Securing the endotracheal tube
Tracheal intubation establishes a secure airway in patients who require effective ventilation, relief of upper airway obstruction, facilitation of suctioning and prevention of aspiration. Unintended removal or dislodgement of the endotracheal tube (ETT) can have serious complications, ranging from localised trauma and aspiration of oral/gastric secretions, to death as a result of a compromised airway. Extended pressure from securing the ETT on the surrounding tissue can lead to pressure sores and mucosal damage due to a decrease in local tissue perfusion. The ETT can also be inadvertently advanced to the carina or into a main bronchus.
Therefore, endotracheal tubes must be stabilised securely to optimise ventilation and avoid displacement or inadvertent extubation. The way in which ETT’s are secured is important to the overall safety and care of the critically ill child. Ideally, the method of securing an ETT should ensure minimal tube migration, maximum patient safety and comfort with regard to skin integrity and ease of oral hygiene.
A variety of methods exist for securing an endotracheal tube, and many devices have been evaluated in search of finding the best method to secure an ETT, each having its advantages and disadvantages. The following is a description of the method used in the PICU of Royal Belfast Hospital of Sick Children.
- Sterile gauze
- Tape Measure
- Benzoin Tincture/Friars’ Balsam™
- Elastoplast™ Fabric Tape 2.5cm width
- Duoderm™ Hydrocolloid Dressing (for neonatal patients)
Securing a Nasal Endotracheal Tube
1. Assemble the correct equipment required. This is a two-person procedure – one to hold the ETT and one to tape.
2. Prepare the tapes by assessing the length and width of tape needed. This can be done accurately by measuring from one tragus of the ear to the other. For neonatal patients, trim the width of the tape by 0.5cm.
3. Cut the Elastoplast tape into appropriately sized “trouser-legs”.
4. Clean any secretions from the face and nose. Apply strips of duoderm to the cheeks of neonatal patients.
5. Apply benzoin tincture to the area of skin where the tapes are to be applied. Avoid contact with the eyes.
6. Start at the same side of the ETT and place the angle of the first tape as close to the nare as possible.
7. Apply the upper trouser leg across the nasal bridge, as high up on the bridge of the nose as possible and secure onto the opposite cheek.
8. Prior to applying the lower trouser leg, ensure correct positioning of the ETT. The tube should be at the correct length and in a central position to reduce risk of pressure damage to the nare. Secure the lower trouser leg under and around the ETT and then across the upper lip and onto the opposite cheek without obstructing the free nostril.
9. The second set of tapes can be applied from the opposite side of the ETT tube.
10. The lower trouser leg is applied straight across the top of the upper lip and onto the opposite cheek.
11. Apply the upper trouser leg across the nasal bridge, wrap around the ETT and down onto the opposite cheek.
12. Ensure the tapes are secure and there is no pressure on the nose or eyes. Observe for whiteness of the nose tip which would indicate the tapes are excessively tight.
13. Trim the length of the tapes so that they do not cover the ears. Ensure the ETT cuff or patient’s ears are not accidentally cut.
Securing an Oral Endotracheal Tube
1. Start at the same side of the mouth where the ETT is positioned. Place the angle of the first tape at the corner of the mouth outside the lips.
2. The upper trouser leg is applied across the top of the upper lip under the nose and onto the opposite cheek ensuring the nostrils are not obstructed.
3. Prior to applying the lower trouser leg, ensure correct positioning of the ETT. The tube should be at the correct length and in a position not touching the corner of the mouth to reduce risk of pressure damage. Secure the lower trouser leg under and around the ETT and then across the chin below the bottom lip and onto the opposite cheek.
4. Apply the second set of tapes from the opposite side with the angle of the tape at the corner of the mouth.
5. The bottom trouser leg is applied across the face below the bottom lip and onto the opposite cheek.
6. The top trouser leg is applied across the top lip below the nose and down to the corner of the mouth.
7. Wrap the tape under and around the ETT and then down onto the side of the cheek.
8. A third section of tape can be applied for added security. This section of tape must have a central wide opening to allow application above and below the lips.
9. Ensure the tapes are secure and that there is no pressure on the lips. Trim the length of the tapes and ensure the ETT cuff or patient’s ears are not accidentally cut.
- Carlson, J, Mayrose, J, Krause, R, Jehle, D (2007) Extubation Force: Tape versus Endotracheal Tube Holders. Annals of Emergency Medicine, 50(6), pp. 686-691.
- Evelina London Children’s Hospital (2016) Clinical Guidance – Paediatric Intensive Care (PICU): Securing of Nasal Endotracheal Tubes (ETT) accessed on 29 September 2017.
- Evelina London Children’s Hospital (2017) Clinical Guidance – Paediatric Critical Care: Securing of Oral Endotracheal Tubes (ETT) accessed on 29 September 2017.
- Fisher, D, Chenelle, C, Marchese, A, Kratohvil, J, Kacmarek, R (2014) Comparison of Commercial and Noncommercial Endotracheal Tube-Securing Devices. Respiratory Care, 59(9), pp. 1315-1323.
- Gardner, A, Hughes, D, Cook, R, Henson, Osbourne, S (2005) Best practice in stabilization of oral endotracheal tubes: A systematic review. Australian Critical Care, 18(4), pp. 158-165.
- Krug, L, Machan, M, Villalba, J (2016) Changing Endotracheal Tube Taping Practice: An Evidence-based Practice Project. American Association of Nurse Anaesthetists, 84(4), pp. 261-270.
- McLean, S, Kirchhoff, K, Kriynovich, L (1992) Three methods of securing endotracheal tubes in neonates: a comparison. Neonatal Network, 11(3), pp. 17-20.
- Smith, S, Pietrantonio, T (2016) Best Method for Securing an Endotracheal Tube. Critical Care Nurse, 36(2), pp. 78-79.