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AnesthesiaMicroCuffNCT03240354

Paediatric Microcuff Pressure Study

A study testing Saline cuff in people with Anesthesia and Pediatric, run by Nottingham University Hospitals NHS Trust at 1 site in United Kingdom.

Completed

Finished. The study has ended and is not enrolling. Results may be posted on the official record.

Official record
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Trial summary

In paediatric anaesthesia, use of cuffed endotracheal (ET) tubes is subject to much debate. The concern is the possibility of damage to tracheal mucosa by excessive pressure from the cuff. The cuff pressure can increase during anaesthesia, especially if nitrous oxide is used. Read more about this study

Who is it for?
Ages Up to 16 yearsHealthy volunteers can take part
Conditions the study is for
Anesthesia, Pediatric, Intubation Complication
What is being tested?
Saline cuff
Type of treatment
Medical device
Could I receive a placebo?
No, everyone receives an active treatment
How many people
49 participants
Where
1 siteUnited Kingdom
Study dates
6 Aug 2018to 30 Jul 2019
Phase
Interventional
Are there results?
None posted in the registry

Key requirements

Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.

  • Ages Up to 16 years
  • All sexes
  • Healthy volunteers accepted
  • Child

Who may be able to join

  • Parent/guardian's written informed consent / age-appropriate participant assent
  • Age: Birth to 16 years
  • Elective surgery
  • Endotracheal intubation with a cuffed tube required as part of general anaesthesia lasting longer than 45 minutes
  • Planned use of N2O as part of balanced anaesthesia
  • For questionnaire follow up; aged over 8 years without significant neurological impairment

Who cannot join

  • Weight less than 3kg
  • Laryngeal or tracheal pathology, including respiratory tract infections
  • Difficulty in intubation (>2 attempts)
  • NG tube placement during anaesthesia
  • Nose, throat or airway surgery

Trial locations and contacts

1 site in 1 country.

United Kingdom1 site
  • Nottingham University Hospital

    Nottingham, Nottinghamshire, NG7 2UH

Other trials in United Kingdom

About this study

Official title: Reducing Intra-operative Pressure Variations in Paediatric Microcuff Endotracheal Tube Cuffs

In paediatric anaesthesia, use of cuffed endotracheal (ET) tubes is subject to much debate. The concern is the possibility of damage to tracheal mucosa by excessive pressure from the cuff. The cuff pressure can increase during anaesthesia, especially if nitrous oxide is used.

Using saline to inflate the cuff has been shown to reduce intra-operative cuff pressure variation in adult studies, although it is not standard practice. Although the literature contains reports of cuff pressure increases during paediatric anaesthesia, there are no reports of attempts to address this. Use of pressure monitoring is recommended by AAGBI, but may not be consistently done. A safe method of limiting pressure, that is effective, imposes minimal extra workload and has minimal cost, would reduce risk to patients.

This study aims to investigate the effect on intra-operative cuff pressure of using saline to inflate the ET tube cuff, compared to standard practice of air inflation. Continuous pressure monitoring will be used to determine the proportion of cases where interventions are required to keep the pressure below a safe maximum level.

Read the detailed description

During surgery under anaesthesia, use of cuffed endotracheal (ET) tubes is standard practice in adults. The cuff prevents air leak and protects the airway from soiling. Traditionally, in paediatric practice an uncuffed ET tube is used, sized according to the child's age. This prevents damage to the lining of the trachea by excessive pressure from the cuff.

The debate regarding the use of cuffed ET tubes in children is long-standing. New insight into the understanding of paediatric airway anatomy and newer designs of cuffed ET tubes (such as the MicroCuff Endotracheal tube, Halyard Health UK) have resulted in a shift towards their more frequent use. Studies suggest cuff pressures should be maintained below 20 - 25cm H2O, to minimise airway complications related to high pressures on the tracheal lining leading to inadequate blood flow, potentially causing swelling and, rarely, tracheal stenosis. This is of particular importance in small children, where even slight swelling can significantly reduce the airway diameter, with potentially serious consequences. Use of pressure monitoring is recommended by AAGBI, but may not be consistently done. A safe method of limiting pressure, that is effective, imposes minimal extra workload and has minimal cost, would reduce risk to patients.

