Protection of the Endotracheal Tube Cuff

The thin plastic envelope of a standard high-volume, low-pressure endotracheal cuff is extremely susceptible to misdirected laser energy. Although combustion is possible, simple puncture may be more common. Unrecognized cuff punctures lead to oxygen enrichment of the gas surrounding the surgical site and endotracheal tube and increase the likelihood of a catastrophic airway fire. Cuffs with significant laser resistance that maintain the mechanical properties necessary to minimize tracheal trauma are not available. Many physicians recommend filling the standard Hi-Lo cuff with colored saline to signal a puncture more clearly and potentially to quench a small cuff fire. The cuff should be placed as far distal in the trachea as possible, and the surgeon should completely cover the visible cuff with moistened cotton pledgets. The cotton strings attached to the pledgets should be replaced by uninsulated wire, and the pledgets should be remoistened as needed. The utility of moistened pledgets in preventing or delaying cuff ignition from CO₂ laser exposure has been confirmed.^[81]