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Description

Prior to a trial of extubation, all patients will have formal evaluation of their airway to assess the
risk of post-extubation upper airway obstruction (UAO). In patients identified as being at high-
risk for developing acute upper airway obstruction, part of that evaluation will include a cuff leak
test. The most widely used method for a cuff-leak test evaluates the decline in expired tidal
volume when the endotracheal tube cuff is deflated. At a minimum, the expired tidal volume
should decline by greater than 110 mL with the cuff deflated. This cut-off value signifies a
reasonable degree of confidence that post-extubation stridor is unlikely to occur.

Note: Cuff leak tests are used primarily to evaluate the risk of post-extubation stridor from
laryngeal or subglottic edema and may not necessarily be sensitive for predicting UAO from other
causes. SFGH quality assurance data from over 180 patients indicate that when using the cut-off
of > 110 mL leak volume, the chances of developing post-extubation stridor are approximately
5%.In contrast, the chances of developing stridor when the leak is < 110 mL is 55%.

Indications for Cuff Leak Test

Patients who meet “at-risk” criteria for post-extubation UAO, a cuff leak test should be ordered
by the ICU physician team and will performed by the respiratory care services as described below.

Physician's Order

Perform cuff leak test. The physician order should include instructions to the nurse regarding
adjustment of sedation for the test.

Procedures

The validity of test result is optimal when the patient is asleep or sedated. The test should be
done the night preceding an extubation trial. The test may be attempted with the patient lightly
sedated or awake. Note: in the presence of coughing, spontaneous breathing, or active expiration
test results are highly susceptible to artifact, and any decision regarding whether or not to proceed
with an extubation trial should not be based upon such data. Notify the ICU team regarding
concerns over test artifact.

1. A 14 Fr suction catheter will be positioned in the posterior oropharynx to suction as much

secretions as possible from the back of the throat prior to cuff deflation.

2. Ventilator settings:

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a. Volume assist/control ventilation

b. Tidal volume between 8-10ml/kg

c. Mandatory rate that suppresses spontaneous breathing efforts.

d. Peak flow rate of 50-60 L/min.

e. Inspiratory time of 1 to 1.5 seconds to create a stable plateau pressure.

3. Monitor the expired tidal volume and plateau pressure for several breaths to determine the
stability / fluctuation in both expired tidal volume and EIP.

4. Remove the Pressure Easy from the pilot balloon.

5. Evacuate air from the pilot balloon until it is completely deflated.

6. Allow approximately 6 breaths with the cuff deflated before monitoring.

7. Record the average tidal volume and EIP observed over the next 3 breaths. Note the
presence and quality of an auditory leak (e.g.: low pitched, high pitched, no auditory leak)

8. Reinflate the endotracheal tube cuff and attach the Pressure Easy.

9. If necessary, re-adjust the tidal volume, inspiratory time and peak flow rate to previously-
used clinical settings.

10. Once the propofol (or other sedative agent) is reduced or discontinued, and the patient
resumes spontaneous breathing, change the ventilator mode back to the previously-used
clinical settings.

11. Document the baseline and leak values for expired tidal volume and plateau pressure in
ICIP and report the values to the ICU physician

Complications

Inadequate removal of oropharyngeal secretions may promote coughing that interferes with the
obtainment of a valid measurement. Values obtained when the patient is coughing are invalid and
should not be documented. The ICU team should be notified when coughing interferes with the
cuff leak test despite the use of additional sedation.

By it’s nature, the cuff leak test may increase the risk of ventilator-associated pneumonia.
Although this risk is unavoidable, the use of the cuff leak test should be restricted to patients who
meet objective risk factors (see Table x in the Extubation Procedure). Daily measurements are

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appropriate in patients who fail the leak test. However, making repeated measurements on any
particular day is unnecessary and should be avoided due to the risk of ventilator-associated
pneumonia.

Charting

Document the baseline and leak values for expired tidal volume and plateau pressure in ICIP and
report the values to the ICU physician

Charges

Charge one unit of therapist assist time.

Reference

Miller RL, Cole RP. Association between reduced cuff leak volume and postextubation stridor.
Chest 1996; 110: 1035-1040.

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Document Change History

Previous History:
Adopted: 12/2009 Reviewed: 12/15/09 Revised: 6/5/2012

Revised
Date Initials Reviewed Notes

12/15/09 RK Draft

6/5/2012 RK 

RCS SFGH reviewed /revised: 6/5/2012