The widespread use of nitrous oxide (N2O) in paediatric anaesthesia raises another issue. Nitrous oxide diffuses easily into the ET tube cuffs, raising the pressure within them. Various interventions have been trialled in adult studies to address this. Inflating ET tube cuffs with a mixture of air and N2O may be beneficial, but varying concentrations of N2O during anaesthesia limit the benefits. Filling the cuff with saline instead of air has been shown to prevent increases in cuff pressures in the adult population without any adverse safety issues, but it is still not standard practice.

Despite reports of similar variation in cuff pressures in paediatric patients, there have been no reported studies to date comparing the intra-operative changes in cuff pressures in children when the cuff is inflated with saline instead of air.

Therefore, the investigators propose to determine whether filling the ET tube cuff with saline prevents the changes in intra-cuff pressures, in children undergoing balanced anaesthesia with N2O, that are seen with air filled cuffs.

CLINICAL RELEVANCE The use of cuffed tubes in paediatric anaesthesia has become more and more common over the last decade. Newer, more anatomically based designs have helped to overcome many of the potential problems, but the issue of safe cuff pressures remains paramount.

Work in the adult literature has demonstrated the pressure at which there is a reduction in capillary perfusion. In paediatrics, the huge variation in capillary perfusion pressure makes finding an exact 'safe' level for every patient very difficult, but attempts have been made to characterise what an 'unsafe' level is.

The widespread use of nitrous oxide in paediatric anaesthesia also complicates the situation. The cuffs on modern paediatric cuffed tubes are very thin, allowing gasses to diffuse into them more easily. This means the volume (and thus the pressure) at the beginning of anaesthesia is not the same as at the end. Studies have also shown that the incidence of post-operative airway complications increases as the cuff pressure increases.

The AABGI has recently recommended cuff pressure monitoring as a minimum standard of care. However, achieving this through a lengthy case, where access to the airway may be limited, can prove challenging.

This studies hypothesis is that the use of saline, instead of air, in the cuff will lead to reduced pressure variation during anaesthesia, meaning that the pressure in the cuff at the end would be the same as at the beginning. This would minimise risk of complications for the patient and give a high level of patient safety and satisfaction, with minimal extra workload for the anaesthetist or expense for the NHS.

Being tested
Saline cuff, Control

What participants receive

What participants receive. In a randomised study each person is assigned to one group by chance.

  • Saline cuffDevice

    Cuff of endotracheal tube inflated with saline rather than air (control)

  • ControlDevice

    Cuff of endotracheal tube inflated with air

Study groups in NCT03240354
Study groupRoleWhat they receive
SalineExperimentalUse of saline to inflate cuff of endotracheal tube
Receives: Device: Saline cuff
ControlActive comparatorUse of air to inflate cuff of endotracheal tube
Receives: Device: Control

What is being measured

The primary outcome is the main question the study is designed to answer.

  1. The number of cases where an intervention was required to maintain cuff pressure below 25cm H2O

    • During anaesthesia, the pressure in the ET tube cuff will be measured continuously by an investigator, separate from the team providing the anaesthesia, using an arterial line pressure transducer set attached to the pilot balloon through a 3-way tap. The initial cuff pressure will be recorded ('Pressure 0')
    • The cuff pressure will be documented every 5 minutes.
    • If the cuff pressure exceeds 25 cm H2O for more than 30 seconds (to exclude artefactual changes), the volume of fluid in the cuff will be reduced until the pressure is returned to the initial level ('Pressure 0').
    • This constitutes an 'Intervention'

    Measured: Intra-operative, 45min - 6 hours

Secondary outcomes (3)
  1. Cuff pressure in each group

    The mean cuff pressure for each patient will be calculated based on the recordings taken during the case

    Measured: Intra-operative, 45min - 6 hours

  2. Post extubation adverse events

    After removal of the ET tube at the end of the case, the attending anaesthetist will note any episodes of cough, stridor, laryngospasm, bradycardia of more than 10% from baseline or desaturation to below 92%, or by more than 10% from baseline. These will constitute a 'post extubation adverse event'

    Measured: up to 20min Post extubation

  3. Post-operative airway complications

    Post-operatively, prior to recovery discharge, children 8 years of age and over will be asked, by an observer blinded to their study group, to score any sore throat, dysphagia or hoarseness on a numerical rating scale.

