REVIEW

CURRENT
OPINION Continuous control of tracheal cuff pressure for the
prevention of ventilator-associated pneumonia in
critically ill patients: where is the evidence?
Anahita Rouzé a and Saad Nseir a,b

Purpose of review
Ventilator-associated pneumonia (VAP) is a major cause of death, morbidity and costs in ICUs. Several
evidence-based clinical interventions have been increasingly described for its prevention. However,
continuous control of tracheal cuff pressure (Pcuff) is rarely mentioned in the latest clinical guidelines. This
review focuses on the available data about the management of Pcuff in the ICU, including discontinuous
and continuous control, and its impact on the prevention of VAP.
Recent findings
Current discontinuous monitoring and adjustment of Pcuff, even well performed, is inaccurate in maintaining
Pcuff in the target range. Underinflation (Pcuff <20 cmH2O) of tracheal cuff is an independent risk factor for
VAP through microaspiration of contaminated subglottic secretions into the lower respiratory tract. Two
main types of devices, electronic and pneumatic, have been developed for the continuous control of
Pcuff. Both have shown effectiveness in maintaining Pcuff in recommended range in ICU patients, but only
the pneumatic device has provided a reduction in microaspiration and VAP incidence.
Summary
Continuous controllers of Pcuff represent effective, easy to use and timesaving devices in today’s busy ICU
environment. However, further studies are required to determine the impact of continuous control of Pcuff on
VAP incidence, patient outcomes, antimicrobial consumption and to compare pneumatic and electronic
devices, before generalizing their use in routine practice.
Keywords
mechanical ventilation, microaspiration, tracheal cuff pressure, tracheal tube, ventilator-associated pneumonia

INTRODUCTION VAP rates. These strategies include reduction of

Ventilator-associated pneumonia (VAP) is the most bacterial colonization of subglottic secretions and
common healthcare-associated infection in patients tracheal tube biofilm formation, prevention of aspi-
receiving mechanical ventilation in the ICU. Its ration and reduction of the exposure to invasive
&

current incidence ranges from 2 to 22 episodes mechanical ventilation [8 ]. Several preventive

per 1000 ventilator-days. The mean incidence rate
of VAP is 2.8 in the United States [1], 14.5 in Europe
[2] and 22 episodes per 1000 ventilator-days in
&
developing countries [3 ], suggesting possible
improvements in VAP prevention.
VAP is associated with increased morbidity,
duration of mechanical ventilation, ICU and hospi-
tal length of stay, and costs. The mortality rate
attributable to VAP reaches approximately 13%,
with higher mortality rates in surgical patients
and those with mid-range severity scores at admis-
&
sion [4 ]. Therefore, clinical preventive strategies
have been increasingly described and implemented
&
in ‘care bundles’ [3 ,5–7], with effective reduction in
interventions, such as routine oral care with an
antiseptic solution, head of bed elevation, or sub-
glottic suctioning, have been recommended in
clinical practice guidelines [9–12]. In most of these
recommendations, maintenance of a tracheal cuff
pressure (Pcuff) of at least 20 cmH2O, regardless of
a
Intensive Care Department, R. Salengro Hospital, CHRU and bEA
2694, Université Nord de France, Lille, France
Correspondence to Saad Nseir, Réanimation Médicale, Hôpital R. Sale-
ngro, CHRU, Boulevard du Pr Leclercq, 59037 Lille, France. Tel: +33
320444084; fax: +33 320445094; e-mail: s-nseir@chru-lille.fr
Curr Opin Crit Care 2013, 19:440–447
DOI:10.1097/MCC.0b013e3283636b71

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 Continuous control of tracheal cuff pressure Rouzé and Nseir
KEY POINTS

Pcuff should be kept between 20 and 30 cmH2O in
order to prevent microaspiration and tracheal
ischemic lesions.

Intermittent Pcuff control using a manometer is
inaccurate in continuously maintaining Pcuff in
normal range.

One randomized controlled study found no significant
impact of continuously controlling Pcuff, using an
electronic device, on VAP incidence.

