The document discusses post-intubation pulmonary complications (PIPC) that can occur due to microaspiration during intubation. Microaspiration occurs when foreign material passes the endotracheal tube cuff into the lungs. A new taper-shaped cuff design has been shown to significantly reduce microaspiration compared to conventional barrel-shaped cuffs. The tapered cuff seals more effectively against the tracheal wall and prevents fluids and pathogens from leaking into the lungs. This may help lower the risks of pneumonia, respiratory failure and other pulmonary issues associated with PIPC.

1. pharma report
Korrekturexemplar
Post-intubation pulmonary complications (PIPC)
Taper-shaped cuff – a new approach in reducing
microaspiration
Although the problem of microaspiration during intubation has been known for years, it is still an
issue leading to pulmonary complications, including postoperative pneumonia and ventilator-
associated pneumonia (VAP). Taper-shaped cuffs which can provide a better sealing and thus ­better
protection against microaspiration constitute a new approach. Research has shown that a new
­tapered design significantly reduces the leakage past the endotracheal tube cuff, limiting passage
of foreign material into the airways and lungs. The advanced-designed tube may help reduce the
risk of post-intubation pulmonary complications (PIPC).
Imprint
Taper-shaped cuff – a new approach
in reducing microaspiration Post-operative pulmonary com-
Fig. 1 Mortality and pneumonia rates with and without evidence of
Literature and Interview plications (PPC) occur common-
microaspiration
ly and are a major cause of over-
Author:
Dr. Katrina Recker, Hamburg all perioperative morbidity and Patients without evidence of microaspiration
mortality, prolonged hospital stay, Patients with evidence of microaspiration
Corporate Publishing (responsible): and increased cost of care [1]. Ac- 50
Ulrike Hafner,
cording to Fleischmann et al., the 40.0
Dr. Katharina Finis, Dr. Friederike Holthausen, 40
Sabine Jost, Dr. Claudia Krekeler, incidence of pulmonary compli-
Patients (%)
Inge Kunzenbacher, Dr. Sabine Lohrengel, cations (2.7%) was highly compa- 30
Dr. Annemarie Musch, Dr. Monika Prinoth, rable to that of cardiac complica- 19.2
Katrin Schader, Dr. Petra Stawinski, 20
tions (2.5%) [2]. The definition of
François Werner, Teresa Windelen 12.0
PPC includes pneumonia, respira- 10
Translated reprint of a tory failure, atelectasis, broncho- 1.7
report in „Der Anaesthesist“ 0
spasm, and exacerbation of chron- Mortality Pneumonia
Volume 60, Issue 6, June 2011
ic obstructive pulmonary disease
modified from [6]
This publication is supported by (COPD) as well as post-intubation
Covidien Deutschland GmbH pulmonary complications (PIPC)
as the intubation-related sub- lated parameters [1]. The closer 12% in patients without such evi-
COVIDIEN, COVIDIEN with logo, Covidien logo
and positive results for life are U.S. and inter- group of PPC. the incision is to the diaphragm, dence of microaspiration (p<0.01)
nationally registered trademarks of Covidien PIPC encompass a broad range the greater the risk for pulmonary (Fig. 1). Morbidity was increased
AG. Other brands are trademarks of a Covidien
of potential clinical outcomes – complications. Aortic, thoracic, and in association with postopera-
company.
from mild and limited symptoms abdominal procedures carry the tive pneumonia because length of
The editors of the journal assume no as sore throat to severe diseas- highest risk, followed by ­upper stay in the surgical intensive care
liability for the content of this column. es such as respiratory failure and ­abdominal surgery (e. g., cholecys- unit (6.2 vs 2.6 days), days intu-
ventilator-associated pneumo- tectomy). bated (2.7 vs 0.6), total postopera-
Springer Medizin
Springer-Verlag GmbH nia (VAP). VAP, defined as pneu- The main cause for develop- tive days (15.3 vs 8.4), and mortali-
Tiergartenstraße 17 monia occurring more than 48 ment of ventilator-associated ty rates (19.2% vs 1.7%) were great-
69121 Heidelberg hours after induction of mechan- pneumonia is not the mechanical er than in patients without pneu-
ical ventilation, is the most com- ventilation itself but the leakage monia [6].
Springer is part of
Springer Science+Business Media mon nosocomial infection in in- past the endotracheal tube cuff
tensive care medicine and associ- allowing pathogens to pass along Innovative shaped cuff for
© Springer-Verlag GmbH 2011 ated with prolonged intensive care the tube towards the lungs. This better sealing
Some commercial names, trade names and
and hospital stay as well as a high- so called microaspiration can re- For decades, it has been assumed
trademarks etc. used in this text are designated er mortality [3]. The mortality rate sult in severe post-intubation pul- that endotracheal tubes (ETTs)
as such. However, neither the presence nor for VAP ranges from 24% to 50% monary complications. Microaspi- prevent aspiration. However, stud-
absence of such designation means that these
names should not be regarded in accordance and is even higher (76%) in specif- ration due to channels on the sur- ies have demonstrated that cur-
with the copyright and trademark laws or that ic settings or when the infection is face of cuffs has been verified both rent barrel-shaped high-volume
they are for general use. Product liability: The caused by high-risk pathogens [4]. in vitro and in vivo [5]. A study low-pressure (Hi-Lo) cuffs allow
printers and publishers cannot be held liable
for information on dosage and methods of published by Ephgrave et al. found aspiration of fluids through chan-
application. Information of this nature should Microaspiration important colonization of sputum with gas- nels formed in the cuff [7]. This
be reviewed for accuracy in each case by the
reader, using other sources of reference.
risk factor tric pathogens in 28% of postop- leakage around the endotrache-
Risk factors for popstoperative erative patients [6]. These patients al tube cuff is known to be one of
pulmonary complications include had a 40% incidence of postoper- the major causes of microaspira-
advanced age and procedure-re- ative pneumonia compared with tion [8].

