What is the recommended method for securing an endotracheal (ET) tube?

Recommended Methods for Securing Endotracheal Tubes

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

Primary Securing Methods

• Adhesive tape is the most commonly used method and can provide superior security when applied with sufficient width and length compared to some commercial holders 1, 2
• Commercial tube holders (such as the Haider Tube-Guard) have been shown to significantly reduce ETT mobility compared to adhesive tape in some studies 3
• After intubation, the tube must be secured immediately, though there is insufficient evidence to recommend any single method as definitively superior 4

Proper Technique for Securing ETTs

• When using tape, ensure it's applied in a manner that avoids compression of the front and sides of the neck to prevent impaired venous return from the brain 5
• Record and document the depth of the tube at the teeth or gums before securing to detect any subsequent displacement 5
• When using tape, wider strips and longer lengths provide better security against accidental extubation 2
• Commercial devices and backboards provide equivalent security to traditional taping methods during patient transport 5

Verification of Proper Placement

• Always confirm proper ETT placement before securing using:
  • Clinical assessment (bilateral chest movement, equal breath sounds) 4
  • Waveform capnography (most reliable method) 5
  • Chest X-ray (when feasible) to confirm positioning above the carina 5
• Re-verify tube position after securing, during transport, and each time the patient is moved 1, 5

Risk Factors for Unplanned Extubation

• Patient movement is the most important factor associated with unplanned extubation 1
• Physical restraints may paradoxically increase risk (OR = 3.11) 1
• Pediatric patients under 5 years of age are at significantly higher risk for ETT dislodgment (OR 6.6) 6
• Prolonged coughing and gagging significantly impact accidental extubation or dislocation 7

Monitoring for Complications

• If an intubated patient's condition deteriorates, consider the DOPE mnemonic:
  • Displacement of the tube
  • Obstruction of the tube
  • Pneumothorax
  • Equipment failure 4, 1
• Continuous waveform capnography is the most reliable method for ongoing monitoring of correct ETT placement 5

Pitfalls to Avoid

• Failure to maintain continuous monitoring of ETT position with waveform capnography increases risk of unplanned extubation 1
• Compression of neck vessels when securing the ETT can lead to impaired venous return from the brain 1, 5
• Relying solely on physical restraints may increase the risk of unplanned extubation 1
• Manually holding the tube in place without proper securing shows significantly higher odds of dislodgment compared to other methods (OR 5.0) 6