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Stabilisation of an ETT

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Contents

Introduction


Invasive ventilation is common practice in an intensive care unit (ICU) for patients with serious breathing difficulties. Ventilation is achieved through the insertion of an ETT into the trachea via the mouth or nose and attaching this tube to a ventilator. It is vitally important that the position of the ETT remain stable for several reasons:

  1. as this tube is fulfilling the function of a patient’s airway, the unexpected removal of the tube (unplanned extubation UEX) poses a significant risk to the patient’s survival;
  2. the tube needs to be stable to ensure optimal ventilation and constant supply of oxygen; and
  3. ETT movement within the trachea may cause local trauma and is a significant source of discomfort for the patient. 


There are also several clinical concerns to address with respect to patient safety when attempting to achieve a stable ETT. These include:

  •  Preventing migration of the ETT and unplanned extubation;
  • Maintaining alignment of the ETT within trachea;
  • Skin integrity of the face and neck; and 
  • Maintenance of adequate levels of venous return from the head through the jugular veins.


There are three main methods of achieving tube stabilisation:

  1. tying the ETT to the patient’s head using white cotton tape;
  2. taping the ETT to the patient’s face using medical adhesive tape; or
  3. using a commercial tube holder.


There is a lack of research into the most effective form of ETT stabilisation with a recent systematic review being unable to
identify a superior method (Gardner, Hughes et al. 2005). 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 [see Appendix 2]. 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.


The recommendations in this guideline were informed by an integrative literature review covering the publication years of  1980-2006 [See Integrative literature review] and the clinical experience of the guideline development network members who were senior clinicians from NSW ICUs. Due to the lack of any evidence these recommendations were considered to be the key guiding principles that a protocol writer should incorporate into whatever method/s of ETT stabilisation are most appropriate for their  patient mix and clinical setting.

Scope

The recommendations in this guideline are focussed on the clinical practices used to maintain the optimal position of an endotracheal tube that is inserted into an adult in an intensive care unit referred to as ‘stabilisation of an endotracheal tube’. The following issues, although considered important, are beyond the scope of this guideline:

  • Issues related to patient autonomy such as patient consent and explanation of procedure.
  • Documentation of patient assessment and outcomes of nursing procedures.


The full guideline is available for download from here.

Purpose

This guideline has been developed to provide intensive care clinicians with recommendations or principles to guide the development of local policy/procedure related to stabilisation of an endotracheal tube. The guideline does not address the minutiae of this practice.


Target Clinicians

The target clinicians are registered nurses and medical officers working in NSW ICUs. This includes both beginner and experienced clinicians and assumes knowledge of: anatomy and physiology of the head and neck; the purpose of an ETT and importance of maintenance of correct position; possible sequelae associated with the different stabilisation methods; and
the consequences of unplanned extubation.


Process of Guideline Development

The guideline was developed by a guideline development network (GDN) composed of intensive care nurse specialists from NSW, Australia. A systematic literature review and review of current practice were completed. Following this recommendations for practice were developed and refined at a consensus development conference (CDC). Group consensus was achieved using a 9-point likert scale. An external validation panel (EVP) was also convened.

Further details of the process are described in the following article

Rolls KD., Elliott D. (2008). Using consensus methods to develop clinical practice guidelines for intensive care: the intensive care collaborative project. Aust Crit Care. Nov;21(4):200-15 ]


Infection Control

Prevention of infection is an important aspect of any clinical practice and guideline users are directed to NSW Health Policy directive (PD2007_036) and local policy to comprehensively identify the infection control elements of this clinical practice. These elements include but are not limited to: use of personal protective equipment, good hand hygiene, correct disposal of equipment and medical waste and isolation of infectious patients.

When renewing ETT tapes both the operator and assistant are at high risk for contact with potentially contaminated patient secretions therefore personal protective equipment including goggles, gloves and masks must be worn.


Occupational Health & Safety

Guideline users are directed to local policy and procedures related to occupational health and safety to ensure operator safety whilst completing this procedure.


Recommendations for Stabilisation of Endotracheal Tube

The purpose of the recommendations listed here is to inform the development of local policy regarding the stabilisation of an endotracheal tube (ETT). The paucity of research literature regarding this topic has limited the ETT guideline development network’s (ETT-GDN) ability to formulate specific recommendations regarding the optimal method of stabilisation and
related issues. Therefore these recommendations are considered to be the key principles that should be addressed when a clinician is developing local policy.


The decision to change or renew a patient’s ETT stabilisation method is influenced by several factors however must be made on the basis of ensuring the ETT remains in the optimal position.

These factors may include:

  • Is the patient’s ETT in the optimal position and will it remain there?  If the ETT is in imminent danger of UEX or endobronchial intubation the clinician should prioritise correcting this.
  • What is the patient’s current clinical status?  Since the risk of UEX is heightened during the procedure if a patient’s clinical
    status is critical and unstable changing the ETT stabilisation method may not be warranted unless the ETT position is unstable.
  • What is the patient’s level of consciousness?  A patient who is restless, agitated or has an inadequate level of sedation is more likely to self-extubate (Boulain 1998) and this risk will be increased when the stabilisation method is being renewed. 
  • What is the impact of the ETT stabilisation method on the patient’s venous return from the head and facial and neck skin and oral cavity?
  • Has the method of ETT stabilisation been renewed within the past 24 hours?
  • Is the method of ETT stabilisation consistent with unit guidelines?


The recommendations for practice have been grouped under the following headings