NHS Lothian Induction: Securing ETT

Hello. We are two practitioners from the clinical education and training department, and today, we’re going to show you video one of a series of videos, which are for guidance for staff who find themselves in a position of having to look after patients who are critically unwell and intubated and ventilated. The skills required to look after the patient are both technical and non-technical, and we are going to demonstrate specifically the technical today. The non-technical skills are exceedingly important, and we must remember that when caring for these patients, we have to be vigilant. We have to use our observational skills.

We have to use very good communication skills, and we really need to empathise with the patient because an intubated ventilated patient will feel very vulnerable, will feel a loss of control, and will possibly be very scared and very frightened. So the first thing we’d like to describe to you is actually the endotracheal tube or ET tube as it’s known for short. An endotracheal tube can be placed by an anaesthetist for many reasons, but in our scenario today, our patient has developed a severe pneumonia and has to be intubated for respiratory support. This will ensure he gets adequate oxygen supply and will secure an airway.

The first thing that we must always do when we come on shift is check that the ET tube is sitting in the mouth and is sitting at the correct level. You will know this because when the patient is initially intubated, we document the level that the ET tube sits in the mouth. So once a shift at least, you should refer to your device check or your nurse records and just check that the tube has not slipped in or slipped out. Another part of caring for a patient with an endotracheal tube it’s making sure that it is well secure in the mouth, and we can do this in a number of ways.

If the patient is going to be ventilated for a while, so more than 72 hours, we favour an in NHS Lothian, the AnchorFast, which is a device that two people can put on, and it prevents or reduces pressure damage to the skin and to the lips. For securing an ET tube, it’s always important that one person talks to the patient, reassures the patient, tells the patient exactly what’s happening, while the other practitioner places the AnchorFast around the tube. So some considerations when it comes to using the AnchorFast is it has two securing devices. One is an adhesive dressing that looks very like a Duoderm and that will stick to the cheeks.

And the secondary device is a strap that goes around the back of the neck secured by Velcro. In a male patient, it’s obviously particularly important to make sure you’ve removed any facial hair from the area the dressing is going to be sitting out, and you should also check that the skin is clean and dry and free from oils to assist that in sticking down. These are very easy to apply when you know how. The backing on the dressing just comes off, and that will be adhered to the cheeks as I’ll demonstrate. The strap will go down the back of the head, and we’ll demonstrate the front mechanism for securing the tube as well.

So I would probably just check that it’s going to sit in a relevant position for my patient, and the shape of their face isn’t going to hinder the device in any way. And then I’m going to apply the device to each cheek. Now because Lindy’s on the other side, I’m going to take hold of the tube to make sure it’s not going to move while she secures the dressing onto the other cheek for me.

All the time, we would be speaking to the patient, reassuring them, making them feel safe while we do this. You want to make sure you’re applying heat to the dressings so that the sticky part activates against the skin, and it will be secure. So you may have to press that for a few moments for that to work on a patient’s skin. That’s going to work better than on a mannequin. And then we can secure the tube to the device. So we have a sticky bit of plastic going around here which can wrap around the tube.

So that is going to adhere to your tube, but as a secondary mechanism, there is a clip to hold it in situ there so it does not slide. At this stage, we can apply, either by going through the crick of the neck or by lifting your patient forward if it’s safe to do so, the back of the dressing.

All the while, I am trying to keep the ET tube as still as possible in the patient’s mouth because movement of it might cause the patient to cough or gag. So I’m just looping through the Velcro and attaching it to the back of the dressing. I want to make sure that’s not too tight for my patient by making sure I can get a minimum of one finger in each side there so it’s less likely to cause pressure damage and will assist in drainage coming back from the brain. That feels nice and secure, Ian.

If you don’t have an AnchorFast, there are other ways of securing an ET tube safely and effectively, and Ian’s going to demonstrate the first of these for us now. Using bandage or some other soft material, make a loop, which you then wrap around the endotracheal tube.

And I’m going to pass the ends through that loop so I’ve now got a tight M knot around my tube, and we’re going to pass one side of that around the back of the head now. And that is how we are going to secure our tube.

It is usually easier to tie at the side of the patient than behind their head because you can see what you’re doing. And if you do want access to that knot, it’s much easier if it’s at the side. And so I’m just going to go around once. You may, at this stage, want to cut because you will know how much you need, but please, don’t do that beforehand. I can get my finger in there. And a nice double knot will be enough to secure. You can let go of it.