Pneumatic continuous control of Pcuff significantly
reduced the microaspiration of gastric contents,
tracheobronchial colonization and VAP incidence.
control method or its frequency, is reported with a
moderate evidence level. Furthermore, recently
published VAP care bundles, including a limited
number of clinical interventions, do not consider
the control of Pcuff as a key component [6,7,11].
However, recent findings with regard to the con-
tinuous control of Pcuff might suggest highlighting
the role of Pcuff management in the prevention
of VAP.
PATHOGENESIS OF VENTILATOR-
ASSOCIATED PNEUMONIA
In order to prevent VAP, the pathophysiology of this
infection should be taken into account.
Microaspiration as a major cause for
ventilator-associated pneumonia
Microaspiration of contaminated oropharyngeal
secretions and gastric contents is the first step in
the development of VAP. These contaminated sub-
glottic secretions pool above the cuff of the tracheal
tube and enter into the lower respiratory tract
through leakage around the cuff. In addition, a
bacterial biofilm formed on the surface of the
tracheal tube serves as a reservoir for airway infec-
tion. This results in bacterial colonization of the
tracheobronchial tree. The balance between local
and general host pulmonary defenses, and quantity
and virulence of infecting microorganisms then
determines whether tracheobronchitis and pneu-
&
monia will develop (Fig. 1) [8 ,13].
Risk factors for microaspiration
Risk factors for microaspiration are related to mech-
anical ventilation, nasogastric tube and enteral
nutrition, and the patient (see list below). However,
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the tracheal tube plays a central role in the occurrence
of microaspiration through impossible closure of
vocal cords, longitudinal folds in high-volume low-
pressure (HVLP) polyvinyl chloride (PVC) cuffs and
underinflation of tracheal cuff [13]. In a prospective
observational study, including 83 patients under
mechanical ventilation, Rello et al. [14] identified
Pcuff below 20 cmH2O as an independent risk factor
for VAP [relative risk (RR) ¼ 4.23, 95% confidence
interval (CI) 1.12–15.92] in the subgroup of
patients who did not receive antibiotics. Limita-
tions of this study included the use of clinical
criteria to diagnose VAP, and the fact that only
VAP episodes diagnosed during the first 8 days of
mechanical ventilation were taken into account. In
addition, subglottic secretion drainage was used in
all study patients, which might limit the generaliz-
ation of the results to all ICU patients. Risk factors
for microaspiration in intubated critically ill
patients are as follows [13]:
(1) tracheal tube:
(a) impossible closure of vocal cords;
(b) longitudinal folds in HVLP tracheal cuff;
(c) underinflation of tracheal cuff (<20 cmH2O);
(2) mechanical ventilation:
(a) zero positive end expiratory pressure;
(b) low peak inspiratory pressure;
(c) tracheal suctioning;
(3) nasogastric tube and enteral nutrition:
(a) gastroesophageal reflux;
(b) loss of anatomical integrity of lower eso-
phageal sphincter;
(c) gastric distension;
(4) patient-related factors:
(a) supine position;
(b) viscosity of secretions above the cuff;
(c) pressure above the cuff;
(d) tracheal diameter;
(e) coma, sedation;
(f) hyperglycemia.
EFFICIENCY OF CURRENT
DISCONTINUOUS REGULATION OF Pcuff
Intermittent Pcuff control using a manometer is
widely used in ICUs to prevent complications
related to underinflation or overinflation of the
tracheal cuff. Although this method might allow
reducing these complications, its accuracy in main-
taining Pcuff in normal range is not optimal.
Current recommendations
The main function of the tracheal tube cuff is to seal
the extraluminal airway against air and fluid leak-
age, both to allow effective positive pressure
www.co-criticalcare.com 441
 Infectious diseases
Tracheal tube to ventilator
Pcuff monitoring, target values = 20–30 cmH2O
Underinflation < 20 cmH2O
microaspiration
Overinflation > 30 cmH2O
tracheal ischemia
Host’s lung defenses
Mucociliary clearance
Humoral and cellular immunity
Ventilator-associated tracheobronchitis
Ventilator-associated pneumonia
FIGURE 1. Pathogenesis of ventilator-associated pneumonia.
mechanical ventilation and to avoid microaspira-
tion of contaminated subglottic secretions. Pcuff
should be kept around 25 cmH2O, as microaspira-
tion occurs below 20 cmH2O [14] and risk of tracheal
ischemic lesions, because of impairment of tracheal
mucosal blood flow, is more important above
&
30 cmH2O [15,16 ]. However, no clear recommen-
dation exists for the frequency and method of Pcuff
measurement and adjustment. Currently, intermit-
tent monitoring of Pcuff is routinely performed
in the ICU using a manual portable manometer
(Fig. 2a), allowing cuff underinflation (Pcuff
<20 cmH2O) or overinflation (Pcuff >30 cmH2O)
corrections. The 1998 French consensus conference
on airway management recommends Pcuff checking
at least once a day and whenever the tracheal tube
position has been modified [17]. However, surveys
of airway management practices indicate that Pcuff is
usually checked every 8–12 h [18]. More frequent
measurements of Pcuff represent a workload for
nurses and may result in aspiration of contaminated
secretions pooled above the cuff, as each connection
of the manometer to the pilot balloon is associated
with transient decrease of Pcuff.
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Contaminated
subglottic secretions
Tracheal tube cuff
Pcuff
Microaspiration
Bacterial biofilm
Tracheobronchial bacterial colonization
Bacterial inoculum
Bacteria type and virulence
Compliance with the current
recommendations
A telephone survey of 24 ICUs conducted in 2002 in
the United Kingdom showed that Pcuff was never
checked in 75% of ICUs [19]. More recently, two
European web-based surveys of VAP prevention
practices in the ICU, conducted in 2008 [20] and
2012 [21], reported a compliance rate in controlling
Pcuff, at least once a day, of 81 and 83%, respectively.
In spite of the increasing compliance, these results
highlight the important potential for improvement,
especially regarding disparities among different
countries [18–21].
Accuracy of discontinuous control of Pcuff
Recently, several studies showed that intermittent
measurement and adjustment of Pcuff was not
accurate. Indeed, Pcuff decreased over time in
mechanically ventilated patients [22] and is also
influenced by patient body and head position
changes, body temperature, use of sedatives and
neuromuscular blockers, airway pressure, tracheal
suctioning and cough (Fig. 3a) [13,23,24]. These
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October 2013
 Continuous control of tracheal cuff pressure Rouzé and Nseir

