Where should an Endotracheal Tube (ETT) be taped?

Endotracheal Tube Securing: Best Practices

The endotracheal tube (ETT) should be secured with tape or a commercial device in a manner that avoids compression of the front and sides of the neck, which could impair venous return from the brain. 1

Proper ETT Securing Technique

Initial Steps

• After confirming correct ETT placement with waveform capnography and clinical assessment, record the depth of the tube as marked at the front teeth or gums before securing 1
• The provider should document this initial position to detect any subsequent displacement 1

Securing Methods

• ETT can be secured using either adhesive tape or commercial tube holders (Class I, LOE C) 1
• When using tape:
  • Apply sufficient length and width of tape for maximum security 2, 3
  • Lateral application of tape with minimized "peel angle" provides higher resistance to extubation forces 3
  • Wider tape strips and longer tape lengths provide superior holding power compared to narrow, short strips 2, 3

Positioning Considerations

• Avoid tape application that compresses the front and sides of the neck to prevent impaired venous return from the brain 1
• Commercial devices and backboards provide equivalent security to traditional taping methods during patient transport (Class IIb, LOE C) 1

Monitoring ETT Position

Continuous Monitoring

• Continuous waveform capnography is recommended as the most reliable method for confirming and monitoring correct ETT placement (Class I, LOE C-LD) 1
• If waveform capnography is unavailable, alternatives include:
  • Nonwaveform CO2 detector
  • Esophageal detector device
  • Ultrasound by an experienced operator (Class IIa, LOE C-LD) 1

Post-Securing Verification

• After securing the ETT, obtain a chest x-ray (when feasible) to confirm proper positioning of the tube above the carina 1
• The ideal position is approximately 3-5 cm above the carina 4

Special Considerations

Patient Movement Risks

• There is significant potential for ETT movement with head flexion/extension and during patient transport 1
• Patient movement is one of the most important factors associated with unplanned extubation 1
• Continuous monitoring of tube position is essential as displacement can occur with movement 5

Tape vs. Commercial Holders

• Studies comparing tape to commercial holders show that with proper technique, tape can provide superior holding power 2, 6
• Commercial holders may be beneficial during transport situations 1
• The choice between tape and commercial holders should consider:
  • Patient factors (facial hair, skin integrity, burns)
  • Expected duration of intubation
  • Transport needs 1

Common Pitfalls to Avoid

• Insufficient tape surface area in contact with both the tube and patient's face 3, 6
• Improper tape application allowing easy "peeling" of the tape 3
• Failure to continuously monitor ETT position with waveform capnography 1, 5
• Relying solely on clinical assessment without objective confirmation methods 1

By following these evidence-based practices for securing ETTs, providers can minimize the risk of unplanned extubation and associated complications, ultimately improving patient outcomes.