Stabilisation of an Endotracheal Tube for the Adult Intensive Care ...

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Number 4 4a 4b 4c 4d 4e 4f Statement: When to change ETT stabilisation method There is minimal research evidence to support the frequency of renewal of ETT stabilisation methods. However there are principles that support the decision about frequency. 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. Grade of 14 recommendation Consensus Opinion Consensus Opinion Consensus Opinion Consensus Opinion Consensus Opinion Consensus Opinion Consensus Opinion The period during renewal of ETT stabilisation methods is a time of increased risk of UEX therefore the decision to carry out this procedure must be made on the basis of clinical need and when the patient’s condition is stable. However despite the centrality of this practice to intensive care nursing there was no research evidence or textbook recommendation identified to frame recommendations concerning when and how frequently to renew the method of ETT stabilisation. Therefore the GDN members developed these recommendations through discussion. The ETT stabilisation method can become soiled quickly by oral secretions or blood and these have potential impacts on both skin integrity and tape security. For these reasons it was considered important that the tapes be renewed when they become soiled.
The consequences of migration or movement of an ETT within a patient’s airway can include patient discomfort and pain, inadequate ventilation and tracheal damage however no reference or research was found indicating a consensus regarding the accepted safe level of ETT movement. ETT movement may be from side to side or ‘in and out’ of the airway (often referred to as telescoping) and movement in either direction is a significant source of discomfort for the patient and may cause damage to the skin and mucosal lining of the trachea. The recommendation of 1cm maximum movement is based on consultation with intensive care medical specialists and group consensus of GDN members. For this guideline an ETT that moves more than 1cm is considered to be unstable and the method should be renewed as soon as prioritised given other factors such as: 1. The amount of ETT movement; 2. Patient’s general condition especially respiratory and cardiovascular status; 3. Patient movement for procedures or transport outside the ICU; and 4. Other life saving procedures. Assessment of restrictiveness of ETT tapes or devices is open to interpretation. The recommendation to use one or two fingers is included in a number of CPGs sourced from across NSW ICU [see http://intensivecare.hsnet.nsw.gov.au/five/staffonly/guidelines_type_ventilation.php]. During discussions a number of concerns were raised regarding this particular practice including the subjective nature of this measure, differences in patients’ facial skin integrity and the potential for facial swelling. However although the recommendation is made to ensure two fingers can be inserted between skin and cotton tapes this should be applied with caution and other recommendations taken into consideration. A daily CXR is a common investigation both to identify the development or resolution of pathological lung changes and to check the position of the endotracheal and nasogastric tube. The optimal position of the ETT measured fiberoptically is between 2.5–4 cm above the carina (Evron, Weisenberg et al. 2007). Migrations of the ETT further down the trachea risks injury to the carina and/or endobronchial intubation, a potentially catastrophic complication. Conversely if the ETT is not positioned far enough down the trachea there are several risks including: vocal cord injury as the cuff impacts on the vocal cords; inadequate ventilation; patient agitation due to discomfort; and unexpected extubation. Therefore for most patients the ETT position on CXR should be checked before the ETT stabilisation method is changed to ensure the ETT is in the optimal position. It is also common practice 15
Page 1 and 2: Stabilisation of an Endotracheal Tu
Page 3 and 4: Index Abbreviations and Acronyms...
Page 5 and 6: Executive Summary Invasive ventilat
Page 7 and 8: Clinical Practice Guideline 1. Intr
Page 9 and 10: each recommendation statement using
Page 11 and 12: Number Statement: Clinician Governa
Page 13: how these variables were defined le
Page 17 and 18: Number Statement: General The venti
Page 19 and 20: What method of ETT stabilisation re
Page 21 and 22: External Validation Process In May
Page 23 and 24: Integrative Literature Review Intro
Page 26 and 27: 5. Summary Tables of Research Paper
Page 28 and 29: Appendix 1: Data Extraction Tools P
Page 30 and 31: Appendix 2: Survey of current NSW E
Page 32: References Alderson, P(2006) Guidel

Stabilisation of an Endotracheal Tube for the Adult Intensive Care ...

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