A Comparative Study of Oral Endotracheal Tube Securing Methods

A Comparative Study of Oral Endotracheal Tube Securing Methods* Howard Levy, M.D., F.C.C.P.; and Linda Griego, M.S.N., R.N., C.C.R.N. A prospective study was done to compare four different methods of securing oral endotracheal tubes: adhesive tape (A), Twill tape (T), Twill tape with FlexBiue bite block (TFXB), and Velcro tie with FlexBiue (VFXB), used on sequential days. Thirty-six patients were enrolled for 136 patient-days and 18 had complete 4-day cycles. The methods were evaluated twice daily by nurses, respiratory therapist, and patient, on a Gve-point Likert scale with regard to oral hygiene, patient comfOrt, nurse satisfaction, and ease of use. Tube movement relative to the incisor teeth was measured at end of shift, the use of a bite block was noted, and near extubatioos were documented. Analysis of variance and Student's t test with Bonferroni correction were performed. Adhesive tape had 33 patient-days, 0.4±0.7 em movement, 3.4±0.9 oral hygiene, 4.0±0.8 comfort, 4.2±0.6 nurse satisfaction, and 4.2±0.7 ease of use. Twill tape had 34 patient-days, 0.7±1.1 em movement, 3.0±0.7 oral hygiene, 3.1 ± 0.9 comfort, 2.8 ± 1.0 nurse satisfaction, and 3.3± 1.1 ease of use. Twill tape with FlexBiue bite block had 35 patient-days, 1.3 ± 2.0 em movement, 2.5 ± 1.2 oral hygiene, 1.9± 1.1 comfort, 1.9± 1.0 nurse satisfaction,

and 2.1 ± 1.1 ease of use. Velcro tie with FlexBiue had 34 patient-days, 0.8± 1.0 em movement, 1.9± 1.2 oral hygiene, 1.5± 1.4 comfort, 1.6± 1.0 nurse satisfaction, and 1.8± 1.1 ease of use. Statistical analysis showed no difference between the groups for tube movement. Method A was statistically superior to VFXB and TFXB on all other parameters, and Ton all except oral hygiene. Twill tape was superior to VFXB on all, and TFXB on patient comfort, nurse satisfaction, and ease of use. There was no sigoiGcant difference between TFXB and VFXB on any measured parameter. Adhesive tape and T required an oral airway on only 14 days compared with 69 days of FlexBiue use. Extubation on 2 and near extubation occurred on 18 occasions with FlexBiue use and only once with T and accounted fur most decisions to change securing method. We cannot recommend the use of the FlexBiue system for securing oral endotracheal tubes.

tubes are required for positive presE ndotracheal sure mechanical ventilation and must be securely

over a 7-month period. The following methods were used: adhesive tape (A), Twill tape (T), with FlexBiue bite block (TFXB), and Velcro tie with FlexBiue (VFXB). P..ltients were enrolled in the study starting with the method designated for use that day. Each afternoon the securing devk-e was changed to the next method to be evaluated, in the order as listed above. The adhesive method uses a 1-m length of 2-cm adhesive tape. Moleskin was applied to the area of tape that (.'OVers the back of the neck. Both tape ends were split and one split was wrapped around the endotracheal tube and the other secured over the face and the upper lip to the opposite cheek. The proc-edure was repeated with the other end of the tape. The T method was a modification of the method described by Dun leap.' A 1-m length ofT was folded in half and looped around the endotracheal tube. The ends were brought through this loop and then tightened by pulling the ends. The one was passed around the patient's head, below one ear, while the other end passed above the other ear. The two ends were tied in a bow on the cheek. This was repeated with a se(.'()nd piece ofT so that two ties secured the endotrdCheal tube. The FlexBiue bite block has a slit in the middle section and is molded to partially wrap around the endotracheal tube (Fig I). The FlexBiue and ties were donated by the manufacturer (King Systems Corpor.ttion, Noblesville, Ind). All nursing and respiratory therapy stalf were instructed in the use of the FlexBiue devk-e by a representative of the manufacturer. The TFXB and VFXB methods were similar ex<:ept that T was used with one method and Velcro with the other. Either T or Velcro was threaded through the slit of the FlexBiue and a loop formed. The tapered end of the FlexBiue was inserted into the center of the mouth over the tongue and between the teeth. The loop was passed around the endotracheal tube and then pulled securely around the endotracheal tube. One end was brought around the back of the head and tied (T) to the other end or secured using the Velcro mechanism. The endotracheal tube was then attached to the end of the Flexblue with A (Fig 2).

