ETT security (part II): expert consensus.

Following my post on securing on how to secure an endotracheal tube (ETT) with tape, I a received a comment from Kaye Rolls a Clinical Nurse Consultant at the Intensive Care Coordination & Monitoring Unit.
You can follow Kay on Twitter (@kaye_rolls).

Turns out she is indeed an expert on the art (but perhaps not quite yet science) of ETT security. She is co-author of a set of guidelines published by NSW Health titled: Stabilisation of an Endotracheal Tube for the Adult Intensive Care Patient (pdf)

The 3 methods currently used to stabilise an ETT are:

• Tying the ETT to the patients head using white cotton (Trachy) tape.
• Taping the ETT to the patients face with medical adhesive tape.
• Using a commercial tube holder.

A recent survey of NSW ICUs and High Dependency Units (HDUs) with the capacity to provide short term ventilation was conducted to determine local ETT management practices.
Participants from 41 of the 44 eligible units responded (response rate 93%). The white cotton tape method was the most frequently reported method for stabilising the position of an ETT (78%, n=32) however nine units reported using this method in conjunction with a commercial product and a further seven units reported using this method in conjunction with medical adhesive tape.
Renewing or changing the ETT tapes is a procedure completed frequently by critical care nurses, however, only 41% (n=17) of NSW ICUs/HDUs had a written guideline for this procedure and only nine of these protocols were less than two years old.
Intensive Care WIKI

There is really not much research evidence to support the use of any one method over another, but the guidelines provide some clear principles for specific clinical situations.

As there is so little evidence, these guidelines are based on consensus opinion reached following a meeting of the Intensive Care Collaborative Consensus Development Conference in 2006–07

Here is a summary of the practice recommendations:

• Two clinicians must always be present to change the method of securing the endotracheal tube. One clinician changes the tapes while the other holds the ETT in position.
• Of the two clinicians changing the ETT securement at least one clinician must be an experienced member of the critical care team.
• The method of stabilisation should be consistent within units to promote staff proficiency in safe and effective ET stabilisation.
• The use of adhesive tape/devices should be avoided in patients with impaired facial skin integrity (for example burns, cellulitis).
• The use of adhesive tape/devices should be avoided in patients with extreme diaphoresis
• The use of adhesive tape/devices should be avoided in male patients with beards.
• Endotracheal tube securing methods that may cause venous occlusion should be avoided for patients at risk of raised intracranial pressure
• The ETT securing method should be renewed if the tapes are soiled.
• The ETT securing method should be renewed if the ETT is able to
  migrate/move more than 1 cm.
• When using cotton tape the ETT securing method should be renewed if a clinician is unable to insert two fingers between tape and skin.
• The ETT securing method should be renewed if the ETT position on CXR is incorrect (tip should be 2.5cm above the carina).
• The ETT securing method should be renewed if the method of tube stabilisation is not consistent with Unit practice.
• In the absence of other indications the tube stabilisation method should be renewed at least once every 24 hrs to enable skin and mucosal assessment and to prevent sustained pressure on a single point.
• Assessment of the face should include the condition of the skin of the face, ears and back of neck. In addition the assessment of the oral cavity should be inline with the assessment completed for adequate oral hygiene and includes the mouth, teeth, gums, tongue, mucous membranes, lips and barriers to mouth care.
• The ventilator tubing should be supported by a ventilator arm that keeps the patient’s head in the midline and prevents pressure on the lips.