    These questions will be asked again 8 - 24 hours post-operatively, prior to discharge home.

    Measured: up to 24 hours post-op

Timeline

From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.

  1. First posted7 Aug 2017
  2. Study start6 Aug 2018
  3. Primary completion30 Jul 2019
  4. Study completion30 Jul 2019

Resources

More details

For doctors and researchers: how the study is designed, who runs it, and its registry IDs.

Study design
Study type
Interventional
Phase
Phase N/A
Primary purpose
Treatment
Allocation
Randomised
Intervention model
Parallel groups
Model description
Prospective, blinded, randomised, parallel group control trial
Masking
Double blind
Who is masked
Participant, Outcomes assessor
Enrolment
49 participants (actual)
IDs, dates and publications
ClinicalTrials.gov ID
NCT03240354
Sponsor's protocol ID
17AN003
Acronym
MicroCuff
Status last verified
Mar 2018
First submitted
17 Jul 2017
Last updated
20 Feb 2020
Results posted
No
Data monitoring committee
No
FDA-regulated drug
No
FDA-regulated device
No
Individual data sharing
No: Individual participant data will not be shared outside the immediate research team

Publications

  • Lonnqvist PA. Cuffed or uncuffed tracheal tubes during anaesthesia in infants and small children: time to put the eternal discussion to rest? Br J Anaesth. 2009 Dec;103(6):783-5. doi: 10.1093/bja/aep330. No abstract available.

    PubMed 19918019
  • Tobias JD. Pediatric airway anatomy may not be what we thought: implications for clinical practice and the use of cuffed endotracheal tubes. Paediatr Anaesth. 2015 Jan;25(1):9-19. doi: 10.1111/pan.12528. Epub 2014 Sep 20.

    PubMed 25243638
  • Weiss M, Dullenkopf A, Fischer JE, Keller C, Gerber AC; European Paediatric Endotracheal Intubation Study Group. Prospective randomized controlled multi-centre trial of cuffed or uncuffed endotracheal tubes in small children. Br J Anaesth. 2009 Dec;103(6):867-73. doi: 10.1093/bja/aep290. Epub 2009 Nov 3.

    PubMed 19887533
  • Suominen P, Taivainen T, Tuominen N, Voipio V, Wirtavuori K, Hiller A, Korpela R, Karjalainen T, Meretoja O. Optimally fitted tracheal tubes decrease the probability of postextubation adverse events in children undergoing general anesthesia. Paediatr Anaesth. 2006 Jun;16(6):641-7. doi: 10.1111/j.1460-9592.2005.01832.x.

    PubMed 16719880
  • Checketts MR, Jenkins B, Pandit JJ. Implications of the 2015 AAGBI recommendations for standards of monitoring during anaesthesia and recovery. Anaesthesia. 2017 Jan;72 Suppl 1:3-6. doi: 10.1111/anae.13736. No abstract available.

    PubMed 28044335
  • Dullenkopf A, Gerber AC, Weiss M. Nitrous oxide diffusion into tracheal tube cuffs: comparison of five different tracheal tube cuffs. Acta Anaesthesiol Scand. 2004 Oct;48(9):1180-4. doi: 10.1111/j.1399-6576.2004.00483.x.

    PubMed 15352966
  • Felten ML, Schmautz E, Delaporte-Cerceau S, Orliaguet GA, Carli PA. Endotracheal tube cuff pressure is unpredictable in children. Anesth Analg. 2003 Dec;97(6):1612-1616. doi: 10.1213/01.ANE.0000087882.04234.11.

