Royal North Shore Hospital Intensive Care Manual

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Endotracheall and tracheostomy aiirway securiity guiidelliines Endotrachea and tracheostomy a rway secur ty gu de nes for the iintensiive care patiient for the ntens ve care pat ent

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Document Authorisation

Document Title Document Applies to: First authors Contact No. Email Version Expiry Date Date Created Last Modified Last Authorised Authorised by Expiry Date Manual No.

Endotracheal and tracheostomy airway security guidelines for the intensive care patient Level 6 ICU R. Elliott and R. Balkin 9926 7853 Rmelliot@nsccahs.health.nsw.gov.au 1 2007-02-06 2005-04-25 2006-02-06 2007-02-06 R.Elliott CNC/ Professor S. McKinley 2007-02-06 xx

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Tablle of Contents Tab e of Contents

1.0 Document Authorisation ......................................................................................................... 1 2.0 Introduction............................................................................................................................. 2 3.0 Aims ........................................................................................................................................ 2 4.0 Standard/Policy statements ..................................................................................................... 3 5.0 Securing the endotracheal tube with tapes.............................................................................. 3 5.1 Indications for changing tapes ............................................................................................ 3 5.2 Brown leucoplast(adhesive) tapes for securing the ETT in patients without cerebral injury ........................................................................................................................................... 3 5.3 White cloth tapes................................................................................................................. 6 6.0 Securing the tracheostomy tube .............................................................................................. 8 7.0 Airway security during patient repositioning.......................................................................... 9 8.0 Supporting the ventilator tubing ............................................................................................. 9 9.0 Changing the endotracheal tube position at the lips ............................................................... 9 10.0 Acknowledgments............................................................................................................. 10 11.0 Resources .......................................................................................................................... 10

2.0

Introduction

Airway security is literally life sustaining in the mechanically ventilated patient. This document pertains to guidelines for the security of oral endotracheal tubes (ETT) and tracheostomy tubes in the intensive care unit at the Royal North Shore Hospital.

3.0

Aims

To prevent unscheduled self-extubations and self decannulations To prevent movement of the endotracheal tube or tracheostomy tube To prevent tube dislodgment To prevent the development of pressure sores on the lips To prevent pain around the tracheostomy stoma

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4.0

Standard/Policy statements

The tapes securing the airway will be changed once per day and more often if they become soiled or the airway is changed The replacement of tapes used to secure an airway and adjustment of the endotracheal tube or tracheostomy will be performed with a minimum of two health care professionals A registered nurse (preferably the nurse caring for the patient) must be in attendance to ensure airway security when procedures are performed e.g. patient repositioning, chest Xray, bronchoscopy Ventilator tubing will be fully supported according to the instructions in this document to prevent trauma and discomfort White cloth tapes will only be used to secure ET tubes for patients who have a sensitivity to leucoplast or for males who have a beard. Blue velcro ties will only be used to secure tracheostomy tubes. The endotracheal tube tip will be positioned 2.5cm above the carina or level with the aortic knob on the chest X-ray. The position of the endotracheal tube at the lips is recorded on the flow chart at the beginning of each shift

5.0

Securing the endotracheal tube with tapes

5.1 Indications for changing tapes Soiled or wet tapes Initial tapes used were inappropriate ET tube position incorrect ET tube tapes too tight or too loose Haemodynamic or cerebral (ICP, CPP) instability related to tape pressure on jugular venous outflow immediately following tape change. 5.2 Brown leucoplast(adhesive) tapes for securing the ETT in patients without cerebral injury
5.2.1 Requirements

Two health care professionals (one to change tapes and one to hold the tube) Functional bedside emergency airway equipment ie suction, rebreather bag Personal protective equipment: non-sterile gloves, aprons and goggles Y suction catheter (the same catheter may be used for 24 hours for the same patient to suction oral secretions if it is kept clean and covered) Brown elastoplast(adhesive)tape Two paddle pop sticks or tongue depressors Universal skin adhesive remover swabs Skin barrier/protection wipes Bowl of water and facial wipes Scissors

