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A Disadvantage of Velcro as an Endotracheal Tube Anchor
Problems with the Pneumothorax Catheter To the Editor:
I read with interest the recent article by Kubitschek and Peters (Chest 1984;86:714-717) on use of a pneumothorax catheter for treatment of pneumothorax as well as drainage of pleural effusions. In my own practice I have used this catheter quite frequently and have found results very similar to those in the study. As they suggested, I have found the catheter to be useful in draining malignant effusions and in completing successful chemical pleurodesis. One problem with the catheter is that during pleurodesis the drainage holes tend to become clogged. However, ifthe catheter is flushed on a daily basis this problem can be alleviated. I have found that with this technique drainage and pleurodesis can be accomplished with less pain and discomfort to the patient. A second problem has been that the catheter is not easily secured in place. If securely taped, it will not fall out. Ralph E . Binder, M.D ., F.C .C .P. , Albert Einstein School of Medicine Bronx, New York Reprint requests: Dr. Binder,l6QO 1/eringAvenue, Bronx, NY 10461. 10461. To the Editor:
We appreciate Dr. Binders remarks about our recent paper. Occasionally, we also noticed occlusion of the original catheters distal perforations. Additionally, the three-way stopcock and Heimlich valve were sites of fibrinous deposition and occlusion. We requested that the original catheter be modified to have larger drainage holes and we discontinued usage of the three-way stopcock and Heimlich valve. These modifications (found in the TPT-IPeters-113082 modified pneumothorax set [Cook, Inc]) decreased the incidence of occlusion significantly. However, ifocclusion does occur, simple flushing is easily accomplished and can be done on a daily basis until the catheter is removed. Dr. Binder also notes some difficulty securing the catheter in place. The modified pneumothorax catheter has been shortened so that it can be fully inserted without difficulty. We have also decreased the frequency of inadvertent dislodgement by suturing the catheter in place, securely taping the catheter and plastic tubing to the patient's chest wall (as Dr. Binder suggests), and educating the patient and nursing staff about care in preventing dislodgement of the catheter during transportation. Kenneth R. Kubitschek , M .D. and jay Peters , M.D. , F.C .C .P. , Veterans Administration Medical Center, Baylor College of Medicine , Houston
A Disadvantage of Velcro as an Endotracheal "Tube Anchor To the Editor:
Longterm stabilization of oral endotracheal tubes has long been a bothersome ICU problem. Recently, a number of hospitals have used the Dale endotracheal tube holder (Dale Medical Products, Inc) to improve on older techniques such as adhesive tape tied around the neck. This new product uses a small Velcro adhesive strip that attaches to the endotracheal tube (Fig 1) and a fabric strap that secures the tube at the Velcro strip and subsequently wraps around the neck for anchoring. 704
FrGURE 1. Velcro adhesive strip on Dale endotracheal tube. After several months of trying this method, we have discontinued its use because we noted that the individual Velcro hooks (2 to 3 mm in length) easily break off the Velcro strips. Several intubated patients were noted to have these hooks sticking from their lips after a short period of use. In subsequently testing new Velcro strips, we found that three to four hooks invariably broke off the Velcro strip after a single attachment and detachment. These hooks can cause tissue injury, as demonstrated by a respiratory therapist who embedded one into her finger while holding a tube at the strip to anchor it into place. The barb-like structure of the plastic fragment allowed it to deeply embed into the finger pad and cause a felon. We suspect that a broken fragment embedded in a patient's lip or tongue could produce a similar foreign body infection . We recommend that ICU staff avoid this endotracheal tube anchoring technique until the manufacturer demonstrates a solution to this problem. ]. E. Heffner, M.D. , F.C.C.P. ; and M. Dietrick, C.R. T.T., Penrose Hospital, Colorado Springs
Correction To the Editor:
The excellent National Heart Lung and Blood Institute National Conference on Oxygen Therapy (Chest I984; 86:237-47) contains a significant misprint on page 238. It states, "In the NOTT study, subgroups showing a high PaC02, elevated hematocrit, elevated pulmonary artery pressure . . . derived the most benefit from continuous as opposed to nocturnal oxygen." The NOTT trial actually showed the most benefit from continuous oxygen therapy in a group with a normal PaCO,, a hematocrit less than 47%, and a mean pulmonary artery pressure less than 27 mm Hg. 1 ]. I. Matthews, M.D ., F.C.C .P., Colonel , Medical Corps , US Army Chief, Pulmonary Disease Service , Brooke Army Medical Center, Fort Sam Houston , Texas
REFERENCE Nocturnal oxygen therapy trials: continuous or nocturnal oxygen therapy in hyperemic chronic obstructive pulmonary disease. Ann Intern Med 1980; 93:391-98 Communications
