Drs. Kimberley Lewis and Waleed Alhazzani from the Division of Critical Care, Department of Medicine, have published a trial on the use of the cuff leak test (CLT) called “Cuff Leak Test and Airway Obstruction in Mechanically Ventilated Intensive Care Unit Patients (COMIC): A Pilot Randomized Clinical Trial” in the Annals of the American Thoracic Society

The CLT is used daily by intensivists to help guide extubation. In the CLT, the cuff at the end of the endotracheal tube (ETT) is deflated and the assessor auscultates for air passing around the ETT. A lack of air auscultated (a failed CLT) implies the presence of laryngeal edema (LE) that could cause airway obstruction upon extubation. A presumptive diagnosis of LE is often treated with systemic steroids and a delay in extubation. While the CLT is non-invasive, and inexpensive, it can be inaccurate. A false positive test (indicating the presence of LE when non-exists) will result in an unnecessary delay in extubation, exposure of the patient to systemic steroids, and increase a patient’s risk of deconditioning.

Drs. Lewis and Alhazzani conducted an international survey of 1197 intensivists from 17 countries which demonstrated that 59% of intensivists do not order a CLT prior to extubation, while the remainder do (10.1111/aas.13838). 100 critically ill patients in three countries (Canada, Saudi Arabia, and Poland) were randomized to extubation with or without the results of the CLT being communicated to the treating team. COMIC not only met, but exceeded the feasibility criteria of consent rate, recruitment rate, and adherence rate. This is the first RCT on this topic. 

Given the success of COMIC, these two experts will lead the “Cuff Leak Test and Airway Obstruction in Mechanically Ventilated Intensive Care Unit Patients (COSMIC): A Pragmatic Randomized Clinical Trial”. This powered trial will assess if using the CLT to guide extubation management impacts patient-important outcomes such as reintubation. It is anticipated that the trial’s international, multi-site recruitment will begin this spring. The results of COSMIC will inform clinical practice guidelines to improve the care of the critically ill around the globe.

Dr. Lewis is an Assistant Professor in the Division of Critical Care, Department of Medicine and a critical care physician-researcher at St. Joseph’s Healthcare Hamilton. She completed the McMaster Clinical Investigator Program and her MSc in Clinical Epidemiology in 2021. Her interests include methods to avoid or shorten the duration of mechanical ventilation. 

Dr. Alhazzani is an Associate Professor in the Division of Critical Care, Department of Medicine and a critical care physician-researcher at St. Joseph’s Healthcare Hamilton. Dr. Alhazzani does research in Critical Care Medicine and Gastroenterology. His areas of interest include clinical practice guidelines, clinical trials, and systematic reviews. 
 
COMIC was supported by the Dr. Paul O’Byrne Research Grant ($5,000). The trial methods centre was supported through the GUIDE (https://guidecanada.org/). Department of medicine co-authors include Dr. Dan Perri and Dr. Roman Jaeschke.


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