Securing an Endotracheal Tube

Skill 14-11

Securing an Endotracheal Tube

Endotracheal tubes provide an airway for patients who cannot maintain a sufficient airway on their own. A tube is passed through the mouth or nose into the trachea. The endotracheal tube is often held in place with adhesive tape and should be retaped every 24 hours to prevent skin breakdown and to ensure that the tube is secured properly. Retaping an endotracheal tube requires two people.

There are other ways of securing an endotracheal tube besides using tape. Knotted twill tape can be used to secure an endotracheal tube (Hess et al., 2021; Walters et al., 2018) but may result in excessive pressure over time with resulting alterations in skin integrity. Commercial devices specifically designed to hold an endotracheal tube in place are available. Figure 1 shows an example of a commercially available endotracheal tube holder. Follow the manufacturer's recommendations for application when using commercial tube holders. Some potential drawbacks to use of these devices include that the size of the holder can interfere with provision of oral and facial care and that they are more costly than the use of tape or twill (Hess et al., 2021).

Any tube, electrode, sensor, or other rigid or stiff device element under pressure can create pressure damage (Baranoski & Ayello, 2020; EPUAP, NPIAP, & PPPIA, 2019). Patients who have an endotracheal tube have a high risk for skin and mucosal breakdown related to pressure from the tube and the securing of the endotracheal tube and moisture, compounded by the risk of increased secretions (Camacho-Del Rio, 2018). Careful assessment of the skin on the patient's face, the lips and tongue, and the skin on the patient's head in the areas where the securement device and the endotracheal tube sit are an important part of care (Mussa et al., 2018). Implement medical device-related pressure injury prevention strategies to reduce the risk for alterations in skin integrity. Interventions may include the use of a prophylactic cushioning/proactive dressings between the skin and securement device, an endotracheal tube repositioning schedule, routine skin and oral assessments, and provision of scheduled skin and oral hygiene interventions (Gupta et al., 2020; Holdman et al., 2020).

One example of a method of taping an endotracheal tube is provided below, but this skill might be performed differently in your facility. Always refer to specific facility policy.

Delegation Considerations

Securing an endotracheal tube is not delegated to assistive personnel (AP). Depending on the state's nurse practice act and the organization's policies and procedures, securing of an endotracheal tube in a stable situation, such as long-term care and other community-based care settings, may be delegated to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Assistant (nurse or respiratory therapist)
Portable or wall suction unit with tubing
Sterile suction catheter with Y-port
1-inch tape (adhesive or waterproof tape)
Disposable gloves
Mask and goggles or face shield
Additional PPE, as indicated
Sterile suctioning kit
Oral suction catheter
Two 3-mL syringes or tongue blade
Scissors
Washcloth and cleaning agent
Skin barrier (e.g., 3M^® or Skin-Prep™)
Cushioning/proactive pressure reducing dressing, such as hydrocolloid/silicone dressing
Adhesive remover swab
Towel
Razor (optional)
Shaving cream (optional)
Sterile saline or water
Handheld pressure gauge

Assessment

Assess for the need for retaping, which may include loose or soiled tape, pressure on mucous membranes, and repositioning of the tube. Assess endotracheal tube length. The tube has markings on the side to ensure it is not moved during the retaping. Note the centimeter (cm) marking at the patient's lip or naris. Assess the patient's respiratory status, including respiratory rate, rhythm, and effort. Assess lung sounds to obtain a baseline. Ensure that the lung sounds are still heard throughout the lobes. Assess oxygen saturation level. If the tube is dislodged, the oxygen saturation level may change. Assess the chest for symmetric rise and fall during respiration. If the tube is dislodged, the rise and fall of the chest will change. Assess the patient's need for pain medication or sedation. Assess pain. The patient should be calm, free of pain, and relaxed during the retaping so as not to move and cause an accidental extubation . Inspect the patient's face, the lips and tongue, and the head in the areas where the securement device and the endotracheal tube sit for alterations in integrity that may result from irritation or pressure from the tube, tape, ties, or endotracheal tube holder.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Altered skin integrity risk
Impaired oral mucous membrane
Injury risk

Outcome Identification and Planning

The expected outcomes to achieve are that the tube remains in place, and the patient maintains bilaterally equal and clear lung sounds. Other outcomes may include that the patient's skin and mucous membranes remain intact; oxygen saturation remains within acceptable parameters, the chest rises symmetrically, the patient's airway remains clear, and the cuff pressure does not exceed 20 to 30 cm H₂O (AACN, 2018; Hess et al., 2021; Hinkle et al., 2022; Turner, Feeney et al., 2020).