held in position to avoid accidental extubation or malposition. Commonly used methods of securing endotracheal tubes include adhesive tape (A), twill tape (T), and a wide variety of endotracheal tube holders.l. 2 However, to our knowledge, none of these methods has been compared and evaluated with regard to which is the ideal way of securing the endotracheal tube. No best method may exist, rather a trade-off between keeping the tube in and patient comfort must be made. While there is extensive literature on accidental extubation, the literature does not relate accidental extubation to taping methods or the presence of a bite block. This study compares four different methods of securing oral endotracheal tubes in critically ill patients requiring mechanical ventilation. These methods were evaluated for tube movement, skin breakdown, mouth hygiene, patient comfort, nurse satisfaction, and ease of use. METHODS Four methods of securing endotracheal tubes in routine use at University Hospital, Albuquerque, were prospectively evaluated *From the Medical Intensive Care Unit, Department of Medicine, University of New Mexim Hospital, Albuquerque. Manuscript re<.-eived July 22, 1992; revision ac(.-epted March 23. Reprint requests: Dr. Levy, Department of Medicine, 5ACC, 22II wmas Blvd NE, Albuquerque 87131

(Cheat 1993; 104:1537-40) A= adhesive tape; T =Twill tape; TFXB =twill tape with FlexBlue bite block; VFXB =Velcro with FlexBiue bite block

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F11. 111 2 l\ ill Fle,bluc (J 1•, ~) utdhud h\111 P." , 'through ~ hi on Flex Blue and encircles endotracheal tube. Adhesive tape secures bite block to endotracheal tube. FIGURE 1. Flex Blue bite block applied to endotracheal tube. An evaluation tool was developed and the securing method used was evaluated twice daily by nurses and respiratory therapists. Each method was evaluated for skin breakdown and endotracheal tube movement in <.-entimeters was re<.~1rded. Movement was re<.-orded and mmpared with the beginning of shift documentation of endotracheal tube position relative to the incisor teeth. The methods were also evaluated on oral hygiene , patient mmfort, nurse satisfaction, and ease of use (ease and successful application) using a five-point Likert scale, where I was bad or difficult and 5 was good or easy. In order to minimize the subjective nature of this assessment , two values were re<.~1rded and averaged and a single value was used fi1r analysis. A<.-omment section was also provided. If the patients were alert enough to answer questions, they were asked wluch method was preferable to them. Some patients were able to provide written <.'Omments. The use of a bite block for A and T methods was noted. Near extubations and self-extubation were re<.-orded. P.atients were kept on the assigned day's securing method unless it was deemed by the nurse or physician caring fi1r the patient that it was unsafe to do so because of near self-extubation. If a patient refused a method , this was noted and an alternative method was selected. Statistical analysis was performed using analysis of variance and Student's t test with Bonferroni mrrection (GraphPAD InStal Vl .lla). A p value of <0.05 was <.~msidered significant. RESULTS

The 36 patients were studied for 136 patient days, 3.8 ± 2.6 (mean± SD) and a range of 1 to 10 days. Therewere21 female and 15 male patients, 56.4± 17.8 1538

years, ranging from 21 to 90 years. They had 5.9±4.5 ventilator days (range, 1 to 17). Skin breakdown could not be analyzed because carryover from one method to another made it impossible to ascribe causation to any particular method. Tube movement and Likert scores for oral hygiene, patient comfort, nurse satisfaction, and ease of use are shown in Table 1. One-way analysis of variance disclosed no difference between the groups for age, days of mechanical ventilation, or endotracheal tube movement. For oral hygiene, A was significantly better than TFXB (p<0.01) and VFXB (p<0.001) while T was superior to VFXB (p<0.01). For patient comfort, A was significantly better than T (p<0.05), TFXB, and VFXB (p<0.001), while Twas superior to both TFXB and VFXB (p
Table 1-Mean± SD Likert Ratings for Endotracheal Tube Securing Methods* Method

A

T

TFXB

VFXB

Patient-days Movment,cm Oral hygiene Comfort Patient satisfaction Ease of use

33 0.4±0.7 3.4±0.9 4.0±0.8 4.2±0.6 4.2±0.7

34 0.7 ± l.l 3.0±0.7 3.1 ±0.9 2.8± 1.0 3.3± l.l

35 1.3±2.0 2.5± 1.2 1.9± l.l 1.9± 1.0 2.1 ± l.l

34 0.8± 1.0 1.9± 1.2 1.5± 1.4 1.6± 1.0 1.8± l.l

*A=adhesive tape; T=Twill tape; TFXB=T with FlexBiue bite block; VFXB =Velcro with Flex Blue bite block.

