Securing and / or Trimming ETT

21/4/05

Dear ICU Connect Member,

At XXX Hospital, we have had problems with pressure areas fom endotracheal tube tapes. We use white trache tapes and reston foam, change them prn. Recently we have been changing them every shift. Does anyone have a protocol on ETT tapes and how to secure a trache.

I have attended to an audit re securing/changing ETT tapes.

Thanks.
Clinical Nurse Specialist
Tertiary Referral Hospital   

26/4/05

we have a protocol and use similar...

 Tracheal tube tying_ETT

CNC Tertiary Referral Hospital   

26/4/05

Good protocol- although I have a few concerns regarding doing oral care during tape change:-
1. Retying the TT is not without risk, with the possibility of accidental dislodgement significant. I believe that this procedure should be done as expeditiously as possible.  Brushing the teeth,
rinsing the mouth and using a yankeur sucker with an unsecured TT poses a significant risk to the patient.
2.  Mouth care which incorporates brushing the teeth, should be done at least twice a day (we aim for three times a day) because according to the literature,(Munro et al 2002, 11,3, 280-286)  brushing is the best method of removing dental plaque which harbours oral bugs. Therefore if comprehensive mouth care was attended during TT change, it would be hard
to justify changing the tapes tds or bd.

Cheers

Clinical Nurse Consultant
Tertiary Referral ICU

26/4/05

interesting protocol, XXXX

Why do you see the need to trim ET tubes? They are not designed to be trimmed in situ and I can't think of a possible reason why I would want to trim a tube that is in a patient. Tube trimming risks complete loss of airway and confers no benefit. You have only a negligible effect on resitive work of breathing (and there are generally much more major factors which should be attended to first). The bit of tube sticking out of the patient is not the bit that gets kinked, it is the bit just adjacent to the teeth where any kinks happen. In addition if you use a closed suction system you have now created a dangerous device where the suction catheter extends much further down the bronchus than it was designed. Plenty of cases also of 'accidental' cutting of pilot balloons while trimming tubes, which is occasionally catastrophic, and also cases of tube tapes being cut with loss of tube.

Interesting to think how a risk manager would respond - a protocol to do something that confers no benefit, with catastrophic potential complications!

Now if only we could convince the ambulance service to stop shortening tubes before they insert them into patients. They trim them way too short for any big person, ony necked person and especially anyone with a face which is going to swell. We've all had "interesting" experiences changing ETT tubes inserted by paramedics in for example burnt patients, as the face swells and the too short tube comes out of the glottis!

Cheers
Staff Specialist (1) in Intensive Care Medicine
Tertiary Referral ICU

27/4/05

interesting discussion XXX

cutting ett is a common timeless practice.  i'm wondering if there is objective information to support the practice either way.  the ambulance service practice has definately caused problems for me in the past, as has cutting the tube shorter after a number of days.  and am aware of critical incidents involved doing this.  near misses are invaluable lessons to learn!

i'd have to say i prefer a tube that has been trimmed BUT not to a minimum length. not so much for the decrease in resistance but because having it long provides an extra anchor for inadvertant dislodging by a restless patient.  however if the tube is to be cut it should happen at intubation where objective evaluation of  whether the tube is in the correct position is known thanks to an x-ray.  never before because too short is worse than too long!!!

is there a clever person who could calculate the difference in resistance per extra centimetre?

not sure i agree with what you said about the in-line suction catheters though.  all of the products i have seen are marked so shouldn't be inserted too far.  as well there are occasions where you do want to go beyond the end of the ett eg BAL, sputum plugs etc

i concur somewhat with XXXX (re retying tapes and cleaning teeth at the same time).  i think there are good arguments both ways.

seems to me we might need to get some consensus on these issues via an expert panel type setup.  Are we mature enough for this yet?  i'd like to think we are!

