negative likelihood ratio ~0.5)( Girard 2017). Restrict the cuff leak test to high-risk patients This provides a streamlined, evidence-based pathway to extubate patients without a cuff leak. This guideline recommends a clever compromise between these extremes, which is the basis of the algorithm below. Delay extubation for 24-48 hours while attempting to elicit a cuff leak.Ī new joint practice guideline by the ATS and ACCP addresses this issue. Conservative approach: If there is no cuff leak, start steroids and leave the patient on ventilation.Extubate the patient and re-intubate as needed. Aggressive approach: If there is no cuff leak, just ignore it.I've encountered attendings who span the entire gamut between two extremes: Thus, many patients without a cuff leak may still be safely extubated. Absence of cuff leak can also occur due to having a large tube relative to the patient's trachea, or caked secretions around the tube. Absence of a cuff leak suggests the presence of airway edema, increasing the risks of post-extubation stridor and reintubation. This consists of deflating the cuff of the endotracheal tube to verify that gas is able to move around the tube. Prior to extubation, the cuff leak is usually checked. ![]()
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