How do you properly secure an Endotracheal Tube (ETT)?

How to Properly Secure an Endotracheal Tube

Use either adhesive tape or a commercial tube holder to secure the ETT, with properly applied tape (using adequate length and width) showing superior resistance to displacement in most studies, while avoiding any compression of the neck vessels that could impair venous return from the brain. 1, 2

Securing Method Selection

Tape Technique (Preferred When Properly Applied)

• Tape demonstrates superior holding force when applied with sufficient length and width, with conventional taping methods requiring forces ranging from 20-156 N for extubation depending on technique 3, 4
• Use wider tape strips with longer lengths for maximum security—one conventional tape method (Cloth Adhesive™ + Mastisol®) showed the greatest mean distraction force of 21.8 N compared to other methods 5
• Apply tape laterally to minimize the "peel angle," which significantly increases resistance to displacement 4
• Increased total surface area of tape on the face correlates with higher peak extubation forces 4

Commercial Tube Holders (Alternative Option)

• Commercial devices provide equivalent security to traditional taping during patient transport and may be preferred in specific situations 2
• The Haider Tube-Guard device reduced ETT movement to 0.3 cm versus 3.4 cm with adhesive tape under standardized tension, with 97% of taped tubes experiencing >1 cm movement versus only 3% with the device 6
• Consider commercial holders for patients with facial hair, compromised skin integrity, facial burns, or anticipated prolonged intubation 2

Critical Steps Before and After Securing

Pre-Securing Documentation

• Record and document the depth of the tube at the teeth or gums before securing to establish baseline position for detecting subsequent displacement 1, 2
• Confirm proper ETT placement using clinical assessment (bilateral chest movement, equal breath sounds over axillae), waveform capnography, and absence of gastric insufflation sounds 7

Post-Securing Verification

• Re-verify tube position immediately after securing using both clinical assessment and confirmatory devices (Class I, LOE B) 7
• Obtain a chest X-ray when feasible to confirm proper positioning above the carina and verify the tube is not in a mainstem bronchus 7, 2
• Maintain continuous waveform capnography monitoring as the most reliable method for ongoing confirmation of correct ETT placement (Class I, LOE C-LD) 2

Head Positioning and Ongoing Monitoring

• Maintain the patient's head in a neutral position after securing—neck flexion pushes the tube deeper into the airway, while extension can pull it out 7
• Re-verify tube position during transport and each time the patient is moved (e.g., from gurney to bed), as patient movement is the most important factor associated with unplanned extubation 1, 2

Critical Pitfalls to Avoid

Application Errors

• Never apply tape in a manner that compresses the front and sides of the neck, as this impairs venous return from the brain 1, 2
• Avoid using tape strips that are too short or narrow, as these provide inadequate resistance to displacement 5, 4
• Do not rely solely on physical restraints to prevent extubation, as their use paradoxically increases unplanned extubation risk (OR = 3.11) 1

Monitoring Failures

• Failure to continuously monitor ETT position with waveform capnography increases complication risk 1, 2
• Most unplanned extubations occur when the caregiver is not at bedside, highlighting the need for continuous monitoring 1

When Patient Condition Deteriorates

If an intubated patient's condition worsens, use the DOPE mnemonic to systematically evaluate: 7, 1

• Displacement of the tube
• Obstruction of the tube
• Pneumothorax
• Equipment failure