Implementation

Action	Rationale
1. Gather equipment.	Assembling equipment provides for an organized approach to the task.
2. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
3. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
4. Assemble equipment on the overbed table or other surface within reach.	Arranging items nearby is convenient, saves time, and avoids unnecessary stretching and twisting of muscles on the part of the nurse.
5. Close the curtains around the bed and close the door to the room, if possible.	This ensures the patient's privacy.
6. Assess the need for endotracheal tube retaping. Administer pain medication or sedation, as prescribed, before attempting to retape endotracheal tube. Explain to the patient what you are going to do and why, even if the patient does not appear to be alert.	Retaping the endotracheal tube can stimulate coughing, which may be painful for patients, particularly those with surgical incisions. Explanation alleviates fears, facilitates engagement with care, and provides reassurance for the patient. Any procedure that may compromise respiration is frightening for the patient. Even if the patient appears unconscious, the nurse should explain what is happening.
7. Obtain the assistance of a second person to hold the endotracheal tube in place while the old tape is removed and the new tape is placed.	This prevents accidental extubation.
8. Adjust the bed to a comfortable working position (VHACEOSH, 2016). Lower the side rail closest to you. Place the patient in an appropriate position based on assessment of individual circumstances. Move the overbed table close to your work area and raise it to waist height. Place a trash receptacle within easy reach of the work area.	Having the bed at the proper height prevents back and muscle strain. Positioning of the patient is based on the circumstances of the individual patient; health status, health problems, presence of drains and/or monitoring devices, etc., that allows access to the site. The overbed table provides a work surface and maintains the sterility of the objects on the work surface. Placing the trash receptacle within reach allows for an organized approach to care.
9. Put on a face shield or goggles and a mask. Suction the patient as described in Skill 14-9 or 14-10.	PPE prevents exposure to contaminants. Suctioning decreases the likelihood of the patient coughing during the retaping of the endotracheal tube. If the patient coughs, the tube may become dislodged.
10. Measure a piece of tape for the length needed to reach around the patient's head one and a half to two times (Hess et al., 2021). Cut the tape. Lay it adhesive side up on the table.	Extra length is needed so that tape can be wrapped around the endotracheal tube.
11. Cut another piece of tape long enough to reach from one jaw around the back of the neck to the other jaw. Lay this piece on the center of the longer piece on the table, matching the tapes' adhesive sides together.	This prevents the tape from sticking to the patient's hair and the back of the neck (Hess et al., 2021).
12. Take one 3-mL syringe or tongue blade and wrap the sticky tape around the syringe until the nonsticky area is reached. Do this for the other side as well.	This helps the nurse or respiratory therapist to manage the tape without it sticking to the sheets or the patient's hair.
13. Take one of the 3-mL syringes or tongue blades and pass it under the patient's neck so that there is a 3-mL syringe on either side of the patient's head.	This makes the tape easy to access when retaping the tube.
14. Provide oral care, including suctioning the oral cavity. Refer to Skill 14-7 (oral hygiene is covered in Chapter 7).	This helps to decrease secretions in the oral cavity and pharynx region.
15. Take note of the “cm” position markings on the tube. Begin to unwrap the old tape from around the endotracheal tube. After one side is unwrapped, have the assistant hold the endotracheal tube as close to the patient's lips or naris as possible to offer stabilization.	The assistant should hold the tube to prevent accidental extubation. Holding the tube as close to the patient's lips or naris as possible prevents accidental dislodgement of the tube.