(a) (b) a
40.0 (a)
20.0
b
Pcuff
0.0
154.0 155.0 156.0 157.0 158.0 159.0 160.0 161.0 162.0 163.0
c (s)

40.0
d
20.0
Paw
0.0
(c) (d) 154.0 155.0 156.0 157.0 158.0 159.0 160.0 161.0 162.0 163.0
(s)

40.0 (b)

20.0
Pcuff
0.0
1362.0 1363.0 1364.0 1365.0 1366.0 1367.0 1368.0 1369.0 1370.0 1371.0
(s)

40.0

20.0
FIGURE 2. Various commercialized cuff pressure controllers. Paw
0.0
(a) Manual portable manometer: VBM universal cuff pressure 1362.0 1363.0 1364.0 1365.0 1366.0 1367.0 1368.0 1369.0 1370.0 1371.0
(s)
Gauge, VBM Medizintechnik GmbH, Sulz a.N., Germany.
(b) Pneumatic device: Nosten, Leved, Saint-Maur, France. a, 40.0 (c)
mobile mass; b, arm; c, fixed mass; d, 300-ml cuff 20.0

connected to the pilot balloon of the tracheal tube. (c) 0.0

Pcuff
Electronic device: Tracoe Pressure Controller, TRACOE 635.0 636.0 637.0 638.0 639.0
(s)
640.0 641.0 642.0 643.0 644.0

medical GmbH, Frankfurt, Germany. (d) Electronic device: 40.0

Mallinckrodt electronic cuff pressure controller, VBM
20.0
Medizintechnik GmbH, Sulz a.N., Germany. Paw
0.0
635.0 636.0 637.0 638.0 639.0 640.0 641.0 642.0 643.0 644.0
(s)