CNC
Clinical Project Officer
Intensive Care Coordination and Monitoring Unit

27/4/05

Thanks Angela for your comments.
I agree with your comments but I do not believe this constitutes a need to change advocated practice within this protocol - although with less experienced staff greater caution would be required - fortunately we do have (as you guys have) a good mentoring process. To do effective mouthcare - most appropriate during TT tape change. As for point 2: I don't get it? Have I written something confusing in the protocol? Tape changes are prn and per shift (12 hour) therefore minimum of b.d. Mouthcare is at least bd and often q 2nd hourly!!! - for vent and non-vent pts. Tape change and mouthcare are independent activities but mouthcare should be done when changing tapes (ease of access, viewing etc, obviously with caution and noting of TT position at lips/teeth) - seriously worried now that I have missed the point....hmmm.

CNC
Tertiary Referral ICU

27/4/05

Re triming ETT.  I would suggest this is essential when setting a patient up for prolonged - ie greater than few hours - ventilation.  It reduces flow resistance, facilitates suctioning, reduces the anchor point for accidental tube dislodgement, reduces tube drag and movement even when stabilised, and reduces "deadspace" ventilation.  Obviously it requires care, confirmed tube placement prior to triming and recording the distance the tube was trimmed to at the time it is done.
It is probably not ideal to do it at the roadside or in the ED.

Assoc Prof Critical Care Nursing

28/4/05

Very strong words there!! I might just note that those of us caring for paediatric and neonatal patients would not concur with this view - the place where small ETT tubes kink is not at the teeth - and we tend to use nasal ETTs anyway. Increased dead space is certainly an issue in this population. Certainly we have had issues in the past with paramedics cutting tubes.

I therefore concur with Prof XXX. It's not something we do routinely,
but from time to time it's necessary

CNS
Children’s ICU

28/4/05

Good afternoon All

From a risk/benifit issue I find this whole tube cutting proposition (in adults) absolutely illogical, especially in the face of the potential risks. Your first point and last point are absolutely negligible and of no significance in clinical practice. These can be easily overcome via ventilation parameter manipulation. I am assuming your other points, given your designation are supported well with evidence, of which i would be interested in perusing.

Nurse Educator
Tertiary Referral ICU

28/4/05

I disagree with most of these [in that they are technically correct but neglible effects in reality, compared with a potentially very dangerous practice] - I accept Kaye's point about the 'anchor' for a willing hand. I haven't searched the literature on this and Gavin you may have done so. What does the evidence say?

Staff Specialist (1) in Intensive Care Medicine
Tertiary Referral ICU

28/4/05

I don't recall trimming ET tubes in the PICU at the Children's when I was training there and I think my argument about the danger of complete loss of airway during the trimming applies doubly so in a sick baby as in anybody else!!

Cheers
Staff Specialist (1) in Intensive Care Medicine
Tertiary Referral ICU

28/4/05

It's arguably less risky in babies and kids - no cuff. I imagine it's mainly nurses who do it in NICU and PICU and we would manage it as per a tube restrap, ie several pairs of hands.  And of course, it's not a common practice, and only in longer-term ventilated kids where the tube has been placed long enough to seriously kink or we're desperate to get CO2 down or to minimise chances of unplanned extubation. And not without due consideration by the team of course.

CNS
Children’s ICU

Hi Troops,

Since this issue has produced some very interesting responses, it would be good to take up Kaye's earlier suggestion of producing a consensus document for our State.  Can ICCMU undertake this kind of activity?  It would be good to have statewide guidelines/ standards especially for such a bread and butter ICU issue.

Regards

CNC
Tertiary Referral ICU

28/4/05

Dear Everyone,
Staff specialist (1) view is  consistent with our (and especially mine) at XXX. SS 1 should be congratulated in putting his finger on the main issue. Changing the policy in the paramedic programme to discontinue the "outdated" 1980's policy (recommended by the then existing Critical Care C'tee Chaired by an intensivist!)( who)  recommended Cutting the ETT.

Both from a Safety and Efficacy point of view( two crucial and basic issues in ICU and medicine in general), cutting the ETT is NOT RECOMMENDED . Therefore ,DON"T DO IT!!!
Everyone reading this should let everyone else know(via this list):

How they Secure an ETT in Their ICU so that everyone can and should adopt the best solution for their ICU.