16. Carefully remove the remaining tape from the endotracheal tube (Figure 2). After the tape is removed, have the assistant gently and slowly move the endotracheal tube (if orally intubated) to the other side of the mouth (Figure 3). Assess the mouth for any skin breakdown. Before applying new tape, make sure that the markings on the endotracheal tube are at the same spot as when retaping began.	The endotracheal tube may cause pressure injuries if left in the same place over time. Repositioning the endotracheal tube may reduce the risk for pressure injury (Gupta et al., 2020; Holdman et al., 2020).
17. Remove the old tape from the patient's cheeks and the side of their face. Use adhesive remover to remove excess adhesive from the tape (Figure 4). Clean the patient's face and neck with a washcloth and cleanser. If the patient has facial hair, consider shaving their cheeks. Pat the cheeks dry with the towel.	To prevent skin breakdown, remove old adhesive. Shaving helps to decrease pain when the tape is removed. The cheeks must be dry before new tape is applied to ensure that it sticks.
18. Apply the skin barrier to the patient's face (under the nose and on the cheeks and lower lip) where the tape will sit; apply a cushioning/proactive pressure reducing dressing if indicated. Unroll one side of the tape. Ensure that the nonstick part of the tape remains behind the patient's neck while pulling firmly on the tape. Place the adhesive portion of the tape snugly against the patient's cheek. Keep track of the pilot balloon from the endotracheal tube, to avoid taping it to the patient's face. Split the tape in half from the end to the corner of the patient's mouth.	The skin barrier/protectant prevents skin irritation and excoriation from the tape, adhesives, and moisture and helps the tape adhere better to the skin (Fumarola et al., 2020; Kelly-O'Flynn et al., 2020). The use of cushioning/proactive dressings between the skin and the securement device reduce the risk for alterations in skin integrity. The tape should be snug to the side of the patient's face to prevent accidental extubation.
19. Place the top-half piece of tape under the patient's nose (Figure 5). Wrap the lower half around the tube in one direction, such as over and around the tube. Fold over the tab on the end of the tape.	By placing one piece of tape on the lip and the other piece of tape on the tube, the tube remains secure. The tab makes tape removal easier.
20. Unwrap the second side of the tape. Split to the corner of the patient's mouth. Place the bottom-half piece of tape along the patient's lower lip. Wrap the top half around the tube in the opposite direction, such as below and around the tube. Fold over the tab on the end of the tape. Apply pressure to the tape on the endotracheal tube to ensure the tape is secure (Figure 6). Remove gloves. Perform hand hygiene.	Alternating the placement of the top and bottom pieces of tape provides more anchorage for the tube. Wrapping the tape in an alternating manner ensures that the tape will not accidentally be unwound. Removal of gloves and hand hygiene reduce the risk for pathogen transmission and contamination of other items.
21. Auscultate lung sounds. Assess for cyanosis, oxygen saturation, chest symmetry, and endotracheal tube stability. Again check the cm marker on the tube to ensure that the tube is at the correct depth.	If the tube has been moved from the original place, the lung sounds may change, as well as oxygen saturation and chest symmetry. The tube should be stable and should not move with each respiration cycle.
22. If the endotracheal tube is cuffed, check the pressure of the balloon by attaching a handheld pressure gauge to the pilot balloon of the endotracheal tube.	Careful monitoring of cuff pressure is necessary to decrease the risk for tracheal necrosis, tracheal rupture, laryngeal nerve palsy, tracheal stenosis, microaspiration, and/or inadequate ventilation (Turner, Feeney et al., 2020). The smallest amount of air that results in an airtight seal between the trachea and the tube is desirable and less likely to result in complications; maintain pressure between 20 and 30 cm H₂O (AACN, 2018; Hess et al., 2021; Hinkle et al., 2022; Turner, Feeney et al., 2020).
23. Assist the patient to a comfortable position. Raise the bed rail and place the bed in the lowest position.	This ensures patient comfort. Proper positioning with raised side rails and the proper bed height provides for patient comfort and safety.
24. Remove the face shield or goggles and mask. Remove additional PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.

