The Operating Theatre Journal - Flipbook - Page 32
Risk Reduction in Endo-Tracheal Tube Fixation
Author: Deborah Glover MBE, BSc (Joint Hons), PGDip Care, Policy & Management
Key Words - Endo-tracheal fixation, infection control, device-related pressure ulceration, surgical tape, LEAFix
Evidence suggests that tracheal intubation has been undertaken for
about 4,ooo years (Szmuk et al 2008). Airway management is vital for
the unconscious, ventilated patient, yet although the Royal College of
Anaesthetists provide guidance for an Initial Assessment of Competence
for UK Anaesthetics (RCA 2022) (Box 1), no national standardised
protocol for ETT insertion and management exists, forcing individual
organisations develop their own practices.
The lack of national guidance is not without issues; a 2009 review of
patient safety incidents pertaining to airway devices (2005-2007) found
that of 1085 incidents, 893 (82.3%) were classed as post-procedure
problems such as displacement from patient (66%, n=317), pressure
ulceration and infection (19%, n=73). Causes of displacement included
patient turning, physiotherapy and patient agitation. Consequently,
the authors recommended that investment should be made in design
solutions to improve the fixation of tubes (Thomas, 2009).
In addition to the lack of guidance, few studies on the securing of ETTs
in the operating theatre have been undertaken (Davies et al 2014).
This article will outline how such complications may arise and present
a potential clinical solution.
Infection
While the process of intubation can lead to tissue damage and
subsequently, infection, (Levine 1991) there is a ubiquitous source
of infection for the intubated patient, the fomite. A fomite is ‘… an
object that becomes contaminated with infected organisms and which
subsequently transmits those organisms to another person.’ (NHS
England. 2020.) has been identified as a source of cross-contamination
and healthcare acquired infection (HAI). Fomites include stethoscopes
(O’Flaherty 2015) and a tiny but potentially lethal source of crosscontamination and healthcare acquired infection (HAI), a roll of
adhesive tape, regularly used to secure ETTs (McCluskey et al 2015). A
survey by McClusky et al revealed:
● no existing policies or standards of care related to tape storage or
use
● tape stored in open containers in infrequently cleaned rooms
● tape rolls being carried in pockets or on stethoscopes
(McClusky 2015)
However, the role of tape on cross-contamination has been understood
for over 50 years (Redelmeier 1999, Garg 2009, Harris 2012, Rammaert
2012, Lalayanni 2012). Berkowitz et al examined 23 rolls of adhesive
tape being used in a 16-bed intensive care unit and found mixed flora
on 15 rolls and pure cultures of Staphylococcus aureus, Pseudomonas
aeruginosa, and various species of Enterobacteriaceae on eight rolls.
(Berkowitz 1974), and concluded that such tape may contaminate the
hands of those who handle it and may directly contaminate patients
when used to secure airways and drainage tubes as it is in close contact
with the mucous membranes. Further studies have explored the
potential infection risks of adhesive tape in the securing of a patient
airway (Krug 2014, Bernatchez 2021). Krug et al reviewed literature
pertaining to endotracheal tube (ET) taping practice and found that
overall, it was not safe as tape rolls were not discarded at the end of
a surgical case, rather returned to the supply bin for re-use on other
patients. They concluded that a disposable, individually wrapped,
single patient use tape roll was needed.
Device-related skin stripping
Numerous studies have shown that surgical tape removal can cause
Medical Adhesive-Related Skin Injury (MARSI) such as skin-stripping,
the removal of the superficial stratum corneum, skin blistering, skin
tears, inflammatory skin reaction and pain (Cutting 2008, Fumarola
2020, Bloria, 2020).