Cutting  the ETT in Westmead is OUT and I would ask NE and CNC to place the XXX  ETT Securing practice on this list for Westmead and Other ICU's to re-view their ETT securing practice and Protocols

Staff Specialist (2) in Intensive Care Medicine
Tertiary Referral ICU

28/4/05

I believe that 'some clever person' has already looked at airway resistance in ETT's. Whilst a little old, Guttman, Wolf et al (1993) did a study entitiled 'Continuous Calculation of Tracheal Pressure in Tracheally Intubated Patients'. This can be found in Anesthesiology, Vol, 79, Sept, 1993. I believe that shortening tubes was found to have a negligible effect on tube resistance. This popped up today when I was looking for something else so I have not actually done a lit search for anything more recent.

28 April 2005

Nice to be stong, confident and Dogmatic. My comments relate to ADULT ICU. I cannot provide an opinion for the Kids or Neonates. Clearly, in Adult ICU there would be variations for individual patients with Burns, Craniectomies,neck injuries etc.

Staff Specialist (2) in Intensive Care Medicine
Tertiary Referral ICU

29 April 2005

I am concerned that many of the discussions on this issue are dogmatic, and based upon personal views. I haven't come across anything in the medical literature that has studied the issue, but I do not know about the nursing literature. It seems to me that there are always going to be some occasions when trimming the tube in adults is desirable, even if it is not part of routine practice. If there is a move towards a consensus view, then I hope any recommendations allow for the occasional need to trim the tube.
Staff Specialist (3) in Intensive Care Medicine
Tertiary Referral ICU

It's OK to start with dogma and then trim things to suit the particular situation in certain patients. Protocols are never absolute. 2005 is the 100th year of the Theory of Relativity

Staff Specialist (2) in Intensive Care Medicine
Tertiary Referral ICU

28 April 2005
Always a good retort - what's the evidence, there of course is little.
The latest ventilators provide for tube compensation so issues of resistance and deadspace in adults are possibly of little consequence. I'm unaware if anyone has properly evaluated the effect on patients trialled on an ETT with mask for extubation, but even that is a process which can be managed better on a modern ventilator.
Paeds and neonates is another issue, not my area of expertise so I'll defer to Tina K.
The practice is related to nursing management and is not without risk, although this can be minimal if undertaken in a procedurally correct fashion.
My recommendations comes from our recent review of 7 years accidental extubation data where tube irritation has a role in promoting self extubation.  Excessive tube length can also be partially to blame during transport and movement in places like CT, OR and Angio Labs.  I can't quantify if we lost more tubes directly because of these issues as opposed to pilot tubes being cut, but this is extremely rare occurrence in our experience.  To do an effective trial would require require thousands of participants given an accidental extubation rate of around 2.5%, and not all of these could be attributed to having a full length tube insitu.  So it comes down to a consensus view informed by risks and benefits.
I'd reiterate my firm belief that tube shortening should not occur at the roadside, back of ambulance or in ED. I think this is where the debate began.

Assoc Prof Critical Care Nursing

29 April 2005

this is  exactly the activity we are proposing to undertake at the EBP workshop in june.  once i have a list of all of the partiicpants attending i will be sending a brief survey to identify priority areas for  development.
see you all there!

CNC ICCMU
Clinical Project Officer

Good Morning All,
Well yes, it is a resonable, valid and credible retort. All of us, especially those of which hold an educational designation must not be responsible for the dissemination of unsupported information.
Potentially it may well be construed by the less experienced members of the critical care society as a reliable yardstick for clinical practice, which unfortunately may result in the perpetuation of questionable
practice. Moreso, it may lead to unsafe practice resulting in compromise to either the patient, or compromise to the professional integrity of the person delivering that practice. When "only 15-20% nursing practice is EBP" (Hickey, J. Heading Forward, Neurosurgical Nursing-Present & Future. Inter-Continental Hotel, Sydney 2004), the challenge for nursing is to cultivate an ever-increasing bed of evidenced based nursing practice and not practice based purely upon nursing tradition.

Nurse Educator, Intensive Care
Tertialry Referral ICU

29 April 2005
..........
My recommendations  comes from our recent review of 7 years accidental extubation data where tube irritation has a role in promoting self extubation.  Excessive tube length can also be partially to blame during transport and movement in places like CT, OR and Angio Labs.  I can't quantify if we lost more tubes directly because of these issues as opposed to pilot tubes being cut, but this is extremely rare occurrence in our experience.  To do an effective trial would require require thousands of participants given an accidental extubation rate of around 2.5%, and not all of these could be attributed to having a full length tube insitu.  So it comes down to a consensus view informed by risks and benefits.
I'd reiterate my firm belief that tube shortening should not occur at the roadside, back of ambulance or in ED. I think this is where the debate began.