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Royal North Shore Hospital Intensive Care Manual Teeth cleaning equipment and shaving equipment for males

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5.2.2 Procedure 1. Check position of tube at lips and consult with the medical officer about the correct tube position (check chest X ray). 2. Collect equipment. 3. Decontaminate hands. 4. Prepare brown tapes according to the photograph below. Cut one piece of brown tape aproximately 70cm long. Cut a split in the tape at each end to make a trouser leg shape and fold over each end to make it easier to remove from the skin for future tape changes. Place a second layer of tape over the middle section of the tape to prevent the tape sticking to the patients hair. Use tongue depressors to make it easier to handle the tape.

5. 6. 7. 8.

Apply personal protective equipment. Apply universal skin adhesive remover to the existing tapes on patients face. Explain procedure to patient. Extra sedation may be required for some patients. Assistant holds tube below the patients lower lip as in the photograph.

9. 10. 11. 12.

Gently remove the old tapes and check the skin for pressure sores and broken areas of skin. Brush the patients teeth and shave the face (if required) especially where tapes will be reapplied. Wipe and thoroughly dry the skin. Apply skin barrier wipe to the skin.

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13. Place the new brown tape behind the patients head with the tape under the ear lobes. 14. Remove the tongue depressors and tear the tape up the middle as shown in the photograph below.

15. Ensure the tube is in the middle of the mouth. If not, gently readjust to the centre. If you are required to adjust the tube depth, follow the instructions in section 9 at this point. 16. Take the top piece of torn tape, stick it to the skin above the top lip and wrap the end of the tape around the endotracheal tube. 17. Check that the tapes are tight enough to secure the tube but not too tight. The assistant should place two fingers under the tape at the back of the patients neck. 18. Repeat with the upper segment of torn tape from the other side then stick the bottom pieces of tape on top of the tape that has been used to wrap around the tube of the tape and above the top lip (the aim is to secure the upper components of the tape to the top of the lip). 19. Inform the patient that the procedure is complete and dispose of equipment according to health and safety guidelines. 20. Assess chest excursions and ensure air entry is bilateral by auscultating the chest. 21. Record the procedure and document the position of the endotracheal tube at the level of the lips on the patient observation chart.

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5.2.3

Procedure for patients with (or suspected) neurological injury

Tapes are not placed around the patients neck but are reinforced across the checks. Two pieces of brown tape are cut in a long trouser leg shape and changed according to the same principles described previously. See the photograph below:

5.3 White cloth tapes White cloth tapes are used if the ET cannot be secured safely with leucoplast tapes or if the patient: has a sensitivity to any product contained in the leucoplast tape has a beard is sweating excessively

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5.3.1 Requirements

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Two health care professionals (one to change tapes and one to hold the tube) Functional bedside emergency airway equipment Personal protective equipment: non-sterile gloves, aprons and goggles. Y suction catheter (the same catheter may be used for 24 hours to suction oral secretions for 24 hours for the same patient if it is kept clean and covered) Length of white tape (approximately 50cm long) Bowl of water and facial wipes Scissors Teeth cleaning and shaving equipment for males if required
5.3.2 Procedure 1. Check position of tube at lips and consult with the medical officer about the correct tube position (check chest X ray) 2. Collect equipment. 3. Decontaminate hands and apply personal protective equipment. 4. Explain procedure to patient. Extra sedation may be required for some patients 5. Assistant holds tube below the patients lower lip as shown in the photograph below. 6. Remove old tapes. 7. Ensure the tube is in the middle of the mouth. If it is not gently readjust to the centre. If you are required to adjust the depth of the tube follow the instructions in section 9 at this point. 8. Place new tapes around the endotracheal tube first, according to the photograph. Form a loop with the tapes and pass the cut ends around the tube and through the loop. Pull the cut ends to tighten the loop around the tube. 9. Pass one end around the tube and secure with a single tie of the two ends.

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10. Tie a knot in the tape with the cut ends on top of the endotracheal tube.