Zeng et al’s study (Zeng, 2016) compared the incidence of facial skin
injury and patient satisfaction with different tapes in 60 adult patients
undergoing anaesthesia. Standard tape caused denudation of the skin
and skin injury in 13.3% (n=4) and 37% (n=11) respectively, compared to
silicone (0%) and 3% (n=1) respectively
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Facial pressure injuries and ETT displacement
Literature has demonstrated that facial pressure injuries, damage to
the skin or damage to underlying tissue can be caused by medical
devices which have been secured incorrectly. Zakaria et al found in
the three weeks of the study, 90% (n=27/30) of control group subjects
developed oral ETT pressure ulcers compared to the intervention group
(avoiding tape where possible and placing padding under areas of cloth
fixation) (Zakaria 2018).
Other studies have found that the use of cloth tape or commercial ETT
fixers can also cause pressure ulceration. Hampson et a’s retrospective
observational study sought to determine the impact a fixing device
(AnchorFast™) on the incidence of oral pressure injuries in mechanically
ventilated patients compared to the previous fixation method. Results
showed that incidence increased from 1.53/100 to 3.73/100 (IRR = 2.43,
95%CI = 1.35–4.38; p = 0.003). There was also a significant difference in
location of pressure injuries sustained with ETTs secured using cloth
tapes (53.6% in corner of the mouth) vs. AnchorFast™ (75% on the lips)
(p = 0.008). (Hampson 2018). Similar results with commercial fasteners
were seen by Sleiwah et al (Sleiwah 2020)
Nursing a patient on the prone position also increases the potential
for ETT pressure injury. Shearer et al observed that 47.6% of proned
COVID-19 patients developed facial pressure ulcers (Shearer 2021)
Landsperger et al (2019) undertook a study that randomised patients
undergoing ETT fixation to adhesive tape or endotracheal tube fastener
at the time of intubation in order to determine the presence of lip
ulcer, endotracheal tube dislodgement or facial skin tears. Results
showed that lip ulcers occurred in 2.6 % (n=4) versus 11 (7.3%) patients
(incidence rate of 6.5 versus 19.5 per 1000 patient ventilator days
(p = 0.053) in the fastener and tape groups respectively. The ETT was
dislodged 3.9% (n=6) and 10.3% (n=15) (incidences of 11.9 and 28.1
per 1000 ventilator days,) respectively. Facial skin tears were similar
between the groups. (Landsperger 2019)
ETT management Studies
Given that an endotracheal tube (ETT) plays a vital part in keeping
a patient alive, it must remain patent and in situ. An unplanned
extubation (UE), ‘the unintentional and uncontrolled removal of the
endotracheal tube either due to actions of the patient or during nursing
care or movement of the patient (da Silva 2012), can lead to serious
harm, including dyspnoea, airway trauma, laryngeal and tracheal
oedema, difficult reintubation, hospital-acquired infections (Hai) and
death (Aydogan 2017).
Mannequin studies
Fisher et al evaluated nine ETT holders in simulated clinical conditions.
ETT security was tested by measuring distance displaced after a tug.
Sensors were located on a mannequin which measured applied forces
when the head was rotated vertically or horizontally. From the results
the authors concluded that non-commercial airway holders exert less
force on a patient’s face than commercial devices (Fisher 2014)
A further study used a mannequin to examine the amount of force
required to dislodge endotracheal tubes secured with four different
varieties of commercially available tape and three different taping
methods, and concluded that the amount of force required to
dislodge endotracheal tubes is affected by tape type, taping method,
and direction of force. The silk tape was superior at holding the
endotracheal tube in place when compared to other tape varieties and
taping methods (Davis 2014). The author’s also concluded that securing
to both the mandibular and maxillary borders (Y-shape), created a
strong fixation.
Interestingly, Shimizu et al’s mannequin study demonstrated that if
tape strips were of sufficient length and width, a conventional tape
method was superior to the tested commercial ETT holders in holding
the ETT in place (Shimizu 2011)
Clinical Studies
A questionnaire to explore anaesthetists’ experiences of ETT fixation
and displacement was undertaken by Li et al (Li 2021).
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