‘Sealing the deal’: An innovative use of the endotracheal cuff manometer

Abstract

# Introduction Intraoperative air leakage from the endotracheal tube (ETT) cuff can lead to significant complications, including compromised tidal volume delivery, ineffective ventilation, and an increased risk of pulmonary aspiration. These issues, if unrecognized and unmanaged, contribute to heightened perioperative morbidity and mortality. While structural defects in the ETT cuff or pilot balloon system are common causes of leakage, additional factors such as cuff malposition, excessive airway pressure, and material degradation can also contribute. Early identification of the underlying etiology is critical for implementing appropriate interventions, mitigating airway-related complications, and ensuring surgical continuity. # Case Report This report presents a case of intraoperative ETT cuff leakage identified after surgical positioning in the prone position. To address this challenge, an innovative approach utilizing an ETT cuff manometer was employed, allowing for continuous monitoring of cuff pressure. This strategy enabled real-time detection of pressure deviations and facilitated prompt reinflation whenever the cuff pressure dropped below 20 cm H₂O or a fresh gas flow leak was observed. This technique effectively maintained adequate cuff inflation, preventing intraoperative airway compromise. # Discussion ETT cuff leaks can be categorized into two primary mechanisms: (1) those resulting from structural failure of the cuff or inflation system and (2) those occurring due to inadequate sealing despite an intact cuff. Intraoperative air leaks pose risks to the patient—through impaired ventilation and aspiration risk—and to operating room personnel by potentially exposing them to unfiltered anesthetic gases. Various strategies for managing ETT leaks have been described, including conservative approaches such as pharyngeal packing, application of lubricating agents like lidocaine jelly, and continuous inflation via an oxygen flowmeter. In cases where these measures fail, ETT replacement remains the definitive intervention. However, exchanging the ETT presents a significant challenge in prone-positioned patients, necessitating a thorough risk-benefit assessment before attempting tube replacement or repositioning the patient. While previous studies have explored methods for addressing intraoperative ETT leaks, continuous quantitative monitoring of cuff pressure using a manometer has not been widely reported. This technique provides a dynamic assessment of cuff integrity and allows for proactive management of intraoperative air leaks. # Conclusion In this case, the application of an ETT cuff manometer enabled continuous, quantitative assessment of cuff pressure, facilitating early leak detection and effective management. This approach represents a valuable adjunct in the intraoperative setting, enhancing patient safety and reducing the likelihood of airway-related complications. Further research is warranted to explore the broader clinical implications of continuous ETT cuff pressure monitoring in perioperative airway management.