An RT clinical team coordinator shares a protocol for assessing and troubleshooting an endotracheal tube cuff leak.

By Anita Cooney, RRT, CPFT

It is your first night back to work after 4 days off. The ICU is busy, and you just received a report on six ventilator patients from a veteran therapist. Although no problems were noted, you are ready for a busy 12 hours.

As you enter an isolation room at 19:30, with clean hands, gloves, and gown, you can hear an obvious cuff leak before you even shut the door behind you. Your cuff pressure gauge is not in the room, so you simply add some air to the cuff with a syringe. All seems fine. Good breath sounds; tidal volume is a tad low on pressure ventilation, but nothing remarkable. You finish the patient assessment, check the ventilator, give the metered dose inhaler medication inline, document, and move on to the next patient.

An hour later, as you are seeing another patient, a nurse asks you to look at the first patient again, saying there is a cuff leak. You gown up again and go in and check the airway more closely. Just as before, there is an audible cuff leak. You use the cuff pressure gauge to check the pressure, and it is 20 cm H20. You give it a few small pumps; and the pressure rises to 26 cm H20, and the leak stops. Your senses tell you something is not right.

You check the placement. The tube is at 21 cm at the lip line. Previous documentation notes 23 cm at the lip line at 1500. The patient had been intubated in the field earlier this afternoon, and there is no documentation of initial placement. Breath sounds are fine, but you hear the leak when you place your stethoscope over the patient’s throat, near the thyroid cartilage. You check tidal volumes, and they are lower than earlier.

You look at the chest x-ray from 1430 this afternoon. The tube looks high, but there is no documentation of tube placement at the time of the x-ray. Something definitely is not right. What do you do?

If you could go back and see what happened throughout the afternoon, you would be able to more easily determine where the tube is, as compared to where it should be. Ideally, post-intubation, proper position should be verified immediately and confirmed by an end tidal CO2 detector, breath sounds, and pulse oximetry. When the clinician is certain the tube is in the trachea—not the right main stem bronchus—placement should be documented and a chest x-ray ordered.

But you cannot go back, and you know something still is not right. What can you do? Table 1 is a guide to assessing endotracheal tube (ETT) function and placement.

Table 1: Assessment of the Endotracheal Tube

Cuff patency• Cuff pressure or volume
• Patency of tracheal seal
• Pilot balloon patency
Confirm endotracheal tube position• Breath sounds, lungs, and upper airway
• Position marking
• Chest x-ray
• Inspect the oral cavity

You are very suspicious of the leak and go through your trouble-shooting list (Table 2).

Table 2: Troubleshooting ETT Problems

• Has the ETT position changed?
• Inspect neck for bulges or misalignment.
• Inspect the mouth; is the tube riding high in the oral pharynx?
• Is there a loss or varying of tidal volume (Vt delivered >Vt exhaled)?
• In pressure ventilation, is there a need for increased driving pressure to meet desired tidal volume (usually with a Vt delivered >Vt exhaled)?
• Inspect the pilot balloon; rule out leaking pilot balloon valve.
• Evaluate need for chest x-ray to confirm placement.
• Evaluate need for an airway specialist (someone who can intubate) to check tube placement with laryngoscope.
• Suction oral airway, deflate cuff, measure amount of air needed to seal.

A cuff leak is usually a compromised cuff or pilot balloon or an improperly positioned tube. Many times, the airway simply needs to be advanced. There could be other rare reasons for cuff leaks, such as a malformation of the tracheal or an esophageal-bronchial.

If the integrity of the tube is compromised, an experienced health care provider should handle replacement of the tube. A difficult intubation cart (with a laryngoscope or bronchoscope) should be on hand, as the patient’s airway may be swollen or traumatized.

If you determine the tube is high and you are ready to advance the tube, take precautions to minimize tracheal aspiration. Suction the oral airway and the CASS Port (continuous aspiration of subglottic secretions port) before deflating the cuff. Be ready for dislodgment of the tube by having the supplies/equipment ready for reintubation and a health care provider who can intubate on hand.

A persistent leaking cuff or a cuff that needs a great deal of air to seal is not to be ignored. Prompt assessment, evaluation, and intervention could avoid self-extubation, inadequate ventilation/oxygenation, and/or tracheal damage.


Anita Cooney, RRT, CPFT, is clinical team coordinator, Respiratory Care Department, Sentara Norfolk General Hospital, Norfolk, Va. For more information, contact [email protected].