AB Patel

C Mietto

Hua-sheng Tong

Lei Su

Ling Zhao

ME Ochoa

SH Shin

WA Pluijms

Wei Wang

Yu Zhou

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Wang et al. Critical Care  (2015) 19:446 DOI 10.1186/s13054-015-1152-xLETTER Open AccessValue of the cuff leak test is limitedWei Wang1,2, Yu Zhou2, Hua-sheng Tong1, Lei Su1 and Ling Zhao2*See related review by Pluijms et al., http://www.ccforum.com/content/19/1/295We read with interest the recent Critical Care review ofpost-extubation laryngeal edema and stridor resulting inrespiratory failure [1]. We mostly agree with the authors’opinion in that article except that the cuff leak test (CLT)was proposed as a standard extubation algorithm. Wehave two reasons to disagree.First, although the CLT has been widely used for theprediction of post-extubation laryngeal edema, evidencefor the predictive value of the CLT is conflicting. Moststudies on the CLT document a high specificity and alow sensitivity, and this means that patients with a nega-tive test have a low probability of developing post-extubation stridor (PES) but that patients with a positiveCLT may not develop PES. In a recent systematic review,Ochoa et al. evaluated the accuracy of the CLT for reintu-bation secondary to upper airway obstruction; the sensitiv-ity was 0.63 (95 % confidence interval (CI) 0.38–0.84), andthe specificity was 0.86 (95 % CI 0.81–0.90) [2]. Shin et al.report that the CLT does not reliably identify thosepatients who will require reintubation in a trauma popula-tion [3]. Similarly, a recent study by Patel et al. demon-strates that the CLT or a combination with laryngealparameters failed to accurately predict PES [4].Second, the CLT is regarded as a simple and non-invasive procedure, but that does not mean this procedureis totally safe for patients. Ventilator-associated pneumo-nia (VAP) is one of the most frequent hospital-acquiredinfections and is associated with higher mortality, morbid-ity, and costs. Contaminated secretions that spill over theendotracheal tube cuff and leak down to the lungs areconsidered a significant pathogenic mechanism of VAP[5]. Although the related evidence is lacking, it is reason-able to posit that the CLT should increase the risk of oro-pharyngeal and subglottic secretions into the airwayduring cuff deflation and mechanical ventilation.* Correspondence: dr.zhaoling@126.com2Department of Critical Care Medicine, Zhuhai Hospital of Jinan University,Zhuhai People’s Hospital, 79 Kang-ning road, Zhuhai 519000, ChinaFull list of author information is available at the end of the article© 2015 Wang et al. Open Access This articleInternational License (http://creativecommonsreproduction in any medium, provided you gthe Creative Commons license, and indicate if(http://creativecommons.org/publicdomain/zeThe poor predictive accuracy suggests that the CLT isan unstable clinical prognosticator, and we consider thatthe CLT should be applied for patients at high risk andthat the excessive use of CLT is inappropriate.AbbreviationsCI: Confidence interval; CLT: Cuff leak test; PES: Post-extubation stridor;VAP: Ventilator-associated pneumonia.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsWW and LZ designed the manuscript and participated in drafting it.YZ, HST, and LS participated in drafting the manuscript. All authors read andapproved the final manuscript.Author details1Department of Critical Care Medicine, Guangzhou General Hospital ofGuangzhou Military Command, Southern Medical University, Guangzhou,Guangdong, China. 2Department of Critical Care Medicine, Zhuhai Hospitalof Jinan University, Zhuhai People’s Hospital, 79 Kang-ning road, Zhuhai519000, China.References1. Pluijms WA, van Mook WN, Wittekamp BH, Bergmans DC. Postextubationlaryngeal edema and stridor resulting in respiratory failure in critically illadult patients: updated review. Crit Care. 2015;19:295.2. Ochoa ME, Marín Mdel C, Frutos-Vivar F, Gordo F, Latour-Pérez J, Calvo E,et al. Cuff-leak test for the diagnosis of upper airway obstruction in adults: asystematic review and meta-analysis. Intensive Care Med. 2009;35:1171–9.3. Shin SH, Heath K, Reed S, Collins J, Weireter LJ, Britt LD. The cuff leak test isnot predictive of successful extubation. Am Surg. 2008;74:1182–5.4. Patel AB, Ani C, Feeney C. Cuff leak test and laryngeal survey for predictingpost-extubation stridor. Indian J Anaesth. 2015;59:96–102.5. Mietto C, Pinciroli R, Patel N, Berra L. Ventilator associated pneumonia:evolving definitions and preventive strategies. Respir Care. 2013;58:990–1007.is distributed under the terms of the Creative Commons Attribution 4.0.org/licenses/by/4.0/), which permits unrestricted use, distribution, andive appropriate credit to the original author(s) and the source, provide a link tochanges were made. The Creative Commons Public Domain Dedication waiverro/1.0/) applies to the data made available in this article, unless otherwise stated.

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Value of the cuff leak test is limited

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Value of the cuff leak test is limited

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