different from T (p<0.05) on oral hygiene. Two patient self-extubations occurred with the VFXB . There were a total of 19 near extubations; 9 each with VFXB and TFXB, 1 with T, and none using A. By Fisher's exact test, there was no significant difference between A and T, and for TFXB and VFXB. A was statistically less likely than TFXB and VFXB to result in near or successful extubation (p = 0.002 for both). Twas similarly less likely than TFXB and VFXB to lead to near self-extubation (p = 0.013 and p = 0.009, respectively). The FlexBiue device replaces the need for an oral airway which was required for 14 patient days for each of the other two methods compared with 35 patient days for TFXB and 34 for VFXB. There was a highly statistically significant difference between the need for an oral airway with A or T compared with TFXB or VFXB by Fisher's exact test (p
Endotracheal tube securing is an extremely important aspect of modern intensive care management since it is required to provide mechanical ventilation and access to the airway for pulmonary toilet. There is no universally accepted retention device and there is a dearth ofliterature on safely securing these tubes. The ideal method should provide minimal tube migration and aUow maximal patient comfort, oral hygiene, and skin integrity, while being easy to apply and requiring minimal nursing or respiratory therapist

time to maintain. None of the literature regarding selfextubation has evaluated correlations with taping methods or bite block use. This study has demonstrated that the A method provides most of the requirements of a safe and convenient securing mechanism with the exception of skin integrity which could not be evaluated adequately by this study design. Using analysis of variance and Student's t test with Bonferroni correction, no difference between the groups was found for tube movement, although A allowed the least tuhe movement. Method A was statistically superior to VFXB and TFXB on aH other parameters, and Ton all others except oral hygiene. T was superior to TFXB on patient comfort, nurse satisfaction, and ease of use and VFXB on these and oral hygiene . While the FlexBiue device appears attractive by combining a retention mechanism and a bite block to maintain endotracheal tube patency, it could not provide these satisfactorily when mmpared with either A or T. There was no significant difference between TFXB and VFXB on any measured parameter. When the 18 patients who had all 4 methods used were analyzed, the differences followed the same trend but failed to reach the same levels of significance only because of the smaller sample size. Problems occurred with the FlexBiue bite block because patients would push the bite block out of their mouths with their tongues. Twenty-three of the 69 patient days with FlexBlue had comments of this nature . Since the endotracheal tube was secured to the bite block, much of the tube movement occurred because of bite block movement. If patients were comatose, there were fewer problems of this nature, but alert patients seemed very uncomfortable and two self-extubations (VFXB) and many near extubations occurred. This problem accounted for most decisions to change from a FlexBiue device to A or T. Erosion of the roof of the mouth and difficulty placing the FlexBiue in the mouth accounted for the remainder of decisions to withhold its use. Only 14 days of an oral airway use compared with 69 days of FlexBiue were required, suggesting that endotracheal tube occlusion is a minor problem in critically ill patients and obviates many of the claimed benefits of the FlexBlue device. Skin breakdown was difficult to measure using this study design, as method rotation made it difficult to determine which method was responsible. Written comments, however, ascribed skin breakdown to A only, particularly when tape was removed to provide clean tape or reposition the endotracheal tube or to change to another method. Methods A and T were both conducive to administration of good oral hygiene. Many of the comments made by nurses evaluating the methods focused on the difficulty providing oral care to patients with the CHEST I 104 I 5 I NOVEMBER. 1993

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FlexBlue bite block in place. Four patients developed erosions on the roof of their mouth when the bite block had been in place for 24 h. Patient comfort was often based on the nurses' assessment of the patient's comfort. Although method A was statistically superior to all other methods, some patients indicated that they preferred T because of skin irritation caused by A. No patient indicated a preference for TFXB or VFXB. Nurses satisfaction was clearly indicated in this study to be method A. Many comments made by the nurses with regard to dissatisfaction with the other methods, especially with use of the bite block, concerned fear of extubation and inability to administer oral care. Many nurses indicated that method Twas better for patient comfort and was preferred in patients who were prone to skin breakdown. Nurses found method A to be easier to use than other methods. The nurses unanimously found methods TFXB and VFXB difficult to use. We must note that our T method uses two pieces of T as we believe that this limits tube movement. Institutions using a single piece cannot generalize our results to their patients. The methods were evaluated

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only in the relatively acute, short-term situation and therefore may not be applicable to longer-term use . Adhesive use may become problematic with longerterm use. Although a study of this nature is at risk for systematic bias, we believe this was minimized by random allocation of nurse and respiratory therapist to patients and evaluating the method twice a day after different shifts and combining the assessments for a single day score. While A should be favored as indicated by this study, T fixation should be individually allocated to patients with marked skin fragility. The results of this study indicate so many problems with the FlexBlue system with regard to tube movement, risk of self-extubation, oral hygiene, and patient comfort that we cannot recommend its use.

REFERENCES I Dunleap E. Safe and easy ways to secure breathing tubes. RN 1987; 50:26-7 2 Kirilloff LH . Upper respiratory problems. In: Lewis S, Collier D, eds. Medical-surgical nursing assessment and management of clinical problems. 2nd ed. New York: McCraw- Hill, 1987, 484

Oral Endotracheal Tube Securing Methods (Levy. Griego)