permanent variations of Pcuff may result in poten-

tially harmful conditions out of the target range
of 20–30 cmH2O. In a pilot study assessing the
feasibility of continuous measurement of Pcuff in
10 mechanically ventilated patients, Pcuff was
recorded for a mean of 9.3 h after the initial adjust-
ment. Only 54% of Pcuff values were within the
20–30 cmH2O range. Pcuff was higher in 16% of
measurements and lower in 30% [23]. In a prospec-
tive observational study on 101 consecutive patients
requiring mechanical ventilation through a HVLP
PVC-cuffed tracheal tube, Pcuff was continuously
recorded for 8 h, just after manual adjustment
[24]. The analysis of 808 h of continuous record-
ing showed that only 18% of patients did not
develop cuff underinflation or overinflation. Study
patients spent 75% of the recording time within the
20–30 cmH2O range, 13% with cuff underinflation
and 11% with cuff overinflation. In addition,
no modifiable risk factor could be identified. In
another prospective observational study, Pcuff was
continuously recorded for 24 h in 76 patients [26
with standard PVC, 22 with cylindrical poly-
urethane (CPU) and 28 with tapered polyurethane
(TPU)-cuffed tracheal tubes] receiving intermittent
manual control of Pcuff every 8 h. Study patients
spent a large amount of recording period with cuff
underinflation or overinflation [25]. Additionally,
FIGURE 3. Continuous recording of tracheal cuff pressure
(Pcuff) and airway pressure (Paw) during cough (personal
data). (a) Discontinuous routine care of Pcuff using a manual
manometer. (b) Continuous control of Pcuff using an
electronic device. (c) Continuous control of Pcuff using a
pneumatic device.
polyurethane and cuff shape (standard, cylindrical
or tapered) did not significantly influence the per-
centage of time spent with cuff underinflation or
overinflation. However, coefficient of variation of
Pcuff was significantly higher in patients intubated
with a TPU-shaped tracheal tube compared with the
two other groups.
‘Pcuff alarm’ in the ICU as a possible
solution?
Sole et al. [22] performed a randomized controlled
crossover study to evaluate the effect of continuous
monitoring of Pcuff, combined with an alarm, in
maintaining Pcuff in the target range. Patients
(n ¼ 32) received two 12-h periods of routine care
and continuous monitoring of Pcuff. During the
intervention period, when pressure fell out of
the target range of 20–30 cmH2O, an alarm warned

