In recent years unplanned extubation has become a focus of continuous quality improvement as a safety and quality issue. Unplanned extubation is a life threatening event and can lead to a variety of complications including but not limited to: vocal cord paralysis, aspiration, hypoxemia, airway edema, hemodynamic instability, and cardiac arrest. Unplanned extubation can occur by self-extubation, or while suctioning, turning and/or moving the patient, moving the ETT, bedside procedures, or just not being secured properly and/or adequately.
So how do we prevent unplanned extubation?
The first step in prevention is to increase awareness by educating staff on the necessity of monitoring risk factors leading up to an unplanned extubation. Staff must continuously assess and take appropriate measurements. The ETT should be checked with ventilator checks but can be increased in the presence of copious oral secretions and diaphoresis. ETT securement devices should be changed if the ETT is able to migrate and move more than 1cm.
The AARC best practices include:
- A proactive quality improvement surveillance program
- Staff education
- A uniformed method for securing ETT’s
- Documenting position according to teeth or gums and referenced to post intubation chest X-ray
- Monitor cuff pressures
- Maintain ventilator circuit on the arm support
What securement device is better?
Currently, common securing practices use adhesive tape, cloth ties, and ETT stabilization devices. The best method to secure an ETT would be to provide maximum security with minimal risk of unwanted movement and/or unplanned extubation, ease of use, and maintaining facial skin integrity. The AHA 2002 ACLS guidelines recommend the use of ETT stabilization devices rather than adhesive tape. It is thought that these devices secure and stabilize the ETT at the correct depth while helping to prevent ETT dislodgement. Adhesive tape and cloth ties allow for tube migration while limiting access to the patient for oral care. Cloth ties are also prone to stretching and with adhesive tape there is not just one way to secure the ETT.
Landsperger et al, over a 12-month period randomized 500 critically ill patients admitted to Medical ICU who were expected to require over 24 hours of mechanical ventilation. Patients were randomized at the time of intubation to either adhesive tape or a tube fastener. 162 of those patients had a duration of mechanical ventilator days less than 24 hours and 40 had missing outcome data, leaving 153 evaluable patients randomized to tube fastener and 145 evaluable patients randomized to adhesive tape. Dislodgement occurred 7 times in 6 (3.9%) in tube fastener and 16 times in 15(10.3%) in tape reflecting incidences of 11.9 and 28.1 per 1000 vent days, respectively. Facial skin tears were similar between the groups. It was concluded that the use of the tube fastener reduces the rate of a composite outcome including lip ulcers, facial skin tears, or ETT dislodgment compared to adhesive tape.
Another study done at Ain Shams University Specialized Hospital included 90 patients randomized to twill, adhesive tape and simple bow tie. Each group had 30 patients. ETT slippage was measured at 15,30,60, and 120 minutes post securement. At 120 minutes, 73% of the group in the twill group had no slippage compared to 50% in the simple bow group and 36% in the adhesive tape group.
It is vital for the ETT to stay secure and not migrate to ensure proper ventilation and oxygenation while avoiding tracheal trauma and unplanned extubation. There is a wide variability of methods to use to secure the ETT including using adhesive tape, cloth tape ties, ties, and commercial ETT holders. No one device or approach performed well in all circumstances however tube fasteners do allow for quick and easy manipulation of the ETT compared to other methods. But what is the optimal way? Optimal securement should prevent migration, require infrequent changes, withstand oral secretions, should be easy to manipulate and change with little time involvement, while maintaining skin integrity. Further studies are needed to determine best practice.
- While unplanned extubation is well documented there is little available evidence regarding the best way to secure ETTS
- The optimal securement method of endotracheal tubes is unknown but should prevent dislodgment while minimizing complications.
- Quality improvement and education are key
- Landsperger JS et al. The effect of adhesive tape versus endotracheal tube fastener in critically ill adults: The endotracheal tube securement (ETTS) randomized controlled trial. Crit Care 2019 May 7; 23:161. (https://doi.org/10.1186/s13054-019-2440-7. opens in new tab)
- Hanan Mohammed Mohammed, Manal Salah Hassan. Endotracheal tube securements: Effectiveness of three techniques among orally intubated patients. Egyptian Journal of Chest Diseases and Tuberculosis. Volume 64, Issue 1, 2015 Pages 183-196. ISSN 0422-7638, https://doi.org/10.1016/j.ejcdt.2014.09.006.