RESEARCH Increasing positive end expiratory pressure at extubation reduces subglottic secretion aspiration in a bench-top model Jack Hodd, Alex Doyle, Joseph Carter, John Albarran and Peter Young ABSTRACT Aim: To estimate the ability of simulated tracheal suction, adjusting the positive end expiratory pressure (PEEP) settings on the ventilator or compressing a self-inflating bag to minimize aspiration during cuff deflation and extubation in a bench-top model. Background: During intubation, colonized secretions accumulate in the subglottic space above the endotracheal tube (ETT) cuff. Consequently, during cuff deflation and extubation, there is a risk of aspiration of the secretions. This may result in pneumonitis or pneumonia. There are a number of techniques used during cuff deflation and extubation to prevent secretion aspiration. Method: A model trachea was intubated and the proximal end of the ETT was attached to a mechanical ventilator. Ten millilitres of water was placed above the inflated cuff and then nine test protocols were implemented in a random order to simulate tracheal suction, adjusting the PEEP settings on the ventilator or compressing a self-inflating bag. The volume of water ‘aspirated’ by the model was determined by weighing the apparatus pre- and post-extubation. Statistical analysis was performed using regression analysis and heteroscedastic t tests with a Bonferroni correction. Results: The level of PEEP was negatively correlated with the volume of fluid aspirated [co-efficient −0·24 (99% confidence interval −0·31 to −0·17), R 2 = 0·75]. Significantly less fluid was aspirated when a PEEP of 35 cmH 2 O was applied when compared with competing techniques. Discussion and conclusions: This study suggests that applying PEEP during cuff deflation and extubation is protective against aspiration. We conclude that unless there is a contraindication, the application of PEEP should be considered when extubating patients. Key words: Aspiration • Intubation • Extubation • Tracheal • PEEP • Positive end expiratory pressure • Ventilation • Ventilator bundle • Patient safety AIM OF THE STUDY To estimate the ability of simulated tracheal suction, adjusting the positive end expiratory pressure (PEEP) Authors: J Hodd, MB, BChir, Critical Care Trainee, Department of Anaesthesia and Critical Care, Queen Elizabeth Hospital NHS Trust, Critical Care, King’s Lynn, UK; A Doyle, MB, BS, Critical Care Trainee, Department of Anaesthesia and Critical Care, Queen Elizabeth Hospital NHS Trust, Critical Care, King’s Lynn, UK; J Carter, MB, ChB, Consultant in Anaesthesia and Critical Care, Department of Anaesthesia and Critical Care, Queen Elizabeth Hospital NHS Trust, Critical Care, King’s Lynn, UK; J Albarran, DPhil, Reader in Cardiovascular Critical Care Nursing, Centre for Clinical and Health Services Research, University of the West of England, Bristol, UK; P Young, MD, MBChB, Consultant in Anaesthesia and Critical Care, Department of Anaesthesia and Critical Care, Queen Elizabeth Hospital NHS Trust, Critical Care, King’s Lynn, UK Address for correspondence: P Young, Consultant in Anaesthesia and Critical Care, Department of Anaesthesia and Critical Care, Queen Elizabeth Hospital NHS Trust, Critical Care, King’s Lynn PE30 4ET, UK E-mail: peter.young@qehkl.nhs.uk settings on the ventilator or compressing a self-inflating bag to minimize aspiration during cuff deflation and extubation in a bench-top model. BACKGROUND While patients are intubated, colonized secretions accu- mulate in the subglottic space above the endotracheal tube (ETT) cuff. Consequently, during cuff deflation and extubation, there is a risk of secretion aspira- tion. This may result in pneumonitis or pneumonia (Estes and Meduri, 1995). This occurs at a time when many patients are particularly vulnerable because of the presence of the ETT in the airway, which prevents their normal protective airway reflexes when the cuff is deflated. Pneumonitis following pulmonary aspiration may worsen respiratory function and increase the re- intubation rate and have a negative impact on outcome (Epstein, 2004).  2010 The Authors. Nursing in Critical Care  2010 British Association of Critical Care Nurses • Vol 15 No 5 257