to the Editor
I read with interest the recent article by Kubitschek and Peters (Chest 1984;86:714-717) on use of a pneumothorax catheter for treatment of pneumothorax as well as drainage of pleural effusions. In my own practice I have used this catheter quite frequently and have found results very similar to those in the study. As they suggested, I have found the catheter to be useful in draining malignant effusions and in completing successful chemical pleurodesis. One problem with the catheter is that during pleurodesis the drainage holes tend to become clogged. However, ifthe catheter is flushed on a daily basis this problem can be alleviated. I have found that with this technique drainage and pleurodesis can be accomplished with less pain and discomfort to the patient. A second problem has been that the catheter is not easily secured in place. If securely taped, it will not fall out. Ralph E . Binder, M.D ., F.C .C .P. , Albert Einstein School of Medicine Bronx, New York Reprint requests: Dr. Binder,l6QO 1/eringAvenue, Bronx, NY 10461. 10461. To the Editor:
We appreciate Dr. Binders remarks about our recent paper. Occasionally, we also noticed occlusion of the original catheters distal perforations. Additionally, the three-way stopcock and Heimlich valve were sites of fibrinous deposition and occlusion. We requested that the original catheter be modified to have larger drainage holes and we discontinued usage of the three-way stopcock and Heimlich valve. These modifications (found in the TPT-IPeters-113082 modified pneumothorax set [Cook, Inc]) decreased the incidence of occlusion significantly. However, ifocclusion does occur, simple flushing is easily accomplished and can be done on a daily basis until the catheter is removed. Dr. Binder also notes some difficulty securing the catheter in place. The modified pneumothorax catheter has been shortened so that it can be fully inserted without difficulty. We have also decreased the frequency of inadvertent dislodgement by suturing the catheter in place, securely taping the catheter and plastic tubing to the patient's chest wall (as Dr. Binder suggests), and educating the patient and nursing staff about care in preventing dislodgement of the catheter during transportation. Kenneth R. Kubitschek , M .D. and jay Peters , M.D. , F.C .C .P. , Veterans Administration Medical Center, Baylor College of Medicine , Houston
A Disadvantage of Velcro as an Endotracheal "Tube Anchor To the Editor:
Longterm stabilization of oral endotracheal tubes has long been a bothersome ICU problem. Recently, a number of hospitals have used the Dale endotracheal tube holder (Dale Medical Products, Inc) to improve on older techniques such as adhesive tape tied around the neck. This new product uses a small Velcro adhesive strip that attaches to the endotracheal tube (Fig 1) and a fabric strap that secures the tube at the Velcro strip and subsequently wraps around the neck for anchoring. 704
FrGURE 1. Velcro adhesive strip on Dale endotracheal tube. After several months of trying this method, we have discontinued its use because we noted that the individual Velcro hooks (2 to 3 mm in length) easily break off the Velcro strips. Several intubated patients were noted to have these hooks sticking from their lips after a short period of use. In subsequently testing new Velcro strips, we found that three to four hooks invariably broke off the Velcro strip after a single attachment and detachment. These hooks can cause tissue injury, as demonstrated by a respiratory therapist who embedded one into her finger while holding a tube at the strip to anchor it into place. The barb-like structure of the plastic fragment allowed it to deeply embed into the finger pad and cause a felon. We suspect that a broken fragment embedded in a patient's lip or tongue could produce a similar foreign body infection . We recommend that ICU staff avoid this endotracheal tube anchoring technique until the manufacturer demonstrates a solution to this problem. ]. E. Heffner, M.D. , F.C.C.P. ; and M. Dietrick, C.R. T.T., Penrose Hospital, Colorado Springs
Correction To the Editor:
The excellent National Heart Lung and Blood Institute National Conference on Oxygen Therapy (Chest I984; 86:237-47) contains a significant misprint on page 238. It states, "In the NOTT study, subgroups showing a high PaC02, elevated hematocrit, elevated pulmonary artery pressure . . . derived the most benefit from continuous as opposed to nocturnal oxygen." The NOTT trial actually showed the most benefit from continuous oxygen therapy in a group with a normal PaCO,, a hematocrit less than 47%, and a mean pulmonary artery pressure less than 27 mm Hg. 1 ]. I. Matthews, M.D ., F.C.C .P., Colonel , Medical Corps , US Army Chief, Pulmonary Disease Service , Brooke Army Medical Center, Fort Sam Houston , Texas
REFERENCE Nocturnal oxygen therapy trials: continuous or nocturnal oxygen therapy in hyperemic chronic obstructive pulmonary disease. Ann Intern Med 1980; 93:391-98 Communications
to the Editor