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 Infectious diseases
the nurse, who adjusted Pcuff at 22 cmH2O by
removing or adding air. This intervention allowed
reducing the percentage of Pcuff values out of range
(11.1 versus 51.7%, P < 0.001) and of cuff under-
inflation (1.2 versus 44.3%). However, the effect of
this intervention on VAP prevention is unknown.
Moreover, this procedure, adding extra work for
nurses and extra alarms in today’s already noisy
and stressful ICU environment for patients and
healthcare workers, could hardly be an effective
solution for the maintenance of Pcuff in the
therapeutic range.
NEW AVAILABLE DEVICES FOR
CONTINUOUS CONTROL OF Pcuff
In recent years, two main types of devices for con-
tinuous control of Pcuff have been developed and
evaluated based on two different regulation systems,
electronic or pneumatic. As a result, several devices
have been marketed for this purpose (Fig. 2),
although not all have been clinically validated.
Electronic devices
Electronic Pcuff controllers (e.g., Tracoe Pressure
Controller, TRACOE medical GmbH, Frankfurt,
Germany; Mallinckrodt electronic cuff pressure con-
troller, VBM Medizintechnik GmbH, Sulz a.N.,
Germany; Fig. 2c and d) maintain a continuous Pcuff
using an automated air pump directly connected to
the pilot balloon of the tracheal tube with flexible
plastic tubing. A pressure sensor, requiring power
supply, regulates the air pump. The use of these
electronic devices simply requires to connect the
pilot balloon to the device, Pcuff is then automati-
cally inflated to 25 cmH2O, unless a different Pcuff
target is set on the device housing.
In a prospective randomized controlled trial
including 80 patients, requiring 2–3 h of intubation
and mechanical ventilation for surgery, effective-
ness of the Tracoe pressure controller was compared
with conventional manual manometer [26]. The
device reliably maintained Pcuff at the target level
of 25 cmH2O  2 cmH2O, whereas increased Pcuff up
to 40 cmH2O was common in the control group,
because of nitrous oxide diffusion through the cuff
membrane.
Another automatic Pcuff controller, not certified
or marketed, created from an aquarium air pump,
was tested at the bench and in clinical practice [27].
In this pilot study performed in eight ICU patients,
the device was effective in maintaining the Pcuff
target of 25 cmH2O  2 cmH2O in vitro and during
a 24-h period of continuous recording in study
patients.
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Pneumatic device
Nosten (Leved, St-Maur, France) is an aluminum-
made mechanical device, which allows continuous
control of Pcuff based on pressure equalization
between two different sized cuffs (Fig. 2b). It does
not require power supply. A single-use 300-ml cylin-
drical cuff encased in a rigid compartment is con-
nected to the pilot balloon of the tracheal tube with
plastic tubing. A weight mounted on an articulated
arm constantly exerts pressure on this cuff. This
pressure can be adjusted by moving another weight
along the arm to modulate the corresponding force,
allowing the user to obtain the desired cuff pressure.
Any variation in Pcuff is immediately cancelled out
by the disproportion between the volumes of the
two cuffs, as shown in Fig. 3c during a coughing
event.
Several experimental and clinical studies have
demonstrated the pneumatic device’s effectiveness
in deleting cuff underinflations or overinflations.
In an animal study conducted in 12 piglets mechan-
ically ventilated for 48 h, the pneumatic device
provided effective continuous control of Pcuff com-
pared with intermittent control of Pcuff using a
manometer [28]. Percentage of time spent with
underinflation or overinflation of Pcuff was signifi-
cantly lower in the intervention compared with the
control group.
Duguet et al. [29] conducted a prospective
randomized crossover pilot study to determine the
effectiveness of the pneumatic device in ICU
patients. They compared two periods of 24 h in nine
mechanically ventilated patients, one with the
pneumatic device and the other with routine care.
Percentage of time spent with Pcuff between 15 and
30 cm H20 was significantly higher during interven-
tion compared with the control period (96 versus
56%, P < 0.01). In addition, percentage of time spent
with Pcuff less than 15 cm H20 was significantly
lower during intervention compared with the con-
trol period (4.7 versus 15%, P < 0.05).
IMPACT OF CONTINUOUS CONTROL OF
Pcuff ON VENTILATOR-ASSOCIATED
PNEUMONIA INCIDENCE
Although available devices have demonstrated their
effectiveness in maintaining a constant Pcuff in ICU
patients, only a clinical benefit in reducing the
incidence of VAP or tracheal ischemic lesions should
result in recommending their use in routine prac-
tice. Only two prospective randomized controlled
trials have studied, one for an electronic device [30]
&&
and the other for a pneumatic device [31 ], the
effect of continuous control of Pcuff on incidence
of VAP.
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 Continuous control of tracheal cuff pressure Rouzé and Nseir
Impact of electronic device on ventilator-
associated pneumonia incidence
In a prospective randomized controlled study
including 142 patients without pneumonia or aspi-
ration at ICU admission, Valencia et al. [30] assessed
the effect of an electronic device for the continuous
control of Pcuff, previously validated by the same
authors [27], on prevention of VAP. In the control
group, routine care of Pcuff was performed using a
manual manometer to check and adjust Pcuff three
times a day. Despite less frequent cuff underinfla-
tions observed in the intervention compared with
the control group (0.7% of all Pcuff determinations
versus 45.3%, P < 0.001), no significant difference
was found in the VAP rates between the two groups
(15 versus 15%, P ¼ 0.89). The automatic device
showed no benefit as well on duration of mechan-
ical ventilation, ICU length of stay, or ICU
mortality. In this study, however, microaspiration,
tracheobronchial colonization, and tracheal ische-
mia were not examined. Other limitations of this
study included single-center design, absence of
blinding and the exclusion of patients with sus-
pected pneumonia at ICU admission.
Impact of pneumatic device on ventilator-
associated pneumonia incidence
Our group performed a prospective randomized
controlled trial, including 122 patients intubated
with PVC-cuffed tracheal tubes, in order to deter-
mine the impact of continuous control of Pcuff using
a pneumatic device on microaspiration of gastric
&&
contents [31 ]. Routine care of Pcuff in the control
group was similar to that in the study of Valencia
and colleagues. As expected, the percentage of cuff
underinflation determinations was significantly
lower in the intervention compared with the control
group (0.1 versus 19%, P ¼ 0.001). The percentage of
patients with abundant microaspiration (as defined
by the presence of pepsin at a significant level [32] in
more than 65% of tracheal aspirates) was lower
in the intervention group compared with the
control group (18 versus 45%, P ¼ 0.002, odds ratio
(OR) [95% CI] 0.25 [0.11–0.59]). With regard to
secondary outcomes, mean bacterial concentration
in tracheal aspirates (1.6 versus 3.1 log10 cfu/ml,
P ¼ 0.014) and VAP rate (9.8 versus 26%,
P ¼ 0.032, OR [95% CI] 0.30 [0.11–0.84]) were sig-
nificantly lower in the intervention group compared
with the control group, respectively. Moreover, per-
centage of days in the ICU with antibiotic treatment
was significantly lower in the intervention group
compared with the control group (83 versus 100%,
P ¼ 0.049). However, the pneumatic device had no
impact on the duration of mechanical ventilation,
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ICU length of stay and ICU mortality. In addition,
no significant difference was found in tracheal
ischemia score between the two groups. Several
limitations of this study should also be outlined,
including single-center design, absence of blinding,
measurement of pepsin only during the 48 h follow-
ing randomization, and the fact that VAP was not
the primary outcome.
Explanations for different results on impact
of continuous control of Pcuff on ventilator-
associated pneumonia prevention
Conflicting results between these two studies need
further analysis (Table 1). Prima facie, other VAP
preventive measures such as routine oral care with
chlorhexidine or semirecumbent position were
similar in the two trials. Nonetheless, differences
between patient population, VAP rates in the con-
trol group and the devices used can be discussed.
Actually, the percentage of surgical patients and
patients suffering from chronic respiratory disorders
were higher in Valencia’s study than in ours. In
addition, VAP rates in the control group were lower
in Valencia’s study than in ours. Finally, the device
used to control Pcuff was different in the two trials,
which may suggest that the electronic device may be
less efficient than the pneumatic one. Pcuff was
maintained in the target range in 98% of all deter-
minations with the pneumatic device, compared
to 79.3% with the automatic device. Further, in
an in-vitro study, Weiss et al. [33] showed that
electronic devices with rapid pressure correction
interfere with the self-sealing mechanisms of HVLP
PVC-cuffed tracheal tubes and reduce their improved
sealing characteristics. These findings are corrobo-
rated by a recent prospective crossover study compar-
ing electronic and pneumatic Pcuff regulators in 10
mechanically ventilated patients [34], which showed
that underinflation events were more common using
the electronic device than the pneumatic one
(in eight patients versus zero patients). This may be
explained by overcompensation of any elevated Pcuff
(Fig. 3b).
Additional clinical benefits of continuous
control of Pcuff
In addition to the potential benefits on preventing
VAP or tracheal ischemia, continuous control of
Pcuff might result in the improvement in the well
being of ICU patients. Several studies in patients
requiring anesthesia for a planned surgical interven-
tion showed a correlation between high Pcuff
and postoperative laryngotracheal complications,
such as sore throat, hoarseness or blood-streaked
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 Infectious diseases

