# The investigation of initial endotracheal tube cuff pressures in the operating room: a multi-center cross-sectional study in China

## TL;DR

This study found that most hospitals in China are not managing endotracheal tube cuff pressures within recommended ranges, with only a small percentage of patients receiving optimal care.

## Contribution

The study reveals widespread suboptimal cuff pressure management in Chinese hospitals and identifies specific risk factors for elevated pressures.

## Key findings

- Median initial cuff pressure was 48 cmH2O, with only 19% within the recommended 20–30 cmH2O range.
- Direct manometry was the only reliable method for achieving appropriate cuff pressures.
- Younger age and certain ventilation practices were linked to higher cuff pressures.

## Abstract

Cuffed endotracheal tubes (ETTs) are widely used in general anesthesia, with recommended cuff pressure (CP) between 20 and 30 cmH2O in adults. This multi-center study investigated actual CP management practices across 19 Grade A tertiary hospitals in China, involving 2058 anesthetized patients. The median initial CP measured within 30 min post-intubation was 48 cmH2O (IQR 32–70), with only 19% within the recommended range (75.4% > 30 cmH2O; 5.6% < 20 cmH2O). All institutions demonstrated similarly suboptimal CP management. Four distinct methods were used for cuff pressure estimation: pilot balloon palpation (96.2%), fixed-volume inflation (2.8%), minimal occlusive volume technique (0.7%), and direct manometry (0.2%). Among them, only direct manometry demonstrated reliable accuracy in achieving appropriate pressures. The remaining three methods showed no clear superiority over one another in terms of pressure assessment accuracy. In orotracheally intubated patients with palpation-estimated CP, independent risk factors for elevated pressure (> 30 cmH2O) included: age < 60 years, pressure-controlled ventilation, absence of PEEP, ETT internal diameter < 7.0 mm, aminosteroid neuromuscular blocker use, and trainee-performed inflation. These findings highlight widespread challenges in optimal CP management across Chinese tertiary care centers.

The online version contains supplementary material available at 10.1038/s41598-026-37279-3.