    PubMed 14633529
  • Tu HN, Saidi N, Leiutaud T, Bensaid S, Menival V, Duvaldestin P. Nitrous oxide increases endotracheal cuff pressure and the incidence of tracheal lesions in anesthetized patients. Anesth Analg. 1999 Jul;89(1):187-90. doi: 10.1097/00000539-199907000-00033.

    PubMed 10389801
  • Karasawa F, Ohshima T, Takamatsu I, Ehata T, Fukuda I, Uchihashi Y, Satoh T. The effect on intracuff pressure of various nitrous oxide concentrations used for inflating an endotracheal tube cuff. Anesth Analg. 2000 Sep;91(3):708-13. doi: 10.1097/00000539-200009000-00040.

    PubMed 10960405
  • Combes X, Schauvliege F, Peyrouset O, Motamed C, Kirov K, Dhonneur G, Duvaldestin P. Intracuff pressure and tracheal morbidity: influence of filling with saline during nitrous oxide anesthesia. Anesthesiology. 2001 Nov;95(5):1120-4. doi: 10.1097/00000542-200111000-00015.

    PubMed 11684980
  • Bennett MH, Isert PR, Cumming RG. Postoperative sore throat and hoarseness following tracheal intubation using air or saline to inflate the cuff--a randomized controlled trial. Anaesth Intensive Care. 2000 Aug;28(4):408-13. doi: 10.1177/0310057X0002800409.

    PubMed 10969368
  • Tobias JD, Schwartz L, Rice J, Jatana K, Kang DR. Cuffed endotracheal tubes in infants and children: should we routinely measure the cuff pressure? Int J Pediatr Otorhinolaryngol. 2012 Jan;76(1):61-3. doi: 10.1016/j.ijporl.2011.09.033. Epub 2011 Oct 22.

    PubMed 22024576
  • Seegobin RD, van Hasselt GL. Endotracheal cuff pressure and tracheal mucosal blood flow: endoscopic study of effects of four large volume cuffs. Br Med J (Clin Res Ed). 1984 Mar 31;288(6422):965-8. doi: 10.1136/bmj.288.6422.965.

    PubMed 6423162
  • Sheraton TE, Gildersleve CD, Hall JE. The use of nitrous oxide in paediatric anaesthetic practice in the United Kingdom: a questionnaire survey. Anaesthesia. 2007 Jan;62(1):62-6. doi: 10.1111/j.1365-2044.2006.04857.x.

    PubMed 17156228
  • Constant I, Louvet N, Guye ML, Sabourdin N. [General anaesthesia in children: a French survey of practices]. Ann Fr Anesth Reanim. 2012 Sep;31(9):709-23. doi: 10.1016/j.annfar.2012.06.004. Epub 2012 Jul 7. French.

    PubMed 22776772

Questions about this trial

What is this clinical trial studying?

A study testing Saline cuff in people with Anesthesia and Pediatric, run by Nottingham University Hospitals NHS Trust at 1 site in United Kingdom.

The full registered description is in the About this study section and the official record.

Who may be eligible to take part?

The sponsor lists 6 inclusion and 5 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.

Is this clinical trial currently recruiting?

The record says: finished, as of the sponsor's last update on 20 Feb 2020. Status can change between updates, so confirm with the study contact before making plans.

Where is the study taking place?

The record lists 1 site in United Kingdom. Whether a site is taking part right now should be confirmed with that site. See every site.

What are the possible benefits and risks?

They depend on the study and the treatment, and no study can promise a benefit. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.

Are results available for this study?

The study is completed, but results are not available in the source record. That does not mean the treatment did or did not work.

How can a doctor refer a patient or contact the research team?

The record lists no contact. The official record names the sponsor, who can be asked directly. AzTrials does not enrol participants or take referrals.

What does the primary outcome measure?

The number of cases where an intervention was required to maintain cuff pressure below 25cm H2O (time frame: Intra-operative, 45min - 6 hours). It is what the study was designed to measure, not a finding.

Where can I read the original study information?

On the ClinicalTrials.gov record for NCT03240354, which also lists 17 linked publications.

Does a listing mean the treatment is approved or proven to work?

No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.

How often is this information updated?

AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 20 Feb 2020.

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