2. pharma report
Korrekturexemplar
To address this problem, the shaped cuff. The new tube pro-
Fig. 2 Design of the endotracheal tube with a taper-shaped cuff
Mallinckrodt™ TaperGuard endo­ vided significant microaspiration
tracheal tube was developed, in- Oropharynx protection compared to the con­
corporating a unique, taper- ventional tube in the categories
shaped cuff made from polyvinyl- Tracheal wall “dye leak“ and “bronchitis” (p<0.05
chloride (PVC) that is designed to Cuff creases
­resp. p<0.016).
substantially reduce the risk of
­microaspiration. The cuff has a
Sealing band
proximal end diameter larger than
the average adult trachea, taper-
ing to a smaller diameter at the
distal end (Fig. 2). By providing a References
more effective fluid seal, the taper-
[1] Smetana GW, Cleve Clin J Med 2009;
shaped device reduces the risk of 76 Suppl 4:S60–65
microaspiration among intubated Lungs
[2] Fleischmann KE et al., Am J Med
patients compared to the current modified from Covidien 2003; 115: 515–520
­Hi-Lo™ ETT. [3] Perl T, Quintel M, Anaesthesist 2011;
60: 236–242
This has been demonstrated in sure (PEEP) to maintain lung vol- and tube. None of the 31 patients [4] Chastre J et al., Am J Respir Crit Care
a study with 63 morbidly obese pa- ume during surgery. At the end intubated with the taper-shaped Med 2002; 165: 867–903
tients (body mass index {BMI} >40) of laparoscopy, water containing cuff endotracheal tube had any [5] Van Aken H et al. Intensivmedizin.
undergoing the Roux-en-Y gastric methylene blue was injected in the evidence of microaspiration com- 2nd edition 2007: 106–108
[6] Ephgrave KS et al., Surgery 1993; 114:
bypass procedure [9]. 31 patients gastric pouch. The water flowed pared to 13 of 32 patients intubat-
815–819
were randomly selected for intu- back in the oral cavity, and dripped ed with the conventional, barrel- [7] Oikkonen M et al., Anaesthesia 52
bation with the new endotrache- out of the mouth. Afterwards, the shaped Hi-Lo tube. 1997: 567–569
al tube and 32 participants were tracheal tube was inspected above These findings were corrobo- [8] Rawlinson E et al., Anaesth Intensive
intubated with a conventional en- and below the cuff by bronchosco- rated by the results of an animal Care 2007; 8: 365–867
[9] Van den Brande F et al., Eur J Anaes-
dotracheal tube using a Hi-Lo cuff. py. The leak test was positive when model of aspiration [10]. Four- thesiol 2010; 27: 250
The patients were ventilated with methylene blue was visualized be- teen pigs were intubated with [10] Lichtenthal P et al., Crit Care 2010; 14
5cm positive end-expiratory pres- low the cuff between tracheal wall either the Hi-Lo-ETT, or the taper- Suppl 1: P229
Different approaches to reduce the risk of microaspiration
Interview with Prof. Michael Quintel, Department of Anaesthesia at Centre of Anaesthesia, Emergency Medicine and Intensive Care,
University of Göttingen
Could you please explain the role of microaspiration How can microaspiration during surgery be prevented?
for the development of post-intubation pulmonary Quintel: There are different approaches to reduce the risk of microaspira-
complications (PIPC)? tion. One would certainly be the reduction of colonization of pathogens
Quintel: The main risk associated with intubation in the oropharynx by either using teeth brushing as a procedure which
is microaspiration during in- and extubation. can be performed by the patient. One may also use substances like clo-
There have been studies performed showing rhexidine for cleaning of the oropharynx immediately prior to intubation
that teeth brushing reduces the bacterial con- which would also reduce the contamination of the oropharynx.
tamination of the oropharynx and thus leads to In addition, three key issues concerning the endotracheal tube
a marked reduction of pulmonary complication after large intrathorac- should be taken into consideration: 1) Supraglottic suctioning during the
ic procedures. This may be seen as evidence that microaspiration plays procedure might reduce the amount of fluid above the cuff which has
an important role in the perioperative period and in the postoperative to be retained by the cuff. 2) Continuous control of the cuff pressure is
intensive care setting. ­important to allow the reduction of any pressure damage to the trachea.
3) The optimal inflation can avoid any kind of rinsing along the endotra-
Why is microaspiration still a problem in the operating room? cheal tube.
Quintel: For a long time, peri- and postoperative pulmonary complica-
tions have been regarded as almost inevitable and microaspiration as Why can it be useful to drain secretions which pool above the cuff with a
a possible cause was underestimated. Today, there are more and more subglottic drainage?
hints from the literature that microaspiration especially during large sur- Quintel: This is because drainage reduces the amount of fluid which po-
gical procedures might influence the outcome of the patients. tentially contains bacterial load and might rinse along the endotracheal
Increase in knowledge as well as new devices like the endotracheal tube or along the cuff down the trachea. While using mechanical ventila-
tube featuring a taper-shaped cuff created a growing awareness of post- tion, this fluid can spread down to the deeper parts of the lungs just by
operative pulmonary problems among anaesthesists. the flow of the inspiration.