The study revealed unsafe tracheal cuff management among the surveyed care providers, supported by a weak knowledge base. Previous studies regarding knowledge and practice of trachea cuff pressure management had indicated wide variation across different practice settings around the world, with evidence of substandard practice in most environments. A single-institution questionnare-based study conducted recently in Pakistan had shown that among the critical care and emergency room practitioners of a tertiary hospital 69% of the participants had no prior knowledge about ETT cuff manometer, 73% had never used a manometer while 72% did not know the hazards of inappropriate tracheal cuff pressure [18]. Similarly, among anaesthesia care providers in a military hospital in USA poor knowledge regarding tracheal cuff management was also evident as only 35% of the care providers knew the correct tracheal cuff pressure [19]. In our multicentre study encompassing both anaesthesia and critical care staff only 31.1% of the care providers knew the correct Pcuff, 97% had never used a tracheal cuff manometer, while 81% were aware that improper cuff pressure could harm patients. Meanwhile, a seemingly higher knowledge of the correct tracheal cuff pressure was recorded by 45% of participants in a multicentre questionnaire-based survey conducted among 160 anaesthesiologists practicing in South Africa [15]. In the South African study the participants were all anaesthesiologists (anaesthesia faculty fellows, residents and diplomates), while in our study and the others, the participants were an admixture of physician and non-physician care providers (nurse anaesthetists, certified registered nurse anaesthetists, student registered nurse anaesthetists, anaesthesia technicians, ICU nurses, etc.) who are involved in tracheal cuff management. Hence, the cadre of the participants in the respective surveys may have impacted on the similarities and differences in the knowledge base regarding tracheal cuff management. Thus, 59.6% of respondents had knowledge of the recommended cuff pressure in a study conducted in a Brazilian teaching hospital among consultants and resident anaesthesiologists [20]. It is of note that all the quoted studies were conducted between 2016 and 2021, and could be adjudged to approximate current trends.

The current practice regarding tracheal cuff management in Nigeria is captured in both parts of our study. The questionnaire-based segment (Part1) shows that 97% of the surveyed care providers have never used a tracheal cuff manometer, with the ‘pilot balloon palpation method’ being the most popular method of tracheal cuff pressure estimation. The nationwide telephone survey (Part 2) supports the findings of the questionnaire-based segment regarding the popularity of the ‘pilot balloon palpation method’ of cuff pressure estimation, and the very limited use of tracheal cuff manometer in tracheal cuff management in Nigeria. Whereas all 10 hospitals included in the South African study had tracheal cuff manometers somewhere within their institution, only half of the participants were aware of this and they were not readily available [15]. Their routine technique of tracheal cuff management showed much variability; minimal occlusive volume technique (38.8%); pilot balloon palpation technique (36.3%); minimal leak technique (11.9%); cuff manometer (2.5%). This would suggest that in addition to making the tracheal cuff manometer widely available for airway management, education and change of attitude are necessary in changing the narrative of poor tracheal cuff management. In contrast, among the anaesthesiologists in a Brazilian university teaching hospital 63.8% used the manometer occasionally, while 4.3% used it routinely. All the anesthesiology residents confirmed having used the tracheal cuff manometer, even though it was not regularly available [20]. It is obvious that in spite of the better level of knowledge and practice among the participants in the Brazilian study tracheal cuff pressure management could be said to be currently poor globally. A bi-national survey was conducted in 2019 to evaluate the prevailing practice regarding intraoperative cuff pressure monitoring in private and public hospitals across Australia and New Zealand [21]. Among the 1000 randomly selected anaesthesia faculty fellows, 78.0% submitted that they had ready access to cuff pressure manometer in their hospital, but only 40.0% used them routinely in their practice. Our current national survey of anaesthesia faculty fellows in Nigeria which revealed that the tracheal cuff manometer is neither available, nor has it ever been used in any of the 13 randomly selected tertiary health institutions is thus a far cry.

Several earlier research works had found that most of the healthcare workers who used the palpation technique underestimated the Pcuffs and hyperinflated the tracheal cuffs in both tracheal models and human subjects [20, 22,23,24]. The palpation technique has remained a very popular technique despite its flaw. It was so unreliable that its use in Iranian ICU patients was associated with universal over-inflation of the tracheal cuff, with all being above 40 cmH2O (mean 88.8 ± 27.1 cmH2O) [25]. The use of tracheal cuff manometer for objective estimation and monitoring of tracheal cuff pressure reduces postoperative morbidity [1, 26]. The very limited use of the manometer in tracheal cuff management in the country cannot be explained away by mere unavailability since other devices for monitoring patients such as the multi-parameter patient monitors are available. In Nigeria, like in most countries, there are no national or professional guidelines prescribing or mandating the availability or use of objective monitoring of tracheal cuff pressure. The weak knowledge base of the surveyed care providers in Nigeria, as elsewhere, may play a role in sustaining this poor practice. Hence, the need for mass education and enlightenment regarding proper management of the tracheal cuff in intubated patients.

It is of note that the participants in our survey are care providers serving in federal tertiary hospitals, otherwise regarded as elite institutions in the country. Anaesthesia manpower deficit in Nigeria is severe [27], and these same care providers also cater for the bulk of state health institutions and private health facilities. It is therefore considered that their knowledge and practice fairly represent the pattern of tracheal cuff management in Nigeria. The unsafe care regarding tracheal cuff management in Nigeria mirrors the current state of anesthesia safety in some other developing countries [28,29,30].

A limitation to this study is that it is, like some other cited studies, questionnaire-based, and as such inherently susceptible to response bias, particularly as it pertains to deliberate false responses meant to gratify social desirability. For instance, disclosures regarding practice as volunteered by the participants may not be accurate, or factual. Given that there is unavailability of the tracheal cuff manometer in all the surveyed facilities, the claim by the six respondents to having used the cuff manometer is unsubstantiated. In effect, the proportion of care providers that have ever used the tracheal cuff manometer may be less than the 3% that declared. Furthermore, since the survey took several days to complete in some hospitals, it could have afforded some respondents the opportunity to make reference to texts, or the internet regarding the recommended tracheal cuff pressure and other knowledge questions before being surveyed. Consequently, the actual knowledge base regarding tracheal cuff management may indeed be lower than what we found.

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