Table 1. Comparison of two prospective randomized controlled trials assessing continuous control of Pcuff in ICU
patients
Valencia, 2007 [30] Nseir, 2011 [31 ]
&&

Number of patients 142 122

Primary objective VAP Microaspiration
Device Electronic Pneumatic
Surgical patients, % 28 0
Chronic respiratory disorders, % 38 27
Target Pcuff, cmH2O 25 25
Semirecumbent position Yes Yes
Oral care CHX 0.12% 3/day CHX 0.10% 3/day
VAP incidence in control group, % 15 26
% Pcuff determinations in 20–30 cmH2O in intervention group 79.3 98
Impact on
Microaspiration of gastric contents – # 60%
Tracheobronchial bacterial colonization – # 48%
VAP rate NS # 62%
Percentage of days in the ICU with antimicrobials – # 17%
Duration of mechanical ventilation NS NS
ICU LOS NS NS
ICU mortality NS NS
Tracheal ischemia – NS

CHX, chlorhexidine; LOS, length of stay; NS, nonsignificant.

expectorant [35,36]. In a prospective randomized
controlled trial, conducted in 90 patients under-
going thyroidectomy under general anesthesia,
monitoring and adjustment of Pcuff throughout
the surgery significantly reduced postoperative sore
throat, in comparison with the group without
adjustment of Pcuff [37]. This purely symptomatic
effect may seem trivial in intensive care practice, but
at a time when improving patient’s comfort and
quality of life in ICU is a main objective in all
medical teams [38], this point needs to be assessed
in the future studies on continuous control of Pcuff,
as all devices have been shown to be effective in
avoiding cuff overinflations.
device in reducing microaspiration and VAP rates.
Continuous control of Pcuff with a pneumatic
device, obviously combined with other evidence-
based preventive interventions, might therefore
be beneficial in preventing VAP in ICU patients.
Further studies are required to determine the impact
of continuous control of Pcuff on VAP incidence, ICU
outcomes, antibiotic use and to compare pneumatic
and electronic devices, before generalizing their use
in routine practice.
Acknowledgements
None.

CONCLUSION Conflicts of interest

S.N.: Covidien (lecture), A.R.: none.
In current ICU practice, with increased workload
and severity of illness, perfect management of Pcuff
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timesaving solution. However, cost-effectiveness of
using such devices has not been evaluated yet.
Furthermore, only one single-center study has
shown a positive effect of the use of pneumatic
Additional references related to this topic can also be found in the Current
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