Evaluation

The expected outcomes have been met when the tube has remained in place and the patient has maintained bilaterally equal and clear lung sounds, the patient's skin and mucous membranes have remained intact, oxygen saturation has remained within acceptable parameters, the chest rises symmetrically, the patient's airway has remained clear, and cuff pressure has not exceeded 20 to 30 cm H₂O (AACN, 2018; Hess et al., 2021; Hinkle et al., 2022; Turner, Feeney et al., 2020).

Documentation

Guidelines

Document the procedure, including the depth of the endotracheal tube from the teeth, lips, or naris; the amount, consistency, and color of secretions suctioned; the presence of any skin or mucous membrane changes or pressure injury and associated interventions; and your before and after assessments, including lung sounds, oxygen saturation, cuff pressure, and chest symmetry. Document cuff pressure.

Sample Documentation

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

Patient is accidentally extubated during tape change: Remain with the patient. Instruct the assistant to notify the health care team. Assess the patient's vital signs, ability to breathe without assistance, and oxygen saturation. Be ready to deliver assisted breaths with a bag-valve mask (Skill 14-16) or administer oxygen. Anticipate the need for reintubation.
Tube depth changes during retaping: Tube depth should be maintained at the same level unless otherwise prescribed by the health care team. Remove the tape around tube, adjust the tube to prescribed depth, and reapply the tape.
Air leak (air escaping around the balloon) is heard on inspiration cycle of ventilator: Auscultate lung sounds and check the depth of the endotracheal tube to ensure that it has not dislodged. Obtain a handheld pressure gauge and check pressure. Air may need to be added to the balloon to prevent the air leak. If pressure is already 20 to 30 cm H₂O, you may need to contact the health care team before adding more air to balloon. Sometimes, a change in the patient's position will resolve air leaks.
Patient is biting on the endotracheal tube: Obtain a bite block (Hess et al., 2021). With the help of an assistant, place the bite block around the endotracheal tube or in the patient's mouth. If prescribed, consider sedating the patient.
Depth of endotracheal tube changes with respiratory cycle: Remove the old tape. Repeat taping of the endotracheal tube, ensuring that the tape is snug against the patient's face. Consider use of a commercial securement device. There are various types on the market; check with your facility for availability.
Patient has trauma to the face that prevents the use of tape when securing the endotracheal tube: You may need to obtain a commercially prepared endotracheal tube holder. There are various types on the market; check with your facility for availability.
Lung sounds are greater on one side: Check the depth of the endotracheal tube. If the tube has been advanced, the lung sounds will appear greater on the side on which the tube is further down. Remove the tape and move the tube so that it is placed properly. If the depth has not changed, assess the patient's oxygen saturation and respiratory rate. Notify the health care team. Anticipate the need for a chest x-ray.
Pressure injury is noted in the mouth or naris (if patient is intubated via naris): If the ulcer is painful, consider consulting with the health care team regarding the use of a topical numbing medication, such as lidocaine viscous jelly. Apply topically with a cotton-tipped applicator. Consider a consult with the wound care team. Keep the area clean by performing more frequent oral or nasal care. Ensure that the ventilator or oxygen tubing is not pulling on the endotracheal tube, thus applying pressure additional on the patient's skin and mucous membranes.
Pilot balloon is accidentally cut while caring for endotracheal tube: Notify the health care team. Obtain a 22-gauge IV catheter and thread it into the pilot balloon tubing, being careful not to puncture the tubing with the needle, below the cut. Remove the needle from the catheter and apply a stopcock or needleless Luer-Lok to the catheter. Alternatively, a blunt needle can be passed into the pilot balloon tubing and a stopcock or Luer-Lok attached to the needle hub (Hess et al., 2021). If air is needed to reinflate the balloon, a syringe can be attached to the stopcock or Luer-Lok so that air may be added. Anticipate the need for an endotracheal tube change.

Special Considerations

Make sure emergency equipment is easily accessible at the bedside. Keep a bag-valve mask, oxygen, an extra endotracheal tube of the same size, and suction equipment at the bedside of a patient with an endotracheal tube at all times.
Evidence suggests that once adhesive tape is outside of its original packaging, it becomes contaminated with pathogens and presents a risk for transmission of pathogens to the patient and risk for an associated health care-associated infection (Bernatchez & Schommer, 2021; Krug et al., 2014; Krug et al., 2016). Krug et al. suggest contamination of the tape used to secure an endotracheal tube is a significant issue and needs to be considered when choosing equipment, including tape that is clean and individually packaged.

EVIDENCE FOR PRACTICE
Endotracheal Tubes and Patient Communication Related Evidence Karlsen, M. M. W., Ølnes, M. A., & Heyn, L. G. (2019). Communication with patients in intensive care units: A scoping review. Nursing in Critical Care, 24(3), 115-131. https://doi.org/10.1111/nicc.12377 Refer to details in Skill 14-9, Evidence for Practice.

section name header

Skill 14-11

EVIDENCE FOR PRACTICE