Assoc Prof Critical Care Nursing

29 April 2005
I'd lke to broaden this debate a little.....

XXXin, you refer to your review of 7 years accidental extubation data. Please tell us more.

I've been vaguely looking for a while for an acceptable figure but have been unable to find one, so I really don't know whether 2.5% is good, bad, or average. There is also a semantic issue. I generally talk about 'unplanned' extubations and that is what we audit in our M&M. That is any extubation which was not immediately intended and initiated by a doctor or nurse. Of course most unplanned extuations are not accidental at all, but are because the patient should have been extubated but the decision hadn't been made yet for whatever reason. The nicest summary of some of this that I have seen is Farhad Kapadia's paper in Crit Care Med a few years back - he did an audit of a good database in Mumbai and came up with challenging findings, including the much higher incidence of problems with tracheostomies compared with transglottic tubes, which challenges some of our current beliefs.

Back to cutting tubes .... a trial is not appropriate methodology for a safety issue, a trial is only useful for determining benefits of therapy. For safety and incident monitoring the best is a good prospective observational study, probably in the form of a comprehensive prospectively collected database. Many of us do have those, both privately and with the ANZICS database, and it may be possible to extract enough information from these databases to answer the question [such as by flagging all airway accidents in the database and then going back to the notes to deternmine the case], and this might be acheivable if someone has the interest in doing such a project. For a rare event such as airway disaster during tube trimming, we know that to be 95% confident of an incidence of 1 in n we need to study at least 3 n patients so the numbers will be huge but maye doable.

To illustrate this (that I'm not just spouting off in fairyland), the Mayo Clinic in Rochester has a superb anaesthetic database now getting up towards 500,000 records. Lots of good work looking at the true incidence of rare events has een done from this data base - search under Mark Warner for examples of a number of these papers.

Why can't we do the same (a good study of airway accidents might be a PhD for someone!!!)

Staff Specialist (1) in Intensive Care Medicine
Tertiary Referral ICU

29 April 2005

Whenever an ETT is correctly placed in the trachea the two worst things that can happen are dislodgement or entering the R main bronchus.

Right Bronchial intubation in a sick patient with respiratory problems is catastrophic and is commonly rapidly fatal due to a combination of:-
1.       Severe hypoxia from ventilating only the R lung or if the tube is beyond the RUL bronchus only the R middle and lower lobes i.e. quarter lung power.
2.       Hypotension from large tidal volumes in the R thoracic cavity decreasing venous return.
3.       R pneumothorax from these high pressures.

This is the reason that in emergency intubation kits for Paramedics or Hospital Cardiac Arrest trolleys I have always insisted on precut tubes - number 9 at 26 cms and numbers 8 & 7 at 24 cms.  With these lengths it is very uncommon to experience endobronchial intubation. The effect of shortening the tube on airway resistance is negligible and of no consequence. On the other hand go to any emergency scene where uncut tubes are used and you will soon get a rich experience of endobronchial intubation which is commonly unrecognized in the heat of battle.  One wonders if Western Sydney could be a hot spot for this?

If, as does happen, the tube placed in an emergency situation is too short it can be replaced early in the Intensive Care admission by an experienced person. If any difficulty is anticipated use a well lubricated Cook Airway Exchange Catheter or if there is serious laryngeal pathology do a tracheostomy.

Once a tube is placed it must be secured so that it cannot fall out and also so that it cannot migrate south into the R main bronchus.  Once the correct position is established the tube should be cut at 2.5 cm from the lips to prevent potential fatal migration which can easily occur if the tube is not tied tightly or at subsequent retyings which should be done as infrequently as possible and never as a routine.

Apart from clinical examination of the chest to ensure equal air entry it is important to know the position of  the carina on the CXR * this is frequently not visible on mobile CXR’s.

The best landmark is the aortic knob which is in the same coronal plane as the carina.  I always ensure that the tip of the tube is just north of a line half way through the aortic knob.

