What is the recommended method for securing an Endotracheal Tube (ETT)?

Recommended Methods for Securing Endotracheal Tubes

Tape or a commercial tube holder should be used to secure endotracheal tubes (ETTs), with tape showing superior results in most studies when properly applied. 1

Primary Securing Methods

• Adhesive tape is the most commonly used and effective method for securing ETTs when applied correctly with sufficient length and width 2
• Commercial tube holders provide an alternative option but may not offer superior security compared to properly applied tape 3, 2
• The combination of Cloth Adhesive tape with Mastisol adhesive showed the greatest resistance to tube displacement in comparative studies 4

Proper Taping Technique

• Use tape strips of sufficient length and width to maximize security 2
• Avoid compression of the front and sides of the neck when securing the ETT to prevent impaired venous return from the brain 5
• When using twill tape for securing ETTs, a "double hitch" knot has been shown to be superior to conventional knots in preventing slippage under both wet and dry conditions 6
• After securing the ETT, maintain the patient's head in a neutral position, as neck flexion may push the tube farther into the airway and extension may pull it out 1

Verification and Monitoring

• Always confirm proper ETT placement before securing using:
  • Clinical assessment (bilateral chest movement, equal breath sounds) 1
  • Waveform capnography (most reliable method) 5
  • Chest X-ray (to verify position above the carina) 1
• Record and document the depth of the tube at the teeth or gums before securing 5
• Re-verify tube position after securing, during transport, and each time the patient is moved 1

Risk Factors for Unplanned Extubation

• Patient movement is the most important factor associated with unplanned extubation 1
• Physical restraints may actually increase the risk of unplanned extubation (OR = 3.11) 1
• Most unplanned extubations occur when the caregiver is not at the bedside 1

Special Considerations

• For patients receiving neuromuscular blocking agents, deep sedation should be maintained to reduce the risk of unplanned extubation 1
• In emergency settings, the worst technique is manually holding the tube; twill tape has shown the lowest rates of unplanned extubation in prehospital care 1
• If a patient's condition deteriorates after intubation, consider the DOPE mnemonic: Displacement of tube, Obstruction of tube, Pneumothorax, Equipment failure 1

Pitfalls to Avoid

• Inadequate tape length or width leading to insufficient securing force 2
• Compression of neck vessels when securing the ETT 5
• Failure to maintain continuous monitoring of ETT position with waveform capnography 5
• Relying solely on physical restraints, which may increase risk of unplanned extubation 1
• Failure to re-verify tube position after patient movement or transport 1