Again, to make sure it’s not too tight for your patient, we want to make sure we can get a finger underneath there so that we’re not causing any pressure damage or problems with venous drainage from the brain. The final method for securing an ET tube for those patients who might be at increased risk of elevated ICP, such as patients who’ve had a traumatic brain injury or those patients who’ve had a subarachnoid haemorrhage, and therefore, need intubated and ventilated for the conditions, they will need their ET tube taped rather than tied. And this is to ensure that there is adequate blood flow down from the damaged brain, and we are not using anything that will impede that.

We use in NHS Lothian currently, tape. And we’re going to demonstrate how we apply that in the case of a patient who’s got elevated ICP. So it’s important to use something like zinc oxide tape that I have here so that it’s not too stretchy because that would be at risk of your tube moving in and out, and also, that it’s sticky enough that it’s going to stick to your patients. Something like mepore might not be adhesive enough, so we recommend the zinc oxide tape. Where I am taping this tube will depend on the position of the tube in my patient’s mouth. If it’s towards the left, I’m more likely to secure it to the left side of the mouth.

If it’s the centre, I would probably use the top and bottom of the mouth, and if it’s towards the right, I would use the right hand side of the mouth mainly. This is probably a good time to mention when someone has an endotracheal tube in, we need to consider pressure damage within the mouth and the trachea itself. So every 12 hours when we are redoing these ties, tapes, or moving the AnchorFast as a minimum, we would make sure we’re moving it to a different location within the mouth to reduce the risk of pressure damage.

So in order to achieve this, I am going to first stick a bit of the tape to the side of my patients mouth, making sure that I have enough surface that it is not going to pull itself off. I am then going to very carefully go around under Lindy’s hand once and at least twice before securing again to the side of the mouth like so. I would then take my scissors, make sure that I am far away from my patient’s skin, and I’m going to make sure that’s nice and tight and that it is well secured to my patient’s skin.

Similar to the AnchorFast, you may have to have considerations for men for shaving, and you would also need to check that the skin is clean and dry. That’s still not entirely secure, so I do want to apply another bit of tape, and with the position of this, I am probably going to do that from the top of the mouth like so. Again, I’m going to go around the tubing once, twice, and then, I’m going to secure either back to the top or towards the bottom so I get a good hold.

At the end of the process again, we’re going to check what the marking is on the tube and compare that to the device’s chart that we showed you at the start of the video to make sure it hasn’t migrated before we let go of the tube and ensure that it is secured in that method. Anatomically, the right main bronchus sits at a more obtuse angle than the left main bronchus, so there is a risk that doing these manoeuvres, you can push the tube in, and it can displace. You will know that because the ventilator will be alarming, or you’ll feel reduced lung expansion on your patient’s chest.

Having secured your ET tube, you do need to think about having equipment readily available should there be an emergency with the patient’s airway. So for example, say the ties became undone or the tape became undone, and the tube slid out. So we have some important kits that we need to make sure is at the bedside. We do have an NHS Lothian airway trolleys. These should readily move to the bedside of the patient. We should always have hanging oxygen, suction, and some form of manually ventilating the patient. A Laerdal bag and mask is absolutely vital to have available. Endotracheal tubes do come in a variety of types and sizes, but the principles of their use remain the same.

You can see that this one is very much smaller than the one that’s in the patient. This is a size 6 compared to a size 8, which is inside our patient just now. A commonly held mis-belief with endotracheal tubes is that they function very like catheters. They do have this balloon that’s called a cuff on the end, and from the exterior port that you can see here, I can inflate that cuff initially with 10 mils of air. So it is now inflated. People believe that this is the fixation mechanism on an endotracheal tube, but as you can tell, we’ve went to quite a lot of trouble to ensure it’s externally fixated. This is not to fixate the tube in place.

This is purely to equip the airway so the only the air can come in and out is the ventilatory support that we are providing the patient at this time. Part of your daily checks will be to check that the cuff pressure is correct, and that should be sitting between 20 and 30 millimetres of mercury. We do have a device called a cough manometer, which will demonstrate that the pressure is correct. You can inflate by pressing it like a blood pressure cuff and deflate with a button on the side, usually red in colour.