11. Pass the tapes around the back of the patients head. 12. Ask the assistant to place two fingers under the tapes to prevent the tapes from being tied too tight (as described previously). 13. Tie the tapes with a secure knot, do not use a bow. 14. Trim the tapes. 15. Inform the patient that the procedure is complete and dispose of equipment according to health and safety guidelines. 16. Observe chest excursions and auscultate the chest to ensure air entry is bilateral. 17. Record the procedure and document the position of the endotracheal tube at the level of the lips on the patient observation chart.

6.0

Securing the tracheostomy tube

The same principles used for securing ETTs apply when securing the tracheostomy tube. Two health care professionals should perform the procedure. One person holds the tube while the other performs the dressing and reties the tapes. There is a choice of tapes: white cloth tapes, blue felt Velcro tapes as shown in the photograph below (available from 6D) or white Velcro ties manufactured by Shiley, the preferred choice. The tracheostomy stoma site should be redressed and thoroughly cleaned with normal saline before the new tapes are applied and while the assistant is holding the tracheostomy tube. Split drain dressings are usually used. Heavily exudating tracheostomy sites require absorbent dressings for example Allevyn dressings (or equivalent). Check air entry after the procedure. NB. Never reconnect the ventilator tubing with one hand. Always hold the flange of the tracheostomy with one hand and replace the tubing with the other. The soft tissue of the neck and tracheal become sore after repeated applications of the ventilator tubing if the flange is unsupported. Velcro fastners on each side secure the tapes

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7.0

Airway security during patient repositioning

A registered nurse must be present to support the airway when the patient is repositioned to prevent accidental removal or misplacement of the endotracheal or tracheostomy tube.

8.0

Supporting the ventilator tubing

The endotracheal or tracheostomy tube should be supported to prevent traction on the upper airway and tracheal discomfort. Ventilator tubing support frames which are designed to prevent pulling and discomfort must be used. They attach to the side of the ventilator. See photograph below:

9.0

Changing the endotracheal tube position at the lips

The ET tube may need to be placed in a higher or lower position in the trachea. The medical officer must order the change in the patient records. The same principles used to maintain safety during tape changes should be applied ie the procedure requires two health care professionals.
9.1.1 Requirements

Two health care professionals (one to change tapes and one to hold and adjust the tube) Functional bedside emergency airway equipment Personal protective equipment: non-sterile gloves, aprons and goggles. Y suction catheter (the same catheter may be used for 24 hours to suction oral secretions for the same patient if it is kept clean and covered) Prepared brown leucoplast tape (and adhesive removal and barrier wipes) and length of white tape (approximately 50cm long)

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Royal North Shore Hospital Intensive Care Manual Bowl of water and facial wipes Scissors Cuff sphygmomanometer and 10ml syringe Medical order to change tube position

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9.1.2 Procedure 1. Check position of tube at lips and consult with the medical officer about the correct tube position (check chest X-ray) and medical order 2. Collect equipment. 3. Decontaminate hands and apply personal protective equipment. 4. Explain procedure to patient. Extra sedation may be required for some patients. 5. Thoroughly suction the patients oropharynx 6. Assistant holds tube below the patients lower lip according to the photograph in section 5: 7. Note the current tube position at the lips. Remove old tapes. 8. Preoxygenate patient 9. Deflate the endotracheal tube cuff completely with the 10ml syringe. 10. Advance or withdraw the endotracheal tube to the correct level that is number of cms positioned at the lips. Ensure tube is positioned in the middle of the mouth. 11. Reinflate cuff and check pressure is no greater than 25cmH2O with the cuff manometer. 12. Reapply the tube security tapes according to instructions contained in previous sections of this document. 13. Observe chest excursions and auscultate the patients chest to check for equal air entry, arrange for a check chest X-ray. 14. Document new position in cms at the lips and the procedure in patients record

10.0 Acknowledgments
Many thanks to Nathan Turney for proof reading the document.

11.0 Resources
Pierce L. Guide to mechanical ventilation and intensive respiratory care, 1995 W.B. Saunders Philadelphia

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Endotracheal and tracheostomy airway security guidelines for the intensive care patient Version:1 Expiry: 2007-02-06