Securing Endotracheal Tubes: Suture vs. Tape
Use adhesive tape or commercial tube holders as the primary method for securing endotracheal tubes, not sutures alone. 1, 2
Primary Securing Method
Tape or commercial tube holders are the recommended standard for ETT fixation. 1, 2 The American Heart Association explicitly recommends securing the ETT 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
Why Tape is Preferred
- Tape shows superior results in most studies when properly applied, according to the American Thoracic Society. 2
- Peak extubation forces with tape range from 20-156 Newtons depending on technique, with long thin strips providing surprising durability by minimizing the "peel angle" during removal. 3
- Cloth adhesive combined with supplementary adhesives (like Mastisol®) provides the greatest resistance to ETT distraction, with mean forces ranging from 7.8 to 21.8 Newtons across different taping methods. 4
When Sutures May Be Considered
Tracheostomy Tubes (Not ETTs)
For tracheostomy tubes specifically, sutures should be removed within 7-10 days and preferably before discharge, unless required to secure the airway during prone ventilation. 5 This guideline applies to tracheostomy tubes, not standard endotracheal tubes.
Combined Tape-Suture Technique
In laboratory testing, combining tape around the tube with a suture through the tape provided the best resistance to accidental removal when head movement is anticipated. 6 However, this is a research finding, not a guideline recommendation for routine practice.
Nasal Intubation Special Case
For naso-endotracheal tubes in prolonged head and neck surgeries, a trans-septal mattress suture technique can prevent columellar necrosis and nasal deformity while maintaining tube stability. 7 This specialized technique relocates the suture knot to the septal area rather than the columella.
Critical Implementation Steps
Before Securing
- Confirm proper ETT placement using clinical assessment, waveform capnography, and absence of gastric insufflation sounds before securing the tube. 1
- Record the depth of the tube as marked at the front teeth or gums before securing and document this initial position. 1
Securing Technique
- Apply tape in a manner that avoids compression of the front and sides of the neck to prevent impaired venous return from the brain. 1, 2
- Maintain the patient's head in neutral position after securing the tube, as neck flexion or extension can displace the tube. 1
After Securing
- Re-verify tube position after securing using waveform capnography (Class I, LOE B recommendation). 1
- Obtain a chest X-ray when feasible to confirm proper positioning above the carina. 1, 2
- Re-verify tube position during transport and each time the patient is moved, as patient movement is the most important factor associated with unplanned extubation. 1, 2
Common Pitfalls to Avoid
- Never rely on sutures alone for routine ETT fixation - this is not supported by guideline recommendations. 1, 2
- Avoid compression of neck vessels when securing the ETT, which can impair venous return from the brain. 2
- Do not use physical restraints as the primary prevention strategy for unplanned extubation, as they paradoxically increase risk (OR = 3.11). 2
- Never skip continuous waveform capnography monitoring after securing, as failure to monitor increases unplanned extubation risk. 2
Monitoring for Deterioration
If an intubated patient's condition worsens, immediately assess using the DOPE mnemonic: Displacement of tube, Obstruction of tube, Pneumothorax, and Equipment failure. 1, 2