Introduction

Although anesthesia providers are widely accepted as airway experts, there exists a troubling shortfall of basic airway knowledge and routine practices that places patients at risk of catastrophic harm. The majority of anesthesia providers are unable to correctly identify the safety limits of cuff-tracheal pressure or tracheal perfusion pressure, none have knowledge of the subglottic blood supply, none are able to compare inner verses outer ETT and cuff inflation diameters with adult tracheal diameters1. Although all evidence demonstrates that damage occurs within 15-30 minutes of high cuff pressure, most believe it’s only with prolonged. Although the injection and palpation technique of cuff inflation is widespread, all research shows this to be an inaccurate method.

The incidence of postintubation subglottic stenosis (SGS) has a reported range of 0.6% to 22%². The incidence would most probably be much higher if nonscientific roadblocks, were removed that prevent its diagnosis. An alarming lack of airway knowledge and intubation practices based on dogma, while ignoring evidence, could allow these roadblocks and harm to persist.

One major roadblock that prevents proper diagnosis is the thought that an intubation must be prolonged to be the cause. The physiologic fact is that when cuff pressure exceeds tracheal perfusion pressure, the blood supply becomes totally occluded.³ Within 15 – 30 minutes⁴ of this occlusion the tissue then becomes ischemic and necrotic and ultimately, the dense scar tissue of SGS. It is not just prolonged intubations as most believe.

Another roadblock is the random timelines imposed for the intubation to be considered as cause. These include: an intubation must be recent, within 2 years ornot remote; none of these timelines are based on scientific facts. The dismissal of a prior intubation based solely on opinion should never preclude the investigation of prior intubations as cause. Without proper etiologic identification, preventative methods will not be mandated that can prevent SGS.

To prevent harm, anesthesia providers must base their practice on scientific and physiologic fact and not opinion-based dogma. They must know tracheal perfusion, cuff pressures, location of the blood supply/RLNs in relation to the overinflated ETT balloon and know adult tracheal diameters compared to ETT outer and cuff inflation diameters. It is imperative to follow research and the manufacturers directions and use a cuff manometer with every intubation, every time to prevent the catastrophic preventable harm of SGS.

References :

1. Weott, P. (2013). Survey of anesthesia providers knowledge of basic airway facts. Unpublished doctoral thesis. University of Virginia.

2. Befkadu, A., & Timerga, S. (2024). Occurrence of post-intubation tracheal stenosis within a week of intubation: A case report. Perioperative Care and Operating Room Management, 35, 100419.

3. Divatia, J. V., & Bhowmick, K. (2005). Complications of endotracheal intubation and other airway management procedures. Indian Journal of Anaesthesia, 49(4), 308-318.

4. Jagpal, N., Sommerfeldt, J., & Shabbir, N. (2023). Subglottic Stenosis. StatPearls Publishing.