The question of the best way of tying a tube with ‘trachy tape’ is something that has interested me for many years.  Unfortunately some of the methods used display a lack of understanding of knots and especially the simple Reef Knot.  This knot should NEVER be used to join 2 lengths of tape as it will slip and become undone.  It is a serious mistake to use this knot on the side of the face as the otherwise excellent Liverpool Protocol recommends.  Bows with “shoelace type knots” are even worse and should only be used for wrapping boxes of chocolates.

The way I advise to tie a tube with tape is the following:
1.       Pass the tape around the neck and then tie it firmly between the nose and tube with a Surgeons knot (i.e. an initial double throw of the tape so that the correct tension can be maintained followed by a single locking throw.  Don’t tie this knot between the tube and chin as it predisposes to the tube slipping over receding chins.
2.       Tie a very firm reef knot (left over right then right over left) around the tube so that the tube cannot slip up or down.
3.       Tie another firm reef knot back the other way (belt and braces) and cut the ends at 2.5 cms.  Never cut the ends short as it will unravel.

Adherence to these simple principles of airway care will save more lives than anything else we do in Intensive Care.

Staff Specialist (4) in Intensive Care Medicine
Tertiary Referral ICU

We wrote up our experiences in an article recently published in Intensive & Critical Care Nurse (Birkett, Southerland, Leslie - Reporting unplanned extubation 2005;21: 65-75).  Our unplanned extubation rate was between 1.06 and 4.86% using number of intubated patients over incidents. This was simply an audit and focussed on incidents.  Our main aim was to get some data from Australia out there. We didn't report on contributing factors to patient or staff related unplanned extubation such as whether the tube was trimmed or not. I certainly concur with your comments re monitoring and descriptive studies.  The challenge is to get the multi site level of cooperation necessary to run with this over a number of years.

Assoc Prof Critical Care Nursing

Tuesday, 3 May 2005 11:53

 We can all  learn from DR Wright on how to secure the ETT. I would  recommend his technique for securing the ETT.

XXX  ICU has not noted an increase in morbidity/mortality from NOT  cutting the ETT.Clearly there are some circumstances where cutting the  ETT may be necessary.These circumstances are the exception to the "usual  guidelines" in units that DO NOT cut ETTs.

 Whilst I commend Staff specialist 4 for his  approach with reference to the  paramedic protocol and his elegant reasons for his recommendations in the out of hospital setting,we would not be cutting the ETT at XXX  ICU.
 We are , like Staff specialist (1), experiencing more problems with  cut ETTs placed by the paramedics.(difficulties in securing the ETT, ETT migration down with disconnection, ETT migrating OUT of the Larynx from facial swelling (burns and facial trauma and during routine ICU procedures.
If We are unable to change "current" practice of the paramedics, we may  have to resort to changing the ETT in ICU and confirm the anatomical  position consistenty with  Dr Wright's ( and my own)view below.
The ETT position, Cut/Trimmed or NOT must be checked on arrival in the  ED and again, on arrival in the ICU, and after any major patient move to or from the ICU.

Staff Specialist (2)
Tertiary Referral ICU

3 May 2005

Glad the protocol on tape tying was of assistance. Its not easy to adequately and accurately describe the tape - tying process, pros and cons etc. I referenced T. Clarke et al's paper, knowing that Therese and colleagues had laboriously researched knot tying in order to come up with appropriate knots and describing the process (Dr Wright - thanks for your tape-tying comments). Please note that tube trimming is not a routine practice in Liverpool ICU - some of our Intensivists had concerns about its representation. However, after discussion, it was felt that on those rare occassions when it is required ) - then at least having the precautions and process described was better than having nothing at all. back to the 'grind'.

CNC Tertiary Referral ICU

4 May 2005

Concord ICU has done a retrospective and prospective study on unplanned/accidental extubations and have submitted the article to the Australian Critical Care.  Hopefully we should hear soon as to whether it will be published.  we also wanted to get some data on unplanned extubations, the circumstances surrounding the events and have  compiled a protocol which will be introduced into the unit. As soon as we hear back from ACC we would be happy to share our findings and the protocol.